Evaluation of bilateral laparoscopic adrenalectomy in adrenocorticotropic hormone-dependent Cushing's syndrome

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Abstract

BACKGROUND

Although laparoscopic techniques are now widely used during adrenal surgery, the role of bilateral laparoscopic adrenalectomy remains poorly defined.

OBJECTIVE

To evaluate the efficacy and safety of bilateral laparoscopic adrenalectomy in the treatment of adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome.

DESIGN AND INTERVENTION

This was a retrospective, observational study of patients with ACTH-dependent Cushing's syndrome who underwent bilateral laparoscopic adrenalectomy at the Mayo Clinic in Rochester, MN, between January 1995 and October 2006. A hand-assisted, lateral transabdominal approach was used in all cases; however, a subset of patients required conversion to open adrenalectomy. Medical records were reviewed through May 2007 to assess perioperative outcomes.

OUTCOME MEASURES

The main outcome measures were perioperative morbidity and mortality, biochemical parameters, and symptom response.

RESULTS

A total of 26 patients with ectopic ACTH syndrome and 42 patients with pituitary-dependent Cushing's disease not cured by pituitary surgery underwent bilateral laparoscopic adrenalectomy. The mean age was 45.2 years, the mean BMI was 32.7 kg/m2, and 69% were women. A total of 45 patients had previously undergone pituitary surgery and 23 had received medical therapy. The mean duration of symptoms related to cortisol excess was 28 months. The median preoperative 24 h urine free cortisol level was 16,714.8 nmol/day in patients with ectopic ACTH syndrome and 748.2 nmol/day in patients with Cushing's disease. The mean operative time was 264.1 min and nine of the patients required conversion to open adrenalectomy. The mean BMI of patients who required conversion was 42.3 kg/m2 (versus 31.2 kg/m2 for patients not requiring conversion) and excess visceral adiposity affecting tumor visualization was cited as the reason for conversion in six cases (67%). Three patients experienced intraoperative complications (two in the bi lateral laparoscopic adrenalectomy group) but none required blood transfusion. Postoperative complications occurred in eight patients in the bilateral laparoscopic adrenalectomy group (14%) and three patients in the open adrenaletomy group (33%). The median hospital stay was 5.5 days after the laparoscopic procedure and 11.9 days after open adrenalectomy (P <0.001). A total of five patients died in the bilateral laparoscopic adrenalectomy group, four of whom were in the ectopic ACTH group. Two patients with Cushing's disease who underwent conversion to open surgery also died. None of the deaths was a direct consequence of the surgical procedure. Follow- up data was available for 60 patients. Hypertension resolved in 21 of 33 patients, diabetes mellitus resolved in 4 of 14 patients, and obesity resolved in 9 of 26 patients. Marked improvements in physical appearance, muscle weakness, hirsutism, menstrual irregularity, and emotional disturbances were also reported. Hypercortisolism resolved in all 43 patients for whom data was available.

CONCLUSION

Bilateral laparoscopic adrenalectomy was a safe and effective treatment option for patients with ACTH-dependent Cushing's syndrome.

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