subtotal adrenalectomy

The surgical treatment of Cushing's syndrome caused by adrenal hyperplasia is still not completely consistent, which is directly related to the failure to make a definitive conclusion. According to the etiology of pituitary gland, it is considered that bilateral adrenal cortical proliferation is pituitary-dependent and secondary, and pituitary radiation therapy should be performed, including 60Co and deep X-ray irradiation. But the effect is quite disappointing, with a total effective rate between 20% and 50% (Richard, 1979). In the cortical hyperplasia of the previous adrenalectomy or subtotal resection, after 5 to 10 years of long-term follow-up, only a few patients showed pituitary tumors. In a group of autopsy patients, the rate of pituitary tumors was as high as 10%, but there was no endocrine symptoms of any cortical proliferation. Therefore, the presence or absence of a tumor based on the pituitary is not an indication for pituitary treatment, nor is it an absolute contraindication to adrenalectomy. In a group of pediatric Cushing's syndrome collected by Dennis and Styne, the rate of finding pituitary tumors was as high as 93% to 95% (1984). Therefore, in recent years, adrenal hyperplasia has been advocated for pituitary treatment, and transsphenoidal microadenomectomy has been performed with transsphenoidal microsurgery. It has received good results (Tyrrell, Styne), but such patients are in Cushing. After all, there are a few syndromes, and most adults still have adrenal cortical hyperplasia without pituitary tumors. Therefore, adrenalectomy is still the current method for treating cortical hyperplasia. Since Liddle divided Cushing's syndrome according to the etiology in the 1960s, the choice of surgical treatment has begun to have a clearer concept: all secondary to pituitary-dependent and ectopic dermal pro-melanoma. Cortical hyperplasia, called Cushing disease, should first treat pituitary tumors, remove ectopic dermal pro-growth tumors, and the hyperplastic adrenal glands do not process, waiting for self-recovery. Cortical hyperplasia, which is not pituitary-dependent and has no ectopic dermatomatoidoma, is called Cushing syndrome and undergoes adrenalectomy. Among the large group of cases reported in the literature at home and abroad, the latter are the main ones, and the efficacy of adrenalectomy reported by each family is also very encouraging. The data and experience collected in China have found that most patients who have undergone adrenalectomy due to hyperplasia have been clinically cured. The efficacy in foreign countries is similar in the early years, including some Cushing's disease in which no primary tumor has been found. Because the cause of cortical hyperplasia in the hypothalamus, pituitary, or other ectopic organs or the adrenal gland itself, due to the secretion of excess cortisol, cortisol and other hormones produce symptoms. After adrenalectomy, the surrounding effects are blocked, the pathogen is cleared, and various symptoms and signs gradually disappear. Since various corticosteroids necessary for life support have been chemically synthesized and have been widely used in the treatment of various clinical diseases, after surgical removal of the adrenal gland, sufficient replacement therapy can be performed to supplement the defects of insufficient physiological function. Therefore, for adrenal hyperplasia, adrenalectomy is a treatment with good efficacy, high safety, few complications, and extremely low mortality. It is considered the preferred procedure. Treatment of diseases: adrenal tumors Indication Adrenal subtotal resection is applicable to: 1. Clinical symptoms, signs typical, long course of disease, endocrine hormone test and drug test are all Cushing syndrome. 2. All kinds of image examinations are shown as bilateral adrenal gland enlargement, deformation, and pituitary tumor-free. 3. Other parts of the body and related organs have no suspicious ectopic dermal progesteroma. 4. Pituitary tumors are treated with radiation, and even after surgery, the symptoms can not be improved, and the secretion of cortisol can not be reduced to normal levels. Contraindications 1. Heart, brain, liver and kidney are accompanied by severe organic diseases. 2. Patients with Cushing syndrome in the late stage of malignant tumors. Preoperative preparation In order to enhance the tolerance of surgery and prevent the rapid in vivo cortisol deficiency that occurs after surgical removal of the gland, adequate preoperative preparation must be given. 1. Give cortisone 50 mg of acetic acid 1 to 2 days before surgery, 4 times a day. In the middle of the subtotal resection of the adrenal gland, intravenous hydroperdazole 100 ~ 200mg, in order to maintain the basic requirements, and continue to the entire surgical procedure. 2. Supply sufficient calories or supplement enough protein by vein. 3. Due to the different degree of sodium retention in the body, it is generally unnecessary to replenish the crystal solution before surgery. If the heart is overloaded, a permeable diuretic can be given as appropriate. Surgical procedure Surgery can be completed in one phase, or it can be performed on both sides. When the first stage of bilateral surgery is completed, the upper abdominal transverse incision or the bilateral dorsal incision can be used. Domestic use of abdominal incision is the majority, intraoperative exploration of the possibility of extra-adrenal tumors in the abdominal cavity or pelvic cavity. If the stage is performed, the upper abdominal oblique incision can be used. As for which side to do first, it depends on the morphology of the adrenal gland. Where the hyperplasia volume is large, suspicious small adenoma or nodular proliferative side, the side surgery is performed first, and the pathological diagnosis is hyperplasia, and the other side is postponed. 1. Expose the adrenal gland into the layer by the selected incision to reveal the adrenal gland. 2. Subtotal resection of the adrenal adrenal gland should include a full cut on one side and 3/4 to 1/3 of the gland on the other side, ie 85% to 90% of the total amount of glands on both sides. , the minimum can not be less than 80%. On the side of the whole side of the section, if there is no special indication, in the first stage of surgery, the left side is performed first, and the middle and upper 3/4 glands are removed, and only the lower 1/4 of the adrenal gland with the adrenal vein is retained. The glandular and sub-adrenal inferior arteries were also preserved at the same time. Because this part of the adrenal gland is low in anatomical position, blood transport is easy to retain, and the reoperation is easy to detect and resected when the symptoms recur. After the middle and upper parts of the adrenal gland were removed, the color of the retained part was observed. If it was bright red, the blood circulation was judged to be good, and the function was maintained after the operation. The wound can have a small amount of bleeding, which can be used to stop bleeding, without suturing and ligation, and the glandular tissue is destroyed. The surgical department does not have to be drained. The peritoneum was sutured and the internal organs were repositioned. The left adrenal gland was removed and preserved, and the right adrenal gland was explored and removed. The right adrenal vein is short and directly into the inferior vena cava. The liver and gallbladder should be pulled outward and upward. After opening, the peritoneum will pull the duodenum inward and downward, and the upper pole of the kidney will be freed and pulled down. Behind the vena cava, the outer edge of the vena cava is turned up to expose the junction of the entire adrenal gland and its veins and vena cava. Grab the upper part of the gland with a non-invasive tissue forceps and pull up and up. The separation revealed the adrenal vein, and after the silk thread was sewed once, the adrenal vein was cut off and the right adrenal gland was completely removed. If there is no obvious oozing in the surgical site, the drainage may be omitted, the peritoneum is closed, the viscera is reset, and the abdominal incision is sutured in layers.