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Adrenalectomy is performed to adrenal tumors that secret excess hormone and for those that are concerning for malignancy. There are many approached to adrenalectomy, including minimally invasive and open approaches. This activity describes adrenalectomy and reviews the role of the interprofessional team in evaluating and treating patients who undergo adrenalectomy. Objectives: Identify the indications of the adrenalectomy. Describe the management of adrenalectomy. Outline the complications of adrenalectomy. Access free multiple choice questions on this topic.

Improving diagnostic techniques has lead to the increase of incidental and non-incidental adrenal tumor detection. When incidentally discovered, adrenal tumors necessitate thorough work-up to determine if they are hormonally functional, malignant, or metastatic. Patients with hormonally functional adrenal tumors should have targeted preoperative optimization, in addition to routine age-appropriate optimization.[1][2]

Primary adrenal insufficiency occurs after bilateral adrenalectomy. Signs and symptoms are volume depletion, hypotension, hyponatremia, hyperkalemia, fever, abdominal pain. Patients are managed by replacement therapy based on glucocorticoids (hydrocortisone or cortisone), mineralocorticoids (fludrocortisone) in cases of confirmed corticoids or aldosterone deficiency, respectively. Only women with androgens deficiency, which presents low libido, depressive symptoms, and/or low energy levels despite otherwise optimized glucocorticoid and mineralocorticoid replacement, are candidates for dehydroepiandrosterone (DHEA) replacement. Other consequences of bilateral adrenalectomy include hypercortisolism due to excess ACTH stimulation of residual adrenal tissue, adrenal crisis, and the development of an aggressive corticotropic tumor called Nelson’s syndrome. Nelson’s syndrome is less common and is typically associated with skin hyperpigmentation due to hypersecretion of proopiomelanocortin (POMC) products.[9][6][7] Diagnosis requires one of the following: 1) expanding pituitary mass lesion compared with pre-bilateral adrenalectomy imaging or 2) plasma level of ACTH more than 200 ng/mL in addition to progressive elevations of ACTH (an increase of >30%) on at least three consecutive occasions. Adrenal crisis is a life-threatening complication of adrenal insufficiency. Patients in the adrenal crisis typically present with profoundly impaired well-being, hypotension, nausea and vomiting, and fever responding well to parenteral hydrocortisone administration. Infections are the major precipitating causes of adrenal crisis.[10][11][7]

Adrenalectomy has been shown to have a relatively low risk of postoperative complications, with an overall rate of 3.6%.[13]. Improved patient outcomes and decreased hospital costs have been demonstrated when adrenalectomy is performed by a high-volume adrenal surgeon (>/=6 adrenalectomies/year).[14] An interprofessional approach to adrenalectomy aids in the prevention and avoidance of intraoperative and postoperative complications, and in some cases, allows for same-day discharge.[15] These improvements are only achieved with close communication across the care team-which includes the patient's endocrinologist, surgeon, anesthesiologist, nurses, and all additional health professionals that may be involved in the patient's care.