Bilateral adrenalectomy for ectopic Cushing's syndrome-discussions on technique and indication.
BACKGROUND
Tumors producing adrenocorticotropic hormone (ACTH) or corticotropin releasing hormone (CRH) often remain undiagnosed until severe Cushing's syndrome appears, and it may be difficult to distinguish from Cushing's syndrome due to pituitary tumors. Many patients suffer from disease spread, with metastases in the liver or other locations, and the main symptoms may be mineral disturbances, diabetes mellitus, or psychological symptoms from the severe hypercortisolism. Bilateral adrenalectomy may alleviate this situation, but is sometimes a troublesome procedure in these severely ill patients.


METHODS
We have retrospectively investigated 8 patients with ectopic Cushing's syndrome who have undergone bilateral adrenalectomy at the University Hospital in Uppsala. In addition, another 5 patients who underwent bilateral adrenalectomy for other reasons (recurrent pituitary Mb Cushing or bilateral hyperplasia) were scrutinized for technical considerations. Indications, timing of surgery, and operative procedures were studied to identify signs that may support our approach to management in the future.


RESULTS
Curative surgery was not possible in any of the cases with ectopic Cushing's syndrome. Of the 13 operated patients, handport-assisted laparoscopic adrenalectomy was successfully performed bilaterally in 5 patients and unilaterally in combination with contralateral open surgery in 1 patient; conventional open surgery was performed on 7 patients, 3 of which were conversions from intitial handport-assisted procedures. Non-fatal complications occurred in 4 out of 10 patients.


CONCLUSIONS
We conclude that bilateral handport-assisted laparoscopic adrenalectomy is safe, and that all surgical techniques in these severely ill patients may be troublesome and technically demanding. Early surgical intervention may reduce the technical disadvantages. Moreover, bilateral adrenalectomy can substantially reduce the symptoms of Cushing's syndrome, although effects on mortality are not obvious.
Hellman
Per
P
Department of Surgery, University Hospital, Uppsala, SE-751 85, Sweden. per.hellman@surgsci.uu.se
Linder
Fredrik
F
Hennings
Joakim
J
Hessman
Ola
O
Eriksson
Barbro
B
Orlefors
Håkan
H
Akerström
Göran
G
D000315:Adrenalectomy / Q000379:methods*; D003480:Cushing Syndrome / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy; D008875:Middle Aged; D012189:Retrospective Studies