Open Adrenalectomy Periprocedural Care

Updated: Mar 24, 2017
  • Author: Peter P Stuhldreher, MD; Chief Editor: Kurt E Roberts, MD  more...
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Periprocedural Care

Patient Education and Consent

Information should be provided to the patient regarding the planned approach to the operation, the approximate length and location of incisions, and the expected postoperative care. In general, operative complication rates are low. Nevertheless, it is important to explain the risks to patients, especially those with suspected adrenal carcinomas, which are often locally invasive.

Knowledge of the relevant anatomic structures in proximity to the left and right adrenal glands will help the clinician remain alert to possible injuries to adjacent structures (eg, aorta, vena cava, small and large bowel, liver, spleen, and ipsilateral kidney). Before undergoing resection for adrenal carcinoma, patients should be counseled about the potential need to perform an ipsilateral nephrectomy. If caval thrombi are present, the patient should be aware of the extensiveness of the surgery required, as well as the possible need for cardiopulmonary bypass when atrial thrombi are present.

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Preprocedural Planning

Preoperative assessment should be tailored to the type of adrenal pathology to be addressed. In general, assessment of blood counts and routine chemistry should be obtained preoperatively. Given the proximity to major vascular structures (vena cava and aorta) and multiple arterial and venous supplies, an active type and screen is recommended. Patients should be optimized from a medical standpoint to safely undergo general anesthesia as well.

If the tumor is hormonally active, it is often important to involve endocrinologists for recommendations and consultation in postoperative care. In addition, with adrenal carcinoma, consultation with vascular surgeons and cardiothoracic surgeons are recommended with evidence of vena cava thrombus based on level of tumor thrombus.

Consultation with anesthesia is important during planned resection of pheochromocytoma because of the preoperative volume contraction and intraoperative blood pressure shifts associated with this procedure, which arise from an adrenergic surge during manipulation of the mass.

In the case of adrenal masses, preoperative evaluation is critical for matching the surgical procedure and anesthesia to the type of mass present. Preoperative computed tomography (CT) or magnetic resonance imaging (MRI) provides invaluable information regarding the size and location of the mass, the involvement of surrounding structures, and the possibility of metastatic disease (in the case of adrenal carcinoma). Additionally, CT and MRI findings can help differentiate a concerning mass from a simple adenoma. A finding of less than 10 Hounsfeld units (HU) on CT is consistent with adenomatous disease, and a findingof HU consistent with fat is indicative of myelolipoma. [5, 8]

MRI is also able to differentiate between adenoma and other pathologies: Adenomas will show signal intensity equivalent to the liver on T2-weighted images. [4, 8]  Cost and convenience may preclude the routine use of MRI in diagnosis of adrenal masses, however. Preoperative imaging is also imperative for planning the proper approach to excision, especially in the case of adrenocortical carcinoma, in that invasion of adjacent structures (eg, the inferior vena cava) is a contraindication for laparoscopy. [17, 19]

So-called incidentalomas that are found on imaging for other reasons that are not diagnostic of adenoma should undergo a hormonal workup, especially when there is a history of hypertension requiring multiple medications, periodic episodes of hypertension and flushing, and glucose intolerance. Virilization in females should also lead one to consider a dehydroepiandrosterone (DHEA)-secreting adenoma. It is important to note that incidentalomas do carry the risk of subclinical Cushing syndrome (5-14%), pheochromocytoma (1.5-11%), and aldosteronoma (1.5-3.3%). [5]

To evaluate for hypercortisolism, measurement should include urinary free cortisol, low-dose dexamethasone suppression test, two or three daytime measurements of cortisol level, and measurement of adrenocorticotropic hormone (ACTH). [5, 8, 20, 21, 22, 23]  Serum potassium levels and aldosterone–plasma renin activity ratios are sufficient to diagnose hyperaldosteronism; DHEA sulfate and testosterone levels will diagnose states of androgen excess; pheochromocytoma can be evaluated with either urinary catecholamines/metanephrines or plasma metanephrines. [5, 8, 20, 21, 22, 23]

Some authors have suggested a minimal protocol that consists of performing a pheochromocytoma workup, assessing potassium levels in hypertensive patients, and measuring glucocorticoids and androgens only in patients whose clinical presentations are consistent with an excess of these hormones. [24]  If neuroblastoma or the less common metastatic pheochromocytoma is being considered, iodine meta-iodobenzylguanidine scanning should be performed to help diagnose and appropriately stage this neoplastic process.

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Equipment

Standard laparotomy trays are used. For resection of ribs in the posterior and flank approaches, Doyen retractors are needed to elevate the periosteum from the rib, and a rib cutter is used for resection. A standard Bookwalter retractor can be employed to provide self-retaining retraction for the anterior and flank approaches. A Finochietto retractor is used for both the bilateral posterior approach and the thoracoabdominal approach. Depending on the surgeon's preference, an ultrasonic scalpel may be used in lieu of ligature for ligation of small and accessory adrenal vessels.

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Monitoring & Follow-up

As expected, routine postoperative follow-up for wound complications, healing, and return to normal activity is warranted. Further follow-up is dictated by the final pathologic examination of the removed specimen. For hypersecreting tumors, with the exception of pheochromocytoma, further follow-up after routine postoperative follow-up is unnecessary.

For pheochromocytoma, the National Comprehensive Cancer Network guidelines recommend that history and physical examination, blood pressure checks, and biomarkers be assessed 3 and 12 months after surgery, every 6 months from years 1 through 3, and annually thereafter for surgically resectable disease. Imaging studies may be obtained when clinically indicated. For cytoreductive surgeries, the recommendations are for the above tests every 3-4 months with imaging when indicated in consultation with radiation oncology and medical oncology for metastases.

Follow-up for adrenocortical carcinoma is based on tumor grade on pathologic section. For low-grade tumors, imaging every 3-6 months and biomarkers (if it was a hormonally active tumor) are warranted. [25]  For high-grade tumors, the clinician also should consider adjuvant radiation therapy or mitotane chemotherapy. In the case of metastatic disease, adrenalectomy can still be considered if it is low-grade and if more than 90% of tumor can be removed surgically; follow-up should be oriented to the residual disease.

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