后腹腔镜肾上腺切除术后患者高血压改善情况的相关因素分析

目的对于功能性肾上腺肿瘤,通过切除或部分切除患侧肾上腺,从而达到治疗的效果。与此相比,对于那些无功能的肾上腺肿瘤合并高血压的患者,行手术治疗是否有效和其手术效果值得探讨。方法纳入2006年1月至2011年12月复旦大学附属华山医院收治的CT考虑为良性肿瘤并行腹腔镜肾上腺切除术的无功能腺瘤和原发性醛固酮增多症伴高血压患者153例,按术前诊断不同进行分组,分析比较各组患者临床资料,探讨术后高血压疗效的相关因素分析。结果 153例高血压中102例患者血压恢复正常水平,29例患者高血压得到改善,共131例患者术后高血压有效改善。131例患者中原发性醛固酮增多症患者占66例,无功能腺瘤患者占46例。21例患者术后高血压无改善,其中原发性醛固酮增多症患者占14例,无功能腺瘤患者占7例。单因素分析发现原发性醛固酮增多症和无功能腺瘤患者术后高血压无效组的高血压病程6年人数比例比术后高血压有效组高(P0.05),而年龄、性别、BMI和术前服用降压药物3种无统计学差异。多因素分析发现高血压发病时间是否6年(P=0.001,95%CI9.447~6403.658)为原发性醛固酮增多症和无功能腺瘤患者术后高血压无效的独立危险因素,而性别、年龄、术前服用降压药物3种和术前是否伴有低血钾与患者术后高血压是否改善没有统计学意义。结论手术治疗原发性醛固酮增多症和无功能腺瘤术后高血压治愈率分别为82.5%和86.79%。对于偶然发现的无功能肾上腺瘤,合并高血压发病时间6年时可以考虑手术治疗。而醛固酮增多症合并高血压发病时间6年的患者,术前应告知患者术后高血压有不改善可能。     

腹腔镜行肾上腺部分切除术与全切术治疗肾上腺原醛瘤的比较:附235例报告

目的 探讨肾上腺部分切除术与全切术治疗腺瘤型原发性醛固酮增多症的效果.方法 回顾性分析235例腺瘤型原发性醛固酮增多症患者的临床资料.85例行后腹腔镜下肾上腺全切,150例行后腹腔镜下肾上腺部分切除.结果 行肾上腺部分切除组手术时间48.0±15.0 min;术中失血量25.0±10.0 ml;拔引流管时间2.2±1.0 d;术后住院天数7.0±2.5 d;病灶大小15.5±4.5 mm.行肾上腺全切组手术时间37.0±12.0 min;术中失血量23.0±9.0ml;拔引流管时间2.4±1.2 d;术后住院天数6.8±2.0 d;病灶大小16.0±3.0mm.部分切除组和全切组术中失血量、拔引流管时间、住院时间及病灶大小差异无统计学意义(P＞0.05).部分切除组手术时间长于全切组(P＜0.05).随访6个月～2年,所有患者血钾恢复正常,198例血压恢复正常.结论 对于单发醛固酮腺瘤的患者,行肾上腺部分切除术治疗腺瘤型原发性醛固酮增多症安全、有效,而且保留了部分有功能的肾上腺组织,优于肾上腺全切术.     

腹腔镜肾上腺全切除术与部分切除术治疗原发性醛固酮增多症的疗效比较

目的:探讨腹腔镜肾上腺全切除术与部分切除术治疗原发性醛固酮增多症的疗效.方法:回顾分析79例原发性醛固酮增多症患者的临床资料,47例行腹腔镜肾上腺全切除术,32例行部分切除术.分析患者高血压、低血钾的恢复情况.结果:本组79例均经后腹腔途径顺利完成手术,手术时间22～115min,平均(43±5)min,术中出血15～...     

腹腔镜肾上腺部分切除与全切除治疗醛固酮腺瘤的比较

近年来，腹腔镜手术已成为治疗肾上腺疾病的标准方法。原发性醛固酮增多症是一种常见的肾上腺疾病。腹腔镜部分和全部肾上腺切除治疗醛固酮腺瘤3（APA）的手术指征目前仍存在争论。作者采用这两种手术方式，比较各自的临床治疗效果。1995-2004年，共92例原发性醛固酮增多症患者采用腹腔镜手术治疗，     

腹膜后腹腔镜手术治疗原发性醛固酮增多症130例

目的　探讨腹膜后腹腔镜手术治疗原发性醛固酮增多症的临床价值。方法2 0 0 0年 2月到 2 0 0 3年 9月 ,我院对 130例 (男 5 4例 ,女 76例 )原发性醛固酮增多症患者行腹膜后腹腔镜手术治疗 ,其中肾上腺皮质腺瘤 119例 ,特发性肾上腺皮质增生 11例 (其中 2例为单侧皮质增生 ) ;肾上腺皮质腺瘤中 6 1例行肾上腺全切、5 8例行肾上腺部分切除术 ,肾上腺皮质增生采用单侧肾上腺全切手术。所有病例术前均有高血压和低血钾表现 ,及血浆醛固酮水平升高伴血浆肾素活性降低。结果　 130例手术均获得成功。手术时间 15～ 2 2 5min ,中位数为 4 3min ;术中出血量 0～ 2 0 0ml(出血量小于 5ml计出血量为 0 ) ,中位数为 2 0ml;术后住院时间 3～ 9d ,平均 (5 1± 1 3)d。所有病例术后 1个月内血钾恢复正常 ,醛固酮 /肾素比值明显降低 ,在未用降压药物情况下 ,88例 (6 8% )术后 2个月内血压恢复正常。随访 82例 ,6个月至 2年无明显并发症。结论　应用腹腔镜行腹膜后肾上腺全切除或部分切除术治疗原发性醛固酮增多症安全、可行。     

原发性醛固酮增多症临床诊疗分析(附63例报告)

目的:探讨原发性醛固酮增多症的诊断及治疗。方法:回顾性分析63例原发性醛固酮增多症患者的临床资料。结果:63例均有不同程度高血压,低钾者58例,通过测定外周血及肾上腺静脉血的激素水平,19例为原发性醛固酮增多症腺瘤型,14例为肾上腺增生。19例腺瘤型直接行腹腔镜肾上腺切除术,增生及其余行外周血及肾上腺静脉取血检查,优势侧肾上腺静脉醛固酮-皮质醇之比除以弱势侧肾上腺静脉醛固酮-皮质醇之比>2,同时外周静脉醛固酮水平高于0.520 5pmol/L,醛固酮/肾素活性比值≥40者共41例行腹腔镜肾上腺切除术。经治疗后57例患者血压及血钾均有不同程度的恢复,术后病理检查提示腺瘤19例、微腺瘤21例、结节样增生17例。结论:原发性醛固酮增多症主要通过影像学检查定位,外周血及肾上腺静脉取血测定激素水平定性诊断。腹腔镜下肾上腺腺瘤切除仍是当前的首选治疗方法,外周血及肾上腺静脉取血测定是早诊断、早治疗,预防疾病进一步发展的关键。     

后腹腔镜下保留肾上腺手术治疗腺瘤型原发性醛固酮增多症

目的 提高对后腹腔镜手术治疗腺瘤型原发性醛固酮增多症时保留正常肾上腺组织重要性的认识. 方法经后腹腔镜手术治疗肾上腺皮质腺瘤型原发性醛固酮增多症患者196例.男78例,女118例.年龄16～69岁,平均(41±12)岁.病程(90±65)个月.196例均存在血浆醛固酮水平升高伴血浆肾素活性降低,均有顽固性高血压和低血钾病史.对保留肾上腺组织患者的术后疗效、高血压和低血钾恢复情况进行临床分析. 结果 行保留肾上腺组织的肿瘤剜除术145例,患侧肾上腺部分切除术51例.196例手术均获成功.手术时间15～87 min,中位数33 min.术中出血量5～200 ml,中位数20 ml.术后病理报告均为肾上腺皮质腺瘤.术后住院时间2～5 d,平均(2.7±1.3)d,恢复过程顺利.196例随访6个月～3年,平均1.8年,168例(85.7%)血压恢复正常;27例(13.8%)血压高于正常范围,复查肾素-血管紧张素-醛固酮水平在正常范围,复查肾上腺CT未见明显异常,上述患者血钾在正常范围;1例患者血压升高,再次手术切除遗留腺瘤后血压恢复正常.196例术后均无心慌、乏力、发热、血压下降等肾上腺皮质功能不足表现. 结论 后腹腔镜下肾上腺腺瘤剜除术或患侧肾上腺部分切除手术安全性与疗效肯定,并能保存相应肾上腺皮质功能,是腺瘤型原发性醛固酮增多症合理的手术方式.     

原发性醛固酮增多症146例临床分析

目的提高原发性醛固酮增多症的诊治水平。方法分析１９７８～１９９８年收治的原发性醛固酮增多症１４６例,其中肾上腺腺瘤１１１例（７６％）,肾上腺增生３５例（２４％）,均经手术和病理证实。结果术后肾上腺腺瘤８２例（８２／１１１）,肾上腺增生１６例（１６／３５）,血压恢复正常,所有病人血钾均恢复正常。结论正确的治疗取决于正确的定性诊断,分型和定位诊断,Ｂ超和ＣＴ是原醛症定位诊断的主要方法,开放性手术是主要的治疗手段。影响疗效的因素,主要与患者年龄大、病史长、周身血管硬化有关。     

经腹腔镜切除肾上腺肿瘤5例报告

目的 探讨腹腔镜下切除肾上腺肿瘤的可行性。方法采用腹腔镜下行肾上腺肿瘤切除术治疗嗜铬细胞瘤及原发性醛固酮增多症5例。结果 平均手术时间200min平均出血量110ml，术后开始行走时间平均2d，高血压及低钾症状逐渐消失。结论 腹腔镜肾上腺切除手术具有创伤小、术后恢复快、住院时间短、术后生活质量高。     

后腹腔镜手术治疗肾上腺疾病（附38例报告）

目的探讨后腹腔镜手术治疗肾上腺疾病的适应证及手术方法。方法应用后腹腔镜手术治疗肾上腺疾病38例,其中原发性醛固酮增多症15例,皮质醇增多症13例,无功能腺瘤7例,肾上腺囊肿3例。结果38例手术中,35例手术成功,3例因术中出血和粘连改开放手术。手术时间60～180min,平均120min。术中出血约50-100ml,平均约80ml,均未输血。患者术后1～2天恢复进食,并可下床活动。术后住院时间4～19天,平均6．8天。结论与开放手术相比,后腹腔镜手术具有创伤小、疼痛轻、康复快等优点,已成为肾上腺疾病的首选手术方法。     

Adrenal Histologic Findings Show No Difference in Clinical Presentation and Outcome in Primary Hyperaldosteronism

Background

Primary hyperaldosteronism is most commonly due to a solitary cortical adenoma. Thus, some surgeons have suggested a subtotal adrenalectomy is a reasonable approach when a mass can be identified. On the other hand, adrenal vein sampling (AVS) is being used more frequently to distinguish patients with unilateral disease for adrenalectomy, even if a discrete mass is not identified on axial imaging. In these cases, surgical pathology may reveal a cortical adenoma, a cortical adenoma with hyperplasia, or cortical hyperplasia. The goal of this study was to compare the presentation and outcome among patients undergoing adrenalectomy and found to have different histologic features.

Methods

We performed a retrospective analysis of 136 patients with primary hyperaldosteronism. A total of 95 patients had an adrenalectomy for unilateral disease. The preoperative clinical and laboratory, and postoperative outcome of the three aforementioned histologic groups were compared.

Results

A total of 95 patients underwent an adrenalectomy. We found no significant difference in age, gender, body mass index, duration of hypertension, number of antihypertensive medications, serum aldosterone level, serum renin level, or adrenal vein sampling ratios among the three histologic categories. We also found no significant difference among the three categories in postoperative cure rate.

Conclusion

The rate of unilateral hyperplasia in patients with primary hyperaldosteronism (16 %) is likely higher than previously reported, which may be due to the increasing use of AVS. The clinical presentation and outcome of patients regardless of the histologic findings are similar. Our data also suggests that subtotal adrenalectomy would not be appropriate in patients with primary hyperaldosteronism.     

Diagnosis and Surgical Management for Primary Hyperaldosteronism

The evaluation of primary hyperaldosteronism presents a challenge to endocrinologists, radiologists, and urologic surgeons. A multidisciplinary approach with biochemical screening and radiologic evaluation is essential in order to assess the nature and function of hypersecreting adrenal glands. Furthermore, it is of great importance to identify individuals that are morbidly affected by aldosterone hypersecretion. Traditionally, open adrenalectomy was the preferred option for these patients. More recently, laparoscopic adrenalectomy has offered a minimally invasive approach, with its resultant advantages of improved perioperative parameters. Herein we describe the evaluation and surgical management for patients with a suspected diagnosis of primary hyperaldosteronism.     

Persistenz eines primären Hyperaldosteronismus nach subtotaler Adrenalektomie

BACKGROUND: Primary aldosteronism is known to be caused by aldosterone-producing adenoma (APA).Total adrenalectomy is the standard procedure. In contrast to bilateral adrenal diseases (e.g., MEN II pheochromocytomas), there is no consensus about the effect of subtotal adrenalectomy. CASE REPORT: A 44-year-old patient with primary aldosteronism caused by APA underwent subtotal adrenalectomy including removal of one adenoma.Because hypertension and hypokalemia did not disappear and hyperaldosteronism persisted, the patient had to undergo reoperation in which the adrenalectomy was completed. DISCUSSION: Subtotal adrenalectomy in patients with Conn's syndrome is an interesting therapeutic option,whereas its effect is much higher in hereditary diseases of the adrenal gland.The benefit of preserved adrenal tissue has to be weighed against a possible persistence of hyperaldosteronism, especially in cases with normal opposite adrenal glands.     

Laparoscopic adrenal-sparing surgery for primary hyperaldosteronism due to aldosterone-producing adenoma

Background: Laparoscopic adrenalectomy has been shown to be safe and effective in the treatment of patients with primary hyperaldosteronism due to aldosterone-producing adenoma. Most laparoscopic adrenalectomies for aldosterone-producing adenomas involve total removal of the adrenal gland, and there have been few reports of laparoscopic adrenal-sparing surgery or partial adrenalectomies. Methods: A prospective review is performed on eight patients with primary hyperaldosteronism due to aldosterone-producing adenoma who underwent laparoscopic transperitoneal adrenal-sparing surgery in our institution over a 2-year period. Results: There were 1 male and 7 females with a mean age of 43.1 years. The mean diameter of the adenoma was 2 cm; there were six right-sided lesions and two left-sided lesions. The adenoma was located in the anterior margin of the adrenal gland in seven cases and was removed by laparoscopic enucleation. One patient had a partial adrenalectomy using the vascular stapler for an adenoma that was located posteriorly in the adrenal gland. Hemostasis was excellent in all cases. All patients were able to tolerate liquid orally on the day of operation and were on diet on the second postoperative day. Postoperative analgesic requirement was minimal. The mean hospital stay was 3.8 days. At a mean follow-up of 25 months, seven patients were cured of their hypertension and one patient had her antihypertensive medications significantly reduced. Conclusion: Laparoscopic transperitoneal adrenal-sparing surgery is safe and effective in the treatment of patients with primary hyperaldosteronism due to aldosterone-producing adenoma.     

Laparoscopic partial versus total adrenalectomy for aldosterone producing adenoma

Purpose:

Laparoscopic surgery has become a standard method for adrenal treatment. Primary hyperaldosteronism is known to be frequently characterized by multiple adrenal lesions. The indication of laparoscopic partial or total adrenalectomy in patients with aldosterone producing adenoma (APA) remains controversial. We performed the 2 procedures and compared the outcomes of these 2 operations retrospectively.

Materials and Methods:

A total of 92 patients with primary hyperaldosteronism were laparoscopically treated at our institution from 1995 to 2004. A total of 29 patients underwent partial adrenalectomy or enucleation, while unilateral total adrenalectomy was performed in 63. A single pathologist examined the number and histopathological characteristics of APAs. Postoperative median followup was 60.3 and 29.3 months, respectively.

Results:

Laparoscopic adrenalectomies were successfully performed in each group, although the partial type had fewer ports and shorter operative time. All 63 patients with total adrenalectomy showed recovery from hypertension, suppressed plasma renin activity and high plasma aldosterone. Two of 29 patients with partial adrenalectomy or enucleation still experienced hypertension with high plasma aldosterone. Of the 63 extirpated specimens 17 adrenals (27.0%) demonstrated multiple space occupying lesions along with the main APA.

Conclusions:

Primary hyperaldosteronism is highly associated with multiple adrenal space occupying lesions. The risk-to-benefit ratio must be carefully weighed against the potential advantage of partial adrenalectomy. We chose total laparoscopic adrenalectomy in patients with unilateral APA and primary hyperaldosteronism.     

Current role of laparoscopic adrenalectomy

OBJECTIVE: Laparoscopic adrenalectomy is now a standard procedure for the vast majority of patients with surgical adrenal disease. Herein, we evaluate various techniques employed during laparoscopic adrenalectomy, and assess the current role of laparoscopic adrenalectomy, and possible future developments. MATERIALS AND METHODS: We reviewed large series of reports presenting the results of laparoscopic transperitoneal and retroperitoneal adrenalectomy and we compared the data of different series and authors, adding our experience. RESULTS: Laparoscopic adrenalectomy is a safe, reproducible and effective procedure with low complication rates. With increasing worldwide experience, the indications for laparoscopic adrenalectomy are expanding. When retrospectively compared to open surgery, laparoscopic adrenalectomy is superior in terms of postoperative pain, hospital stay, return to normal activity and complications. CONCLUSIONS: Laparoscopic adrenalectomy is a safe and effective option for most surgical adrenal pathologies. Moreover, laparoscopic adrenalectomy is associated with a superior patient tolerance profile. It is safe to say that today, laparoscopy must be considered the first choice procedure for excision of benign surgical adrenal lesions.     

Laparoscopic management of primary hyperaldosteronism: clinical experience with 212 cases

PURPOSE: Laparoscopy is now widely used to remove benign adrenal tumors. We assessed the value of transperitoneal partial or total adrenalectomy for primary hyperaldosteronism. MATERIALS AND METHODS: From September 1994 to October 2001, 212 consecutive patients with a mean age of 48 years who presented with primary hyperaldosteronism and related arterial hypertension underwent transperitoneal laparoscopic adrenalectomy (193) or tumor enucleation (20) performed by a single surgeon, including 1 who underwent bilateral adrenalectomy. In all cases preoperatively high plasma and urine aldosterone was associated with low plasma renin and hypokalemia. RESULTS: Mean followup was 44 months. Conversion to open surgery was necessary in 30 patients (14%) due to bleeding or adhesion and a procedure duration of greater than 3 hours. Mean operative time was 102 minutes (range 30 to 260). Six patients (2.8%) required blood transfusion. No deaths occurred. Postoperatively complications were observed in 10% of patients and the most frequent one was electrical myocardial ischemia without infarction. Mean postoperative pain medication was 17 mg. morphine sulfate equivalents (range 0 to 60). Mean and median hospital stay was 3.6 and 2.9 days, respectively (range 2 to 20). Postoperatively blood pressure was normal in 58% of patients without any drug, while treatment was decreased in the remainder. Kalemia was normalized in all cases. CONCLUSIONS: Although some complications can occur, mostly at the beginning of the learning curve, laparoscopic transperitoneal adrenalectomy is effective treatment for primary hyperaldosteronism.     

Diagnosis and surgical treatment of adrenal tumors

Adrenal surgery is necessary for the management of functioning adrenal tumors, such as aldosterone-producing adenoma, cortisol-producing adenoma, and pheochromocytoma. The role of adrenal imaging in primary hyperaldosteronism is to separate the surgically resectable unilateral aldosteronoma from bilateral hyperplasia. Once the clinical diagnosis of primary hyperaldosteronism is confirmed, adrenal computed tomography (CT) with 3-mm sections should be the first imaging study. If the results of CT and NP-59 scintigraphy are equivocal, adrenal venous sampling is necessary. Cortisol-producing adrenocortical adenomas are seen as adrenal masses 2.5 cm or larger in diameter in CT scanning. When an adrenal mass measures more than 5 cm in diameter, a functioning adrenal carcinoma should be considered. Symptomatic pheochromocytomas are almost always 2 cm or larger. On MR scanning, pheochromocytomas are extremely bright on T2-weighted images. In patients with ectopic pheochromocytomas, 131I-MIBG scintigraphy should be mandatory. In the past decade, laparoscopic adrenalectomy has replaced open adrenalectomy as a standard operative procedure for benign adrenal tumors. Adrenal-sparing laparoscopic surgery has recently become a feasible option in patients with hereditary bilateral pheochromocytomas.     

Outcome of patients undergoing laparoscopic adrenalectomy for primary hyperaldosteronism.

OBJECTIVES: To study the long-term outcome of patients with primary hyperaldosteronism who underwent laparoscopic adrenalectomy and to determine the preoperative predictive factors of persistent hypertension. METHODS: Between 1996 and 2002, 47 patients with primary hyperaldosteronism underwent transperitoneal laparoscopic adrenalectomy at our institution. Their clinical and biochemical parameters were reviewed retrospectively, and the outcome of 46 patients with complete follow-up notes were determined. RESULTS: The study comprised 16 male and 30 female patients with a mean age of 45.6 years (range, 18 to 63 years). Almost all patients had hypertension and hypokalemia at presentation, requiring medication. The average operating time was 127 minutes (range, 70 to 240 min), and the mean postoperative stay was 2.6 days (range, 1 to 5 days). No mortalities occurred, and perioperative morbidity was minimal. Forty-two (91%) patients had adrenal cortical adenoma (including 1 with both adenoma and hyperplasia), and 4 (9%) had adrenal hyperplasia on histology. The average follow-up time was 21 months (range, 1 to 60 months), and at the end of follow-up, all patients had normal serum potassium levels without potassium supplements. Twenty-three (50%) patients were cured of hypertension, and 13 (28%) patients had better control of their hypertension as evidenced by the decrease in the number of antihypertensive medications used. On multivariate analysis, the age of the patient at surgery was shown to be an independent predictive factor of persistent hypertension after successful surgery. CONCLUSION: Laparoscopic adrenalectomy is a safe and effective way to treat primary hyperaldosteronism, especially in controlling hypokalemia and in the management of hypertension. The age of a patient at surgery is an independent preoperative risk factor of persistent hypertension.