total 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 Adrenalectomy is available for: 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. 5. Various symptoms are quite serious, and the symptoms did not improve 4 to 8 months after radiotherapy for pituitary or even pituitary surgery, and the secretion of corticosteroids failed to fall to normal levels. 6. In the past, subtotal adrenal resection, the recurrence rate of symptoms is about 30%, the retained adrenal gland may re-expand, so the adrenal gland can be completely resected. Preoperative preparation For patients who are ineffective for long-term treatment, in addition to preoperative preparation for general Cushing syndrome, hypertension, diabetes, and neurological symptoms are heavier. Preoperative control of hypertension and application of blood glucose lowering drugs and improvement of neurological status should be performed. Surgical procedure An upper abdominal transverse incision or a 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. 1. Expose the adrenal gland into the layer by the selected incision to reveal the adrenal gland. 2. Total resection of the adrenal gland The left adrenal vein is longer than the right side and merges into the upper edge of the middle segment of the left renal vein, which is easy to clamp, cut, and ligature. It can be pulled to the medial and superior left kidney and then pulled downward. The separation reveals the adrenal gland and common blood vessels, and then ligates and cuts the blood vessels into and out of the adrenal gland. The left adrenal gland can be completely 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 free 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.

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