腹腔镜肾上腺切除术23例报告

目的：探讨腹腔镜在肾上腺手术中的应用。方法：２０００年２～１１月对２３例肾上腺疾病患者施行腹腔镜肾上腺切除术,其中经腹腔途径１６例,经后腹腔途径７例。结果 ：除１例中途改行开放手术后,余２２例均获得成功,手术时间：经腹腔途径的５０～２５０ｉｎ,平均１０４ｍｉｎ,经后腹腔途径者６５～１３０ｍｉｎ,平均９５ｍｉｎ,后有患者术中及术后均未输血,无明显并发症。结论：腹腔镜肾上腺切除术具有损伤小,术后恢复快和住院时间短等优点。具有良好的临床应用前景。     

Glucocorticoids induce glutamine synthetase in folliculostellate cells of rat pituitary glands in vivo and in vitro

Glutamine synthetase (GS) is a glucocorticoid-inducible enzyme that has a key role for glutamate metabolism in the central and peripheral nervous system. In this study GS activity was measured and the amount of immunoreactive GS (ir-GS) cells in the rat anterior pituitary gland was quantified as a function of age. In addition, the effects of GS inhibitors, glucocorticoid administration, and adrenalectomy on GS activity were examined. Some of the ir-GS cells were also immunoreactive for S100 protein (ir-S100) which is a known marker for folliculostellate cells (FS) in the anterior pituitary. FS cells expressing GS were first detected in 3-d-old rats, and this cell population, expressed as the immunostained cell area divided by a standard unit area, increased as a function of age. The percentages of FS cells also expressing GS were 0.2, 6.4, 25 and 74% at 3 d, 30 d, 60 d and 2 y of age, respectively. GS enzyme activity also increased in parallel with the increase of ir-GS cell population maturation. The subcutaneous injection of methionine sulphoximine, a GS and γ-glutamylcysteine synthetase inhibitor, reduced pituitary GS activity by 83%, but increased the population of ir-GS cells 3.5-fold in 30-d-old rats. Buthionine sulphoximine, a specific inhibitor of γ-glutamylcysteine synthetase, had little effect on GS activity or the ir-GS cell population. Neither methionine sulphoximine nor buthionine sulphoximine changed the population of ir-S100 protein cells (FS cells). Dexamethasone and hydrocortisone increased the population of ir-GS cells by 3.1 and 4.2-fold, respectively, within 12 h after administration. A significant increase of GS activity due to the injection of glucocorticoids was observed in the anterior pituitary, but not in the brain, retina or liver of immature rats. Adrenalectomy did not cause decrease of pituitary GS activity, and dexamethasone administration increased GS activity in both adrenalectomised and intact rats. In the monolayer culture of anterior pituitary cells, glucocorticoids increased GS activity by ×1.5, and methionine sulphoximine reduced the activity by over 94%. These results demonstrate that GS in folliculostellate cells is a glucocorticoid-inducible enzyme in vivo and in vitro, and that the age-dependent increase of GS activity is independent of endogenous adrenal glucocorticoids.     

腹腔镜下经腹腔径路肾上腺切除术治疗肾上腺疾病(附80例报告)

目的探讨腹腔镜下经腹腔径路肾上腺切除术治疗肾上腺疾病的适应证、手术技巧及优缺点。方法对80例肾上腺疾病患者行腹腔镜下经腹腔径路肾上腺切除术。结果80例手术均获成功,无1例中转开放手术;手术时间30～200(60±18)分钟;术中出血10～150(35±12)ml;住院时间3～12(6±2)天。结论腹腔镜经腹腔径路肾上腺切除术创伤小、出血少、并发症少,术后患者恢复快、住院时间短。肿瘤<10cm,无转移及局部重要脏器、大血管浸润和粘连的肾上腺肿瘤均适合行腹腔镜手术切除。     

原发性醛固酮增多症术后高血压未治愈的危险因素

目的: 分析原发性醛固酮增多症患者术后高血压未治愈的危险因素，评价ARS(aldosteronoma resolution score)对于原发性醛固酮增多症术后高血压状态的预测价值。方法: 选择2018年1月—2021年6月于北京大学人民医院行手术治疗的原发性醛固酮增多症患者的病例资料进行回顾性分析，根据术后高血压疾病状态，将患者分为高血压治愈组和高血压未治愈组，比较不同预后组间术前相关因素差异，分析原发性醛固酮增多症患者手术后高血压不缓解的危险因素，并评估ARS对于预测原发性醛固酮增多症术后高血压治愈的价值。结果: 共纳入112例患者，至少6个月术后随访后，大多数患者(94.6%)都达到术后高血压完全缓解或部分缓解。根据患者术后高血压状态，将患者分为高血压治愈组(51例)和高血压未治愈组(61例)。两组间患者年龄、体重指数、腰围、高血压病程、术前降压药物种类、术前收缩压、糖尿病病史、心脑血管疾病病史、血清肌酐、估算肾小球滤过率(estimated glomerular filtration rate，eGFR)、高密度脂蛋白胆固醇和甘油三酯差异有统计学意义。Logistic回归分析发现年龄(OR=1.111，95%CI：1.029~1.199)、腰围(OR=1.073，95%CI：1.013~1.137)、术前收缩压(OR=1.033，95%CI：1.008~1.060)和心脑血管疾病病史(OR=16.061，95%CI：1.312~196.612)是原发性醛固酮增多症患者术后高血压未治愈的危险因素，但性别并不是高血压未治愈的危险因素。高血压治愈组患者中位ARS为4分，而未治愈组为2分，在ARS4~5分患者中，术后高血压治愈率为76.5%，ARS的ROC曲线下面积(AUC)为0.743。结论: 心脑血管疾病病史是术后高血压不治愈的重要危险因素，ARS对于预测原发性醛固酮增多症术后高血压状态有一定价值，但仍需进一步研究设计出更适合中国人群的原发性醛固酮增多症手术结果的预测模型。     

Risk factors for postoperative hypotension after adrenalectomy for phaeochromocytoma: derivation of the PACS risk score

BackgroundDue to the risk of postoperative hypotension (PH), invasive monitoring is recommended for patients who undergo adrenalectomy for phaeochromocytoma. Due to high costs and limited availability of intensive care, our aim was to identify patients at low risk of PH who may not require invasive monitoring.MethodsData for patients who underwent adrenalectomy for phaeochromocytoma between 2012 and 2020 were retrospectively collected by nine UK centres, including patient demographics, intraoperative and postoperative haemodynamic parameters. Independent risk factors for PH were analysed and used to develop a clinical risk score.ResultsPH developed in 118 of 430 (27.4%) patients. On univariable analysis, female sex (p = 0.007), tumour size (p < 0.001), preoperative catecholamine level (p < 0.001), open surgery (p < 0.001) and epidural analgesia (p = 0.006) were identified as risk factors for PH. On multivariable analysis, female sex (OR 1.85, CI_95%, 1.09–3.13, p = 0.02), preoperative catecholamine level (OR: 3.11, CI_95%, 1.74–5.55, p < 0.001), open surgery (OR: 3.31, CI_95%, 1.57–6.97, p = 0.002) and preoperative mean arterial blood pressure (OR: 0.59, CI_95%, 0.48–1.02, p = 0.08) were independently associated with PH, and were incorporated into a clinical risk score (AUROC 0.69, C-statistic 0.69). The risk of PH was 25% and 68% in low and high risk patients, respectively.ConclusionThe derived risk score allows stratification of patients at risk of postoperative hypotension after adrenalectomy for phaeochromocytoma. Postoperatively, low risk patients may be managed on a surgical ward, whilst high risk patients should undergo invasive monitoring.     

Practice status and influencing factors of adrenalectomy in patients with Wilms tumor

To investigate the clinical practice status and factors that influence adrenalectomy along with the impact on prognosis in patients with Wilms Tumor (WT). We retrospectively reviewed the demographic, clinical, and follow-up data of patients with WT, including age, tumor side, tumor volume, tumor location within the kidney, stage, pathological type, tumor rupture, levels of adrenocorticotropin (ACTH), renin, aldosterone, and adrenal management, as well as outcomes. The primary outcomes are adrenal practice status and 5-year relapse-free survival (RFS). A total of 162 patients were enrolled in this study. Of these, 131 patients underwent radical nephrectomy with adrenalectomy, and adrenal invasion was only noted in three patients (2.3%). Adrenalectomy was associated with tumor volume and clinical stage (P < 0.05). Multivariable logistic regression analysis (OR = 3.982, P = 0.005) and ROC curve analysis (AUC = 0.708, P = 0.0003) revealed that a larger tumor volume independently increased the risk of adrenalectomy. Adrenalectomy was not significantly associated with tumor location, tumor rupture, or local recurrence (P > 0.05). In addition, the study median follow-up was 50.95 months. The 5-year RFS rates of patients with removed adrenal gland and preserved adrenal gland were 90.3% and 75.8%, respectively (P = 0.078). We followed up children more than 3 years after removal of the adrenal glands, and no children with reduced ACTH, aldosterone, or renin were found. Multivariate Cox regression analysis showed no significant difference on prognosis (P = 0.203), even after adjusting for clinical stage and pathological type. Finally, no evidence of adrenal insufficiency was reported during the follow-up examinations. Our data indicated that invasion of the ipsilateral adrenal gland is rare in WT. Preserving the ipsilateral adrenal gland was not associated with prognosis. Preoperative adequate assessment tumor volume and intraoperative detection of adrenal invasion were necessary to determine whether or not to perform an adrenal resection.