Retroperitoneal laparoscopic adrenalectomy in a pregnant woman with Cushing's syndrome

Cushing's syndrome during pregnancy caused by adrenal cortical adenoma: a case report and literature review

Cushing's syndrome (CS) during pregnancy is a rare condition with significant maternal and fetal complications. A case of CS during the third trimester of pregnancy secondary to adrenocortical adenoma was reported. Literature review revealed the disadvantages of different treatments in this period. Besides the conservative treatment, surgery is recommended for CS during the third trimester of pregnancy secondary to adrenal adenoma, if an experienced surgeon is available.

A Pregnant Woman Who Underwent Laparoscopic Adrenalectomy due to Cushing's Syndrome

Cushing's syndrome (CS) may lead to severe maternal and fetal morbidities and even mortalities in pregnancy. However, pregnancy complicates the diagnosis and treatment of CS. This study describes a 26-year-old pregnant woman admitted with hypertension-induced headache. Hormonal analyses performed due to her cushingoid phenotype revealed a diagnosis of adrenocorticotropic hormone- (ACTH-) independent CS. MRI showed a 3.5 cm adenoma in her right adrenal gland. After preoperative metyrapone therapy, she underwent a successful unilateral laparoscopic adrenalectomy at 14-week gestation. Although she had a temporary postoperative adrenal insufficiency, hormonal analyses showed that she has been in remission since delivery. Findings in this patient, as well as those in previous patients, indicate that pregnancy is not an absolute contraindication for laparoscopic adrenalectomy. Rather, such surgery should be considered a safe and efficient treatment method for pregnant women with cortisol-secreting adrenal adenomas.

Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review

Treatment of surgical disease in the gravid patient requires a unique and careful approach where safety of the mother and fetus are both considered. Approaches to diagnosis and therapy of surgical disease in the gravid patient are increasingly clarified and defined in the literature. Laparoscopy, once described as contraindicated in pregnancy, has been steadily accepted and applied as data supporting its safety and use have accumulated. An extensive review of the literature was performed to define the use of laparoscopy in pregnancy. Diagnoses for independent surgical diseases as well as imaging modalities and techniques during pregnancy are reviewed. Preoperative, intraoperative, and postoperative management of the pregnant patient are described and evaluated with focus on use of laparoscopy. Literature supporting safety and efficacy of laparoscopy in cholecystectomy, appendectomy, solid organ resection, and oophorectomy in the gravid patient is outlined. Based on level of evidence, this review includes recommendations specific to surgical approach, trimester of pregnancy, patient positioning, port placement, insufflation pressure, monitoring, venous thromboembolic prophylaxis, obstetric consultation, and use of tocolytics in the pregnant patient.

[Surgery during pregnancy]

The decision for surgical intervention during pregnancy should be interdisciplinary and include all aspects of prenatal care. The risk of surgery to mother and fetus must be calculated and weighed against the disadvantages of other, nonradical methods. If there is no danger to the mother, the highest priority in all therapeutic considerations is the fetus and its development. The greatest threat to the fetus exists during the first trimester. In case surgery cannot be postponed till after birth, they should be done if possible during the 4th to 6th months of pregnancy, not the first trimester. In case of danger to the mother, necessary surgery must be performed any time during the pregnancy. Once extrauterine fetal survival is possible (the 24th or 25th week of pregnancy), danger to the mother and the child's mortality and morbidity of the various options must be carefully weighed for both premature delivery and continued pregnancy. Due to the problems of prematurity, any surgery during pregnancy should be carried out only in perinatal clinics outfitted with neonatologic intensive care units.

Laparoscopic adrenal surgery in a Brazilian center

BACKGROUND AND PURPOSE

The laparoscopic approach to the adrenal gland was first reported in 1992. Since then, many publications about this issue have come from Europe, Japan, and North America. We reviewed our 7-year experience with laparoscopic adrenal surgery. This is the first large series presented from Latin America.

PATIENTS AND METHODS

Laparoscopic adrenalectomy was carried out in 61 female and 33 male patients between January 1994 and February 2001. Their ages ranged from 1 to 72 (42.8 +/- 16.4 years) years. Ten patients (10.6%) were 20 years or younger, 10 (10.6%) had unilateral tumors >4 cm, 22 (23.4%) had a Body Mass Index >/= 30, and 10 (10.6%) had had previous open upper abdominal surgery. The size of the lesion ranged from 1 to 9 cm (2.9 +/- 4 cm). Ninety-seven operations were performed, of which 91 were unilateral and 6 were bilateral, adding up to 103 adrenalectomies. Among the 97 procedures, the lateral transperitoneal approach was employed in 94 cases, whereas a lateral retroperitoneal approach enabled 3 adrenalectomies.

RESULTS

Unilateral procedures lasted 117 +/- 43.7 minutes (range 45-250 minutes); bilateral procedures lasted 186 +/- 91.6 minutes (range 100-345 minutes). Five operations (5.1%) were converted to open surgery. Twenty patients (21.3%) suffered complications, 8 (8.5%) being intraoperative and 12 (12.8%) postoperative. Six cases (6.4%) were considered major complications. No deaths occurred. The blood transfusion rate was 4.2%. The hospital stay averaged 6.1 +/- 15.3 days (range 1-140 days). The follow-up period was 17 +/- 12.6 months (range 1-60 months).

CONCLUSIONS

Laparoscopic adrenalectomy is feasible and has excellent results in properly selected patients.