ACTH非依赖性双侧肾上腺皮质增生所致库欣综合征的外科治疗

目的探讨促肾上腺皮质激素（adrenocorticotropic hormone,ACTH）非依赖性双侧肾上腺皮质增生的临床特点与诊治经验。方法回顾性分析1980年1月至2011年5月诊治21例ACTH非依赖性双侧肾上腺皮质增生患者资料,包括8例ACTH非依赖性肾上腺皮质大结节样增生（AIMAH）和13例原发性色素性肾上腺结节增生（PPNAD）。男6例,女15例。年龄12～58岁,平均34.3岁。临床表现为典型库欣综合征（Cushings syndrome,CS）者18例,表现为体重增加、高血压等非特异性症状者3例。CT检查提示双侧肾上腺结节样增生改变者14例,2例提示左肾上腺占位;5例肾上腺未见明显异常。双侧肾上腺全切3例;双侧肾上腺次全切除术2例,为初次手术行单侧肾上腺切除,术后库欣症状复发,再次行对侧肾上腺次全切除术;单侧肾上腺切除16例。结果手术标本病理结果报告8例为AIMAH,13例为PPNAD。随访16～120个月,CS症状消失。16例单侧肾上腺切除术后血尿皮质醇、血钾、血糖等均恢复正常,对侧肾上腺无明显增大;3例行双侧肾上腺全切者术后醋酸可的松终身替代治疗,无尼尔森综合征发生;2例肾上腺次全切除者系一侧肾上腺全切术后随访中库欣症状复发,行对侧肾上腺次全切术后症状完全缓解。结论 AIMAH和PPNAD均为库欣综合征中罕见的特殊类型,首次手术可行单侧肾上腺切除术缓解症状。术后应密切随访,对症状不缓解或复发者可行对侧肾上腺切除或次全切除。     

肾上腺手术在治疗皮质醇增多症中的疗效评价(附90例报告)

目的：提高皮质醇增多症的治疗水平。方法：总结90例皮质醇增多症的临床资料以及随访情况。90例患者均有库欣综合征的临床表现,内分泌检查提示高皮质醇状态。71例患者影像学检查发现肾上腺肿块,其中左侧32例,右侧34例;双侧肾上腺肿块5例。19例患者显示双侧肾上腺结节样增生。结果：90例患者均行肾上腺手术,其中60例行肾上腺肿块切除加同侧肾上腺部分切除;6例行肾上腺肿块切除加同侧肾上腺全切除;4例行同时行双侧肾上腺全切除术,6例行先后双侧肾上腺全切除术;11例行单侧肾上腺全切除术;3例行先后双侧肾上腺次全切除。病理显示6例原发性色素性皮质结节状肾上腺皮质增生（PPNAD）;5例大结节样肾上腺皮质增生（AIMAH）;57例肾上腺皮质腺瘤;5例肾上腺皮质癌;17例肾上腺皮质结节样增生,其中7例考虑异位ACTH综合征所致。结论：肾上腺皮质腺瘤切除术效果最好,库欣症状改善最显著。迁延难愈的库欣病,单侧肾上腺全切除,在短期内能缓解代谢症状。分时分侧行肾上腺全切除术,对治疗AIMAH和PPNAD更安全、稳定;根据异位ACTH综合征患者症状和病程,可同时行双侧肾上腺全切除或单侧肾上腺全切除。     

原发性色素沉着性结节性肾上腺皮质病9例诊治分析

目的:探索原发性色素沉着性结节性肾上腺皮质病(PPNAD)的诊治方案。方法:总结我院2010~2016年9例PPNAD患者的临床资料,包括其临床症状、体征,实验室检查、影像学检查、随访资料等,探讨该种疾病的诊断和治疗。结果:9例患者中8例具备典型库欣综合征体貌,1例患者仅表现为高血压。9例患者均具备促肾上腺皮质激素(ACTH)非依赖性特征,表现为ACTH5pg/ml或大剂量地塞米松抑制试验尿游离皮质醇(UFC)未被抑制。影像学可表现为肾上腺基本正常、双侧肾上腺增粗或小结节改变、单侧肾上腺结节或肿物。7例患者行腹腔镜单侧肾上腺切除,术后随访2例症状复发,遂行腹腔镜对侧肾上腺次全切除术。2例仅表现为单侧肾上腺结节或肿物患者,行腹腔镜肾上腺肿物切除术,术后恢复良好。结论:PPNAD为罕见ACTH非依赖性库欣综合征类型,其可依据高皮质醇血症、ACTH非依赖性、影像学检查等做出诊断,明确诊断需术后病理确定。治疗方式可根据患者的病情程度及术后恢复情况以及实验室指标等进行个体化制定。     

肾上腺大结节增生的外科治疗

目的探讨肾上腺大结节增生(AIMAH)的临床特点与诊治方法。方法总结17例　AIMAH　患者的临床表现、内分泌检查、影像与病理特点以及治疗和预后。男9例,女8例,年龄15～66岁,平均42岁,双侧15例,左右侧各1例。有典型库欣综合征临床表现者10例,另7例表现为高血压或糖尿病症状;实验室检查显示　ACTH<2.2 pmol/L,血皮质醇325.1～1876.8 nmol/L,24 h　尿游离皮质醇71.7～2332.2 nmol/24 h,皮质醇分泌节律消失,大、小剂量地塞米松抑制试验不被抑制12例。CT或MRI显示双侧或单侧不规则结节或团块样增大,直径最大5 cm。结果16例行手术治疗,病理报告为肾上腺皮质结节样或腺瘤样增生。其中行单侧肾上腺切除术10例,双侧肾上腺全切除术4例,双侧肾上腺次全切除术2例。双侧肾上腺全切及次全切除6例症状完全缓解,未复发,未发生尼尔森综合征;单侧肾上腺切除者,库欣症状缓解4例,1例未缓解;5例亚临床AIM- AH,术后血压均降至正常,但糖尿病症状未缓解。结论AIMAH作为皮质醇症一种独立的临床亚型,具有自主性皮质醇分泌、肾上腺多发大结节、双侧肾上腺切除术后不发生尼尔森综合征等临床特征。单侧肾上腺切除可缓解多数AIMAH症状,对于症状不缓解或复发者可行双侧肾上腺次全切或全切。     

库欣综合征208例

目的：提高库欣综合征的诊治水平。方法：分析108例促肾上腺皮质激素(ACTH)非依赖性库欣综合征和100例ACTH依赖性库欣综合征患者的临床资料、诊断和手术效果。结果：ACTH非依赖性和依赖性库欣综合征均有库欣综合征的体征和血或尿皮质醇升高；腺瘤型库欣综合征主要显示大剂量地塞米松抑制试验(HDDST)不抑制和CT发现较小的肾上腺占位病变，99例行腺瘤切除术获治愈；肾上腺皮质癌主要表现瘤体直径＞6cm及DHEAS升高，预后差；大结节样肾上腺皮质增生(AIMAH)的CT主要表现双侧肾上腺大结样增生，行双侧肾上腺切除可获治愈；库欣病可被HDDST抑制，CT显示双侧肾上腺增生或无变化，对69例垂体无阳性发现的患者行一侧肾上腺全切除加另一侧肾上腺次全切除症状缓解，20例轻型行一例肾上腺切除加垂体放疗能获长期症状缓解，肾上腺全切分期进行较安全；异位ACTH综合征主要表现ACTH明显升高及发现分泌ACTH肿瘤。结论：对库欣综合征应行鉴别诊断，对不同类型库欣综合征采用适当手术方法可获较满意的手术效果。     

促肾上腺皮质激素非依赖性肾上腺皮质大结节样增生的外科治疗

目的 探讨促肾上腺皮质激素(adrenocorticotropic hormone,ACTH)非依赖性肾上腺皮质大结节样增生(ACTH independent macronodular adrenal hyperplasia,AIMAH)的诊治经验. 方法 回顾性分析1972年8月至2010年7月诊治14例AIMAH患者资料.男5例,女9例.年龄26～58岁,平均45岁.临床表现为典型库欣综合征( Cushing syndrome,CS)者10例,表现为体质量增加、高血压或高血糖等非特异性症状者4例.生化检查示皮质醇分泌昼夜节律消失,大、小剂量地塞米松抑制试验均不被抑制.CT检查示双侧肾上腺弥漫性增大伴多发结节.14例均行开放手术治疗,其中单侧肾上腺切除5例;一侧肾上腺全切,对侧肾上腺次全切除6例;双侧肾上腺同时切除3例. 结果 14例病理诊断均为肾上腺大结节样或腺瘤样增生.随访12～120个月,平均69个月,CS症状消失.5例单侧肾上腺切除者术后血、尿皮质醇值恢复正常,对侧肾上腺无明显增大.3例双侧肾上腺切除患者中,1例术后7d发生肾上腺皮质功能危象而死亡,2例术后出现皮质功能减退症状,给予糖皮质激素替代治疗.其他患者病情稳定,无Nelson综合征出现. 结论 AIMAH具有独特的临床症状特点,是CS的一种独立罕见类型.首次手术多行单侧肾上腺切除术,可获较长时间的症状缓解.术后应密切随访患者的皮质醇水平、症状和体征,对症状不缓解或复发者可行对侧肾上腺切除或次全切除.     

ACTH非依赖性肾上腺皮质大结节增生症的诊断与手术处理

目的 总结促肾上腺皮质激素（adrenocorticotrop hichormone，ACTH）非依赖性肾上腺皮质大结节增生症（ACTH independent acronodular drenal yperplasia，AIMAH）的诊治经验。方法 回顾性分析5例AIMAH患者的临床资料。结果 5例患者均具有库欣综合征的临床和生化特点，小剂量、大剂量地塞米松抑制试验均不被抑制，血浆ACTH水平低。4例患者行CT检查示双侧肾上腺大结节样增生改变，所有患者均经病理检查证实为双侧肾上腺大结节样或腺瘤样增生。例1、例2行单侧肾上腺切除后，分别于症状缓解3年和5年后复发，行对侧肾上腺全切除后治愈；例3分期行双侧肾上腺切除后治愈；例4、例5行单侧肾上腺切除后，前者5年症状持续缓解，后者仍在随访中。术后无Nelson综合征。结论 IMAH具有独特的内分泌、CT影像和病理学特点，是一种独立的库欣综合征病因，确诊主要依据病理检查。单侧肾上腺切除可获较长时间的症状缓解，应坚持随访患者的皮质醇水平和症状体征，如有复发可行对侧肾上腺切除。     

原发性色素性结节状肾上腺皮质病(附4例报告)

目的：探讨原发性色素性结节状肾上腺皮质病(PPNAD)的临床表现和诊断治疗方法。方法：总结4例PPNAD的临床资料，4例均有库欣综合征的临床表现，内分泌检查结果提示为功能自主性肾上腺皮质肿瘤，但影像学检查并未发现肾上腺肿瘤。结果：4例患者均行单侧肾上腺全切除术，手术标本均表现为肾上腺大小正常或轻度增大，外表和切面上见黑色或深褐色小结节，结节间皮质萎缩，光镜下见组成结节的细胞体积大，脑质嗜伊红染色、颗粒状，部分细胞脑质中的颗粒状色素颗粒具脂褐质染色特征。结论：PPNAD在青少年中是一种引起库欣综合征的罕见病因，双侧肾上腺切除术是治愈本病的方法。     

腹腔镜单侧肾上腺切除术治疗8例原发性双侧肾上腺大结节样增生患者的疗效随访

目的探讨行腹腔镜单侧肾上腺切除术的8例原发性双侧肾上腺大结节样增生(PBMAH)患者的治疗效果。方法回顾性分析香港大学深圳医院2015年1月至2020年12月收治的8例确诊为PBMAH患者的临床资料。其中男性5例,女性3例,平均年龄50(34～61)岁。定性诊断有4例为促肾上腺皮质激素(ACTH)非依赖性库欣综合征(CS),另外4例为ACTH非依赖性亚临床库欣综合征(SCS)。完善内分泌、生物化学、病理及影像学检查。所有患者术前均分别行多学科讨论,手术先切除增生明显或者增生体积较大的一侧肾上腺,围手术期和术后均予以激素替代治疗。术后定期随访患者血常规、肝功能、肾功能、血钾、肾上腺相关激素水平与功能试验、垂体及肾上腺MRI/CT等。结果 8例均行后腹腔途径的腹腔镜单侧肾上腺切除术治疗,右侧5例,左侧3例,手术顺利,均无并发症发生。术前肾上腺增强CT提示7例患者双侧肾上腺弥漫性增大且伴有多发结节,1例患者6年前切除左侧肾上腺故表现为右侧肾上腺弥漫性增大伴结节。病理结果提示肾上腺皮质结节状增生5例,肾上腺皮质腺瘤3例。平均随访30.5个月,2例典型CS临床表现和体征的患者,症状得到缓解。8例患者术后的血压和体重指数(BMI)较术前有明显改善,24h的尿皮质醇水平及血钾均正常,双侧肾上腺均被切除的1例患者术后行终身激素替代治疗。结论腹腔镜单侧肾上腺切除术治疗PBMAH安全有效,能改善患者的CS临床症状,推荐为临床一线治疗方案。若行双侧肾上腺全切术,术后需要终身激素替代治疗。     

促肾上腺皮质激素非依赖性肾上腺皮质大结节样增生的治疗

目的 提高促肾上腺皮质激素( adrenocorticotropic hormone,ACTH)非依赖性肾上腺皮质大结节样增生( ACTH-independent macronodular adrenal hyperplasia,AIMAH)患者的治疗效果. 方法 回顾性分析2000至2011年收治并确诊的17例AIMAH患者的临床资料,包括亚临床AIMAH3例、临床AIMAH 10例以及高危AIMAH患者4例.影像学均表现为双侧肾上腺明显增大,伴多个大小不等结节,呈典型“生姜样”改变.3例亚临床AIMAH患者ACTH水平降低,血、尿皮质醇正常或轻度升高,l mg过夜地塞米松抑制试验被抑制,无典型库欣综合征(Cushing syndrome,CS),仪存在高血压、糖尿病等非特异性症状.临床AIMAH以及高危AIMAH患者表现为CS症状,血、尿皮质醇升高,血浆ACTH降低,皮质醇昼夜分泌节律消失,大、小剂最地塞米松抑制试验均不被抑制.高危AIMAH患者表现为骨质疏松2例,肝功能不全2例,心肺功能不全3例,严重高血压4例.亚临床AIMAH患者行对症治疗,临床AIMAH患者行手术治疗,高危AlMAH患者行酮康唑(800 mg/d)加手术治疗. 结果 3例亚临床AIMAH患者经对症治疗,血压、血糖平稳出院,随访3个月～3年,内分泌指标检查正常.7例临床AIMAH患者行单侧肾上腺肿块加同侧肾上腺部分或者全部切除,6～9个月后CS症状完全消失.2例临床AIMAH患者同时行双侧肾上腺全切除术,其中1例因肾上腺皮质功能危象而死亡,另1例出现肾上腺皮质功能减退症状,给予糖皮质激素替代治疗,随访5年,生化指标显示正常,无Nelson综合征.l例临床AIMAH患者先后行单侧肾上腺全切术,随访10年,常规补充糖皮质激素,无Nelson综合征.4例高危AIMAH患者经酮康唑治疗后行右侧肾上腺全切术,术后继续服用酮康唑(400 mg/d或800 mg/d),1～2个月后血、尿皮质醇恢复正常,随访1～3年,生化指标正常. 结论 不同亚型AIMAH 应采取不同治疗方法.对于亚临床AIMAH,重点在于对症治疗,随访期间宜定期进行肾上腺影像学以及内分泌功能检查,一日进展为临床AIMAH,首选单侧肾上腺全切术.高危AIMAH应先通过药物抑制皮质醇合成,患者能够耐受于术后尽快切除一侧肾上腺.对于临床AIMAH,单侧肾上腺切除是一种有效的治疗方法.     

The Role of Unilateral Adrenalectomy in Corticotropin-Independent Bilateral Adrenocortical Hyperplasias

Background

The objective of the present study was twofold: to demonstrate our experience with unilateral adrenalectomy in the treatment of adrenocorticotropic hormone (ACTH)-independent Cushing syndrome (CS) caused by bilateral adrenocortical hyperplasias, and to evaluate the long-term results as evidenced by the main laboratory and clinical findings.

Methods

From February 2000 to August 2009, unilateral adrenalectomy was performed on 27 patients with ACTH-independent CS and bilateral adrenocortical hyperplasias, including 14 patients with ACTH-independent macronodular adrenal hyperplasia (AIMAH) and 13 patients with primary pigmented nodular adrenocortical disease (PPNAD). Signs and symptoms of CS, endocrine examinations, and radiographic imaging were evaluated preoperatively and postoperatively.

Results

At a median follow-up of 69 months (range: 23–120 months) for AIMAH and 47 months (range: 16–113 months) for PPNAD, 25 patients were cured by unilateral adrenalectomy. Serum cortisol level, daily urinary free cortisol (UFC), and plasma ACTH regained the normal range in both AIMAH and PPNAD patients at monthly follow-up visits; the circadian serum cortisol rhythm returned to normal, and a normal responsiveness to overnight low-dose dexamethasone administration (LDDST) became obvious. Both systolic and diastolic blood pressure (BP) levels were significantly reduced: 85 % of patients recovered normal BP levels, and the remaining patients need antihypertensive drugs, but at a reduced dose. No surgery-related morbidity occurred, and there was no sign of further enlargement of the residual adrenal gland after successful unilateral adrenalectomy. One patient with PPNAD and another patient with AIMAH with similar weights and sizes of the bilateral adrenals needed contralateral adrenalectomy.

Conclusions

Unilateral adrenalectomy may be the suitable treatment for selected patients with AIMAH and PPNAD. It can achieve long-term remission of CS and improve glycemic control and BP values.     

The Clinical Conundrum of Corticotropin-independent Autonomous Cortisol Secretion in Patients with Bilateral Adrenal Masses

Background Management of patients with bilateral adrenal masses and corticotropin (ACTH)-independent Cushing syndrome (CS) or subclinical CS is problematic. We report our experience with adrenal venous sampling (AVS) in the evaluation of 10 patients with bilateral masses who had ACTH-independent CS or subclinical CS. Patients and Methods Ten patients (9 women, 1 man, mean age 56.4 years) with bilateral adrenal masses and ACTH-independent CS (n = 3) or subclinical CS (n = 7) underwent AVS. Autonomous cortisol secretion was documented in all cases with suppressed serum ACTH concentrations and lack of cortisol suppression with dexamethasone administration. Adrenal venous sampling was performed on the second day of dexamethasone administration. Cortisol and epinephrine levels were measured from each adrenal vein (AV) and from a peripheral vein (PV). Results Mean (± SD) maximal diameter of the adrenal masses on computed tomography was 3.3 ± 1.3 cm (range: 1.2–6.0 cm). Successful catheterization was confirmed with AV:PV epinephrine gradients. A cortisol AV:PV gradient >6.5 was consistent with a cortisol-secreting adenoma in 11 adrenal glands; 5 patients had clinically important bilateral autonomous cortisol hypersecretion, 3 had bilateral cortisol-secreting adenomas, and 2 had ACTH-independent macronodular adrenal hyperplasia. Adrenal venous sampling-guided adrenalectomy was completed in all 10 patients—2 patients had total bilateral adrenalectomy and 2 others had subtotal bilateral adrenalectomy. During a mean follow-up of 36.1 months (range: 0.7–123 months), CS or clinically important cortisol secretory autonomy did not recur. Conclusions Adrenal venous sampling contributed to the localization of autonomous hypercortisolism in the setting of ACTH-independent CS or subclinical CS in patients with bilateral adrenal masses. Presented at the Annual Meeting of the International Association of Endocrine Surgeons, Montreal, Canada, August 26–29, 2007. J. A. Carney is an Emeritus Member of the Department of Laboratory Medicine and Pathology.     

肾上腺小肿瘤的后腹腔镜手术治疗体会

目的探讨肾上腺小肿瘤的后腹腔镜手术治疗体会。方法回顾性分析2005年9月至2008年12月我院施行的389例后腹腔镜。肾上腺切除术的临床资料,其中肾上腺小肿瘤96例,分成最初40例组和后期56例组。术前所有病例行CT形态定位检查。所有手术均经后腹膜入路完成。结果96例肾上腺肿瘤平均大小0．7cm（0．5～1．0cm）,其中原醛76例（单侧腺瘤69例、单侧皮质增生7例）,无功能性腺瘤11例,库欣综合症3例,嗜铬细胞瘤2例,黑素瘤1例,髓样脂肪瘤1例,转移癌l例。4例（3．5％）中转开放手术。最初40例组的手术时间明显长于随后的56例组（P〈0．01）,两组术中出血量无明显差异。结论尽管腹腔镜技术是治疗良性肾上腺肿瘤的金标准,但对于肾上腺小肿瘤,腹腔镜手术有一定难度,术中先游离寻找靠近后腹膜的。肾上腺内侧支、充分游离及探查整个肾上腺组织是手术成功的关键。     

Selective use of steroid replacement after adrenalectomy: lessons from 331 consecutive cases

HYPOTHESIS: Only selected patients require steroid replacement therapy following adrenalectomy. DESIGN: Retrospective review. SETTINGS: University tertiary care center and veterans' hospital. PATIENTS: A total of 331 patients who underwent adrenalectomy by 1 surgeon (Q.-Y.D.) between April 1, 1993, and August 31, 2005. INTERVENTIONS: Laparoscopic, open, and hand-assisted adrenalectomy. Steroid replacement therapy was administered using a standardized hydrocortisone taper protocol. MAIN OUTCOME MEASURES: Indications for adrenalectomy, operative approach, requirement for postoperative steroid replacement, and episodes of acute adrenocortical insufficiency. RESULTS: Of the 331 adrenalectomies, 304 were laparoscopic, 23 were open, and 4 were hand assisted. There were 299 unilateral adrenalectomies and 32 bilateral adrenalectomies performed. Fifty-seven (17%) of the 331 patients required steroid replacement after adrenalectomy. Of the 57 patients requiring steroid replacement, 52 had Cushing syndrome and 5 had bilateral pheochromocytomas. The 52 patients with Cushing syndrome included 16 with pituitary tumors who had failed pituitary resection and/or medical therapy, 14 with unilateral adrenal adenomas, 9 with ectopic corticotropin-secreting tumors who had failed resection and/or medical therapy, 7 with incidentalomas and subclinical Cushing syndrome, 4 with macronodular hyperplasia, and 2 with adrenocortical carcinoma. No patients undergoing unilateral adrenalectomy for non-Cushing adrenal disease required steroid replacement. Four (7%) of the 57 patients receiving steroid replacement had episodes of acute adrenocortical insufficiency following operation and required increased steroid supplementation. There were no cases of acute adrenocortical insufficiency in the 274 patients who did not receive steroid replacement. CONCLUSIONS: Steroid replacement therapy after adrenalectomy should be reserved for patients with Cushing syndrome (overt or subclinical) and patients undergoing bilateral adrenalectomy. Patients undergoing adrenalectomy for unilateral non-Cushing adrenal tumors do not require postoperative steroid replacement.     

Laparoscopic simultaneous bilateral adrenalectomy: assessment of feasibility and potential indications

Objective: To report a single‐center experience with laparoscopic simultaneous bilateral adrenalectomy (LSBA) and to evaluate its safety, surgical outcomes, and potential indications of the procedure. Methods: A total of 21 patients underwent LSBA between 2000 and 2010 at our institution. Four patients had bilateral Cushing's syndrome (CS), two had bilateral pheochromocytoma, and one had a bilateral metastatic tumor. Eleven patients had unilateral or bilateral aldosterone‐producing adenoma (APA), associated with CS or subclinical CS. Three patients had unilateral APA with contralateral non‐functioning adenoma. Partial adrenalectomy was performed first by using with four ports. After the excision of one gland, the contralateral gland was removed after repositioning of the patient. Results: LSBA was completed in all 21 patients without major complications. Mean operative time was 329.7 min and the estimated blood loss was 94.1 mL. Mean tumor size was 21.8 mm. Of the 16 patients receiving an adrenal‐sparing procedure, nine of 11 discontinued glucocorticoid replacement after 2 years. The remaining five patients receiving bilateral total adrenalectomy required 0.5–0.75 mg of dexamethasone permanently. No open conversions, no deaths or no adrenal insufficiencies were encountered. Conclusions: LSBA represents a safe and viable treatment option for selected patients with bilateral adrenal disease.     

后腹腔镜同期手术治疗双侧肾、肾上腺疾病的临床研究

目的：探讨后腹腔镜同期手术治疗双侧肾、肾上腺病变的方法和经验。方法：回顾性分析同时发现的需手术治疗的57例双侧肾、肾上腺病变患者,均采用了后腹腔镜同期手术。其中包括双侧肾囊肿去顶减压术21例,一侧肾囊肿去顶减压、对侧肾癌肾部分切除8例,一侧肾囊肿去顶减压、对侧肾上腺手术12例,双侧肾上腺肿瘤同期手术10例,一侧肾上腺手术、对侧肾癌肾部分切除6例。术中均采用了自行研制的实用腹腔后腔扩张器扩张后腹膜腔。结果：57例患者手术全部一次成功。手术时间60-260min,平均140min;术中出血量约20～300ml,平均80ml;术后肠蠕动恢复时间16-32h,平均22h;术后住院时间4～12d,平均7d。术中无大出血、休克、周围脏器损伤等意外发生,患者术后恢复顺利。结论：后腹腔镜同期手术避免了患者二次手术痛苦,缩短了住院时间,节约了医疗费用,在后腹腔镜技术成熟的基础上,选择性开展是安全、有效和可行的。     

Functional Results After Endoscopic Subtotal Cortical-Sparing Adrenalectomy

Purpose: We examined the required amount of residual adrenal tissue and whether an intact adrenal vein are necessary to achieve sufficient function after endoscopic subtotal adrenalectomy. Method: Endoscopic subtotal adrenalectomy was performed in 14 patients. Two patients underwent unilateral subtotal and contralateral total adrenalectomy and another two patients underwent unilateral subtotal adrenalectomy after contralateral total adrenalectomy several years earlier. We analyzed the postoperative serum levels of cortisol and adrenocorticotropic hormone (ACTH). Patients with bilateral tumors underwent an ACTH test. Results: We had to cut the main adrenal vein in ten patients, and less than one third of the adrenal gland was left in situ in four patients. Subtotal adrenalectomy was performed unilaterally in two patients with bilateral tumors. One third of the adrenal gland was preserved in these patients, and also in the two patients with unilateral subtotal adrenalectomy after previous contralateral total adrenalectomy. The postoperative ACTH test confirmed satisfactory adrenocortical function. During the follow-up period of about 24 months no recurrent tumors have been found. Conclusion: Subtotal cortical-sparing adrenalectomy can be successfully performed laparoscopically. The venous drainage of the main adrenal vein does not seem to be crucial for sufficient adrenocortical function. We estimate that leaving about one third of the entire adrenal gland as remnant adrenal tissue will result in sufficient function. Received: March 25, 2002 / Accepted: September 3, 2002 Reprint requests to: M. Brauckhoff