Feocromocitoma maligno. A propósito de tres casos / Malignant Pheochromocytoma. As Regards of Three Cases

Introducción: Los feocromocitomas son tumores que se desarrollan a partir de las células cromafines localizadas en la médula suprarrenal, ganglios simpáticos y parasimpáticos. La distinción entre tumores benignos y malignos es compleja, pues no existen marcadores que puedan discriminar esta diferencia con alta sensibilidad y especificidad. Objetivo: Presentar tres casos clínicos de feocromocitoma maligno, diagnosticados y/o tratados en la sala de hospitalización de adultos del INEN. Método: Se revisaron las historias clínicas y se resumieron los datos. Presentación de los casos: Los 3 pacientes eran del sexo masculino, con edades entre 41 y 51 años al diagnóstico del tumor primario. De ellos, dos tenían una hipertensión arterial controlada y el tercero se comenzó a estudiar por crisis paroxísticas de hipertensión; dos tenían antecedentes de diabetes mellitus y no se demostraron evidencias en ningún caso de lesiones en órganos diana por la hipertensión. En los tres pacientes el tumor se localizó en la suprarrenal derecha. Solo en uno de los casos, la etiología maligna fue informada en el estudio anatomopatológico. En los otros dos pacientes, la malignidad se diagnosticó a punto de partida de lesiones metastásicas, años después de la adrenalectomía, en un caso de cadera y en el otro, de pulmón. Conclusiones: El feocromocitoma maligno es una enfermedad infrecuente de la edad mediana y el diagnóstico de su naturaleza es complejo. Se debe sospechar la aparición de enfermedad metastásica ante la reaparición de los síntomas que motivaron el estudio inicial en el paciente, incluso, años después de la adrenalectomía(AU)

Introduction: Pheochromocytomas are tumors developed from chromaffin cells located in the suprarenal medulla, as well as in sympathetic and parasympathetic ganglia. The distinction between benign and malignant tumors is complex, since there are no markers to discriminate this difference with high sensitivity and specificity. Objective: To present three clinical cases of malignant pheochromocytoma, diagnosed and/or treated in the adult hospitalization ward at the National Institute of Endocrinology. Method: The medical records were reviewed and the data was summarized. Case presentation: The three patients were male and aged between 41 and 51 years at the diagnosis of the primary tumor. Of them, two had controlled arterial hypertension and the third began to be studied for paroxysmal hypertension crises; two had a history of diabetes mellitus and no evidence of target-organ lesions due to hypertension was shown in any case. In the three patients, the tumor was located in the right suprarenal gland. Only in one of the cases, malignant etiology was reported in the pathological study. In the other two patients, the malignancy was diagnosed at the starting point of metastatic lesions, years after adrenalectomy: two respective hip and lung cases. Conclusions: Malignant pheochromocytoma is a rare disease that appears at middle age and whose diagnosis is complex, due to its etiological nature. The appearance of metastatic disease should be suspected, given the reappearance of the symptoms that motivated the initial study in the patient, even years after adrenalectomy(AU)

Neoplasia oncocítica adrenocortical de potencial maligno incierto: reporte de un caso / Adrenocortical oncocytic neoplasm with uncertain malignant potential: a case report

Resumen Objetivo Describir el caso clínico de una paciente con neoplasia oncocitica adrenocortical, tratado quirúrgicamente en una clínica de Lima, Perú. Caso clínico Paciente mujer de 26 años ingresa a emergencia por dolor abdominal inespecífico. Se evidencia tumoración de 15x14x12 cm dependiente de glándula suprarrenal izquierda por lo que se decide tratamiento quirúrgico. Al análisis patológico se evidencia neoplasia oncocítica de potencial maligno incierto. Discusión Las neoplasias oncocíticas adrenocorticales son entidades poco frecuentes, con escasos reportes de casos de esta enfermedad. Para clasificarlas, se usa la escala de Weiss modificada. Obtenemos una neoplasia oncocítica de potencial maligno incierto, cuyo tratamiento incluye la cirugía de resección de tumor y observación. Conclusión Considerar a las neoplasias oncocíticas dentro del diagnóstico diferencial de incidentalomas adrenales.

Objective To describe a case report of a oncocytic adrenocortical neoplasm, treated surgically in a clinic in Lima, Peru. Case report A 26-year-old woman is admitted to the emergency due to nonspecific abdominal pain. A tumor measuring 15x14x12 cm dependent on left adrenal gland is evidenced, so surgical treatment is decided. Pathological analysis evidences oncocytic neoplasia of uncertain malignant potential. Discussion Oncocytic adrenocortical neoplasms are rare entities, with few case reports of this disease. To classify them, the modified Weiss scale is used. We obtain an oncocytic neoplasm of uncertain malignant potential, whose treatment includes surgery for tumor resection and observation. Conclusion Consider oncocytic neoplasms within the differential diagnosis of adrenal incidentalomas.

Adrenalectomía laparoscópica en 40 pacientes para el tratamientodel feocromocitoma adrenal / Laparoscopic adrenalectomy in 40 patients for the treatment of adrenal pheochromocytoma

RESUMEN Introducción: D esde el año 1997 se comenzó a realizar la adrenalectomía laparoscópica en nuestro centro. Objetivo: Analizar los resultados de la adrenalectomía laparoscópica en el tratamiento quirúrgico del feocromocitoma en el servicio de cirugía general del Hospital Clínico Quirúrgico "Hermanos Ameijeiras". Métodos: Desde noviembre de 1997 a junio del año 2019 se realizaron 192 adrenalectomías por vía laparoscópica en 190 pacientes y en 41 fueron realizadas por feocromocitoma adrenal, en el servicio de cirugía general del Hospital Clínico Quirúrgico "Hermanos Ameijeiras". Se empleó la técnica laparoscópica con abordaje lateral intraperitoneal en la mayoría de los casos, y el abordaje en decúbito supino en un caso para la adrenalectomía bilateral. Resultados: Se realizaron 41 adrenalectomías laparoscópicas en 40 pacientes por feocromocitoma adrenal, en 1 pacientes se realizó adrenalectomía bilateral en un tiempo. La edad promedio fue de 44 años. Predominaron las lesiones del lado derecho en 26 pacientes, 14 del lado izquierdo y uno bilateral. Fueron convertidos a cirugía convencional 1 pacientes (0,41 por ciento). El tiempo quirúrgico promedio fue de 80 minutos. La estadía postoperatoria promedio fue de 2,5 días. Todos los pacientes se curaron de la hipertensión arterial. Conclusiones: La adrenalectomía laparoscópica es una técnica reproducible y segura en el tratamiento del feocromocitoma adrenal(AU)

ABSTRACT Introduction: Since 1997, laparoscopic adrenalectomy began to be performed in our center. Objective: To analyze the results of laparoscopic adrenalectomy in the surgical treatment of pheochromocytoma in the general surgery service of the "Hermanos Ameijeiras" Surgical Clinical Hospital. Methods: From November 1997 to June 2019, 192 adrenalectomies were performed laparoscopically in 190 patients and in 41 they were performed for adrenal pheochromocytoma, in the general surgery service of the "Hermanos Ameijeiras" Surgical Clinical Hospital. The laparoscopic technique with an intraperitoneal lateral approach was used in most cases, and the supine approach in one case for bilateral adrenalectomy. Results: 41 laparoscopic adrenalectomies were performed in 40 patients for adrenal pheochromocytoma, in 1 patients bilateral adrenalectomy was performed at one time. The average age was 44 years. Lesions on the right side predominated in 26 patients, 14 on the left side and one bilateral. 1 patients (0.41 pèrcent) were converted to conventional surgery. The average surgical time was 80 minutes. The average postoperative stay was 2.5 days. All patients were cured of high blood pressure. Conclusions: Laparoscopic adrenalectomy is a reproducible and safe technique in the treatment of adrenal pheochromocytoma(AU)

Challenging risk factors for right and left laparoscopic adrenalectomy: A single centre experience with 272 cases

ABSTRACT Purpose This study aimed to compare perioperative and postoperative results of right and left laparoscopic adrenalectomy (LA), and to evaluate the impact of challenging factors on these outcomes. Materials and Methods A total of 272 patient's medical records that underwent single side LA between October 2006 and September 2017 were retrospectively reviewed. The patients were divided into 2 groups according to operation side. Moreover, pheochromocytoma, metastatic masses and adrenal lesions >5cm in size were considered to be difficult adrenalectomy cases and the outcomes of these cases were compared between two groups. Results 135 patients (49.6%) underwent right LA and 137 patients (50.4%) underwent left LA. Operation time, estimated blood loss (EBL) and hospitalization time were similar between the groups (p=0.415, p=0.242, p=0.741, respectively). Although EBL was higher on the right side than the left (p=0.038) in the first 20 cases, after this learning period has been completed, there was no significant difference between the groups. In patients with pheochromocytoma, metastatic mass and a mass >5cm in size, despite bleeding complications were clinically higher on the right side, this difference was not statistically significant. Conclusions During the learning period of LA, EBL is higher on the right side. Due to the greater risk of bleeding complications on the right side even on the hands of experienced surgeons, extra care and preoperative planning are required in patients with pheochromocytoma, metastatic masses and masses >5cm in size.

Limited significance of repeated long-term radiological and hormonal examination in nonfunctioning adrenal incidentalomas

ABSTRACT Purpose: The purposes of the present study were to evaluate growth rate of nonfunctioning adrenal incidentalomas (AIs) and their development to hormonal hypersecretion on follow-up. Materials and methods: A retrospective study was conducted from the electronic medical records. A total of 314 patients were diagnosed with adrenal tumors between 2000 and 2016. After excluding patients who had overt adrenal endocrine disorders or whose adrenal tumors were clinically diagnosed as metastatic malignancies, we investigated 108 patients with nonfunctioning AIs including characteristics, the treatment, the way of follow-up and pathology. Results: Fifteen patients received immediate adrenalectomy because of the initial tumor size or patient's preference. Pathological examination revealed malignancy in 2 patients. In the remaining 93 patients, radiological examinations were performed periodically. Tumor enlargement of ≥ 1.0cm was observed in 8.6% of the patients who were followed up as nonfunctioning AIs with a median follow-up period of 61.5 months (range: 4-192). Eleven patients underwent adrenalectomy. On the pathological examinations, all of the tumors, which showed a size increase, were diagnosed as benign tumors. Regarding the followed up patients without adrenalectomy, only 2.4% of the patients had tumor enlargement during the prolonged follow-up. Furthermore, none of the patients developed hormonal hypersecretion or clinical signs such as obesity, glucose intolerance or poorly controlled hypertension. Conclusions: Tumor enlargement of AIs did not correlate with malignancy. The value of repeat radiological and hormonal examinations may be limited in the long-term follow-up of patients whose AIs are not enlarged.

Total and partial laparoscopic adrenalectomy

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Manejo quirúrgico del quiste adrenal gigante: reporte de caso y revisión de la literatura / Surgical management of giant adrenal cyst: case report and review of the literature

OBJETIVO: Presentar un caso de quiste adrenal (QA) gigante resecado por vía mínimamente invasiva y realizar una revisión narrativa de la literatura disponible al respecto. MATERIALES Y MÉTODOS: Se presenta el caso de un paciente de sexo masculino de 54 años, con una masa retroperitoneal izquierda de crecimiento lento, asintomático, con imágenes y biopsia sugiriendo un QA complejo con sospecha de infiltración renal. Se indica una resección laparoscópica transabdominal. RESULTADOS: Se encuentra como hallazgo intraoperatorio un QA complejo hemorrágico de 9 cm de diámetro, con adherencia a la fascia de Gerota izquierda, logrando exéresis completa del QA por mínima invasión. El paciente evolucionó satisfactoriamente y fue dado de alta al segundo día posoperatorio. Es asintomático en 19 meses de seguimiento. Si bien los QA son benignos, los QA gigantes con crecimiento rápido, sintomáticos o de conversión hemorrágica, pueden ser resecados por adrenalectomía laparoscópica sin aumento de morbimortalidad. DISCUSIÓN: El abordaje laparoscópico de los QA no funcionales gigantes debe ser considerado como el manejo de elección. Es necesaria más evidencia sobre resultados en diferentes abordajes para generar recomendaciones claras. CONCLUSIÓN: Este reporte se suma a la evidencia actual en cuanto al abordaje mínimamente invasivo para QA gigantes hemorrágicos.

OBJECTIVE: Present a giant adrenal cyst (AC) case treated with minimally invasive resection and to perform a narrative literature review available. MATERIAL AND METHODS: A 54 year-old male presents with a left retroperitoneal slow growing mass, no symptoms, with a complex AC evidenced by previous images and mass biopsy, with suspected renal infiltration. A transabdominal laparoscopic resection is indicated. RESULTS: A complex hemorrhagic 9 cm diameter AC was found, with adhesions to left Gerota's fascia. Complete resection of the AC was achieved through minimally invasive approach. The patient had an uneventful clinical recovery and was discharged on the second postoperative day. On 19th month of follow-up is completely asymptomatic. Even though the AC are benign lesions, the symptomatic giant AC, with fast growing ratio, and/or hemorrhagic conversion could be resected though laparoscopic adrenalectomy, with no increased morbidity or mortality. DISCUSSION: The laparoscopic approach for giant non-functional AC should be considered as the standard of care. More evidence is required in terms of surgical approach outcomes to define clear recommendations. CONCLUSION: This report adds to the actual evidence in terms of minimally invasive approach for hemorrhagic giant AC.

Carcinoma adrenal em crianças: estudo longitudinal em minas gerais, brasil / Adrenal carcinoma in children: longitudinal study in minas gerais, brazil

RESUMO Objetivo: Analisar as características clínicas, laboratoriais e histopatológicas e o percurso até o estabelecimento do diagnóstico e do tratamento de pacientes com carcinoma de suprarrenal (CSR). Métodos: Estudo retrospectivo com 13 pacientes tratados no serviço de oncologia pediátrica do Hospital das Clínicas da Universidade Federal de Minas Gerais (HC-UFMG) entre 2004 e 2015. Resultados: A idade ao diagnóstico variou de 1,0 a 14,8 anos (mediana: 2,0 anos). As manifestações de hipercortisolismo foram identificadas em todos os casos, e as de virilização, em todas as meninas. Todos os pacientes preencheram os critérios de Weiss para diagnóstico histopatológico de CSR. A imuno-histoquímica foi realizada em 61,5% dos casos. A maioria dos pacientes apresentou doença em estádio I (76,9%). Todos foram submetidos à ressecção tumoral total. Dois pacientes (estádios III e IV) receberam quimioterapia associada ao mitotano. O único óbito observado foi do paciente com doença em estádio IV. A probabilidade de sobrevida global para todo o grupo aos 5,0 anos foi de 92,3±7,4%. A mediana de tempo entre o início dos sintomas e o diagnóstico foi de 9,5 meses, e de 6,0 meses entre a primeira consulta e o início do tratamento. Conclusões: A baixa idade ao diagnóstico, o predomínio de casos com doença localizada e a ressecção tumoral completa - com apenas um caso de ruptura de cápsula tumoral - são possivelmente a explicação para a evolução favorável da população estudada. O longo percurso entre o início dos sintomas e o diagnóstico sugere a importância da capacitação dos pediatras para o reconhecimento precoce dos sinais e dos sintomas do CSR.

ABSTRACT Objective: To analyze clinical, laboratory and histopathological features and the path to diagnosis establishment and treatment of patients with adrenal carcinoma (AC). Methods: Retrospective study with 13 patients assisted at the pediatric oncology service of Hospital das Clínicas, Universidade Federal de Minas Gerais, Brazil, between 2004 and 2015. Results: Age at diagnosis ranged from 1.0 to 14.8 years (median: 2.0 years). Manifestations of hypercortisolism were identified in all cases and virilization in all girls. All patients met the Weiss criteria to AC histopathological diagnosis. Immunohistochemistry was performed in 61.5% of the cases. Most patients had stage I disease (76.9%). All subjects were submitted to total tumor resection. Two patients (stages III and IV disease) received chemotherapy associated to mitotane. The only death case was that of a patient with stage IV disease. The probability of overall survival for the entire group up to 5.0 years was 92.3±7.4%. The median time between the onset of symptoms and diagnosis was 9.5 months, and 6.0 months between first visit and start of treatment. Conclusions: Low age at diagnosis, predominance of cases with localized disease and complete tumor resection - with only one case of tumor capsule rupture - can possibly explain the favorable evolution of the studied population. The long period between onset of symptoms and diagnosis highlights the importance of training pediatricians for early recognition of AC signs and symptoms.

Robotic excision of complex adrenal mass with retrocaval extension and encasement of renal hilum with renal preservation

ABSTRACT Objective: The purpose of this video is to present robotic excision of a complex adrenal mass with retrocaval extension and encasement of renal hilum in a 16 year old boy. Biochemical screening was negative for metabolically active component. Computerized tomographic scan with contrast revealed a homogenous mass of approximately 10.8 cm x 6.2 cm x 4.2 cm in the suprarenal area on right side that was extend-ing behind inferior vena cava and encasing renal hilar vessels. Imaging findings were that of a classical ganglioneuroma. Material and methods: Robot assisted laparoscopic adrenalectomy with sparing of renal hilar vasculature was performed. With patient in lateral position, five ports were used, including one for liver retraction. Da Vinci® system with four arms was docked from over the right shoulder. The displaced renal hilar structures were identified by opening Gerota's fascia. Mass was dissected completely and removed through Pfan-nensteil incision. Results: Duration of procedure was 345 minutes and console time was 290 minutes. Blood loss was 250 mL. Post-operative renal doppler showed normal blood flow. He was discharged on post-operative day three. Histopathologic examination of specimen revealed ganglioneuroma arising from adrenal gland. Conclusion: Ganglioneuroma is a rare adrenal tumor with good prognosis on surgical removal. The advent of robotic surgery has made complex surgical procedures involving vital structures like inferior vena cava be performed using minimally invasive techniques without compromising oncologic principles.

Mielolipoma suprarrenal: doce años de experiencia en su diagnóstico, tratamiento y seguimiento / Adrenal myelolipoma: twelve-years' experience in diagnosis, treatment and follow-up

Introducción: Los mielolipomas suprarrenales son tumores benignos e infrecuentes, formados por tejido adiposo y hematopoyético. Se consideran incidentalomas porque se diagnostican fortuitamente en estudios de imagen investigando síntomas abdominales o lumbares o en chequeos rutinarios. Son hormonalmente inactivos casi siempre. Se operan si presentan gran tamaño y usualmente se mantienen estables durante su evolución natural. Objetivos: Identificar las características de los mielolipomas suprarrenales y describir su evolución natural. Métodos: Se realizó un estudio descriptivo retrospectivo en 17 pacientes con mielolipomas suprarrenales diagnosticados por tomografía axial computarizada entre enero de 2006 y abril de 2018. Se estudiaron variables clínicas, hormonales y tomográficas al inicio en 17 pacientes y evolutivamente en 5 pacientes no operados. Se utilizaron medidas de resumen para las variables cualitativas (número y porcentajes) y para las cuantitativas (media y desviación estándar). Resultados: La edad promedio fue 52,9 años y la distribución por sexo: 13 mujeres y 4 hombres (razón 3,2:1). Se indicó tomografía axial computarizada en 11 pacientes por síntomas dolorosos. El tamaño promedio fue 5,6 cm. En 8 tumores el diámetro fue de 6 cm y más. En 9 pacientes se realizó adrenalectomía laparoscópica. Durante la evolución natural, que promedió 5 años y 1 mes, una paciente presentó crecimiento de sus dos masas bilaterales; la derecha se extirpó por sobrepasar los 6 cm. Conclusiones: Los mielolipomas suprarrenales fueron benignos, alcanzaron gran tamaño y provocaron síntomas dolorosos. Fueron hormonalmente inactivos en su mayoría. Evolutivamente, el crecimiento fue muy infrecuente y no hubo transformación maligna ni desarrollo de hiperfunción endocrina(AU)

Introduction: Suprarenal myelolipomas are infrequent benign tumors formed by adipose and hematopoietic tissue. They are considered to be incidentalomas because they are found and diagnosed accidentally in imaging studies intended for abdominal or lumbar problems, or in routine checkups. Suprarenal myelolipomas are almost always hormonally inactive. They are operated on when they are large, and they usually remain stable during their natural evolution. Objectives: Identify the characteristics of suprarenal myelolipomas and describe their natural evolution. Methods: A retrospective descriptive study was conducted of 17 patients with suprarenal myelolipomas diagnosed by computerized axial tomography from January 2006 to April 2018. Clinical, hormonal and tomographic variables were analyzed initially in 17 patients and evolutionarily in 5 non-operated patients. Summary measurements were used for qualitative variables (number and percentages) and for quantitative variables (mean and standard deviation). Results: Mean age was 52.9 years and sex distribution was 13 women and 4 men (ratio of 3.2:1). Computerized axial tomography was indicated for 11 patients with pain symptoms. Average size was 5.6 cm. In 8 tumors the diameter was 6 cm or more. Laparoscopic adrenalectomy was performed on 9 patients. During natural evolution, which averaged 5 years and 1 month, one female patient experienced growth of her two bilateral masses, and the one on the right side was removed for it exceeded 6 cm. Conclusions: The study suprarenal myelolipomas were large, benign and caused pain symptoms. Most were hormonally inactive. In evolutionary terms, growth was very infrequent and there was no malignant transformation or development of endocrine hyperfunction(AU)

Adrenalectomía derecha videoasistida por metástasis de adenocarcinoma sigmoides / Video-assisted right adrenalectomy for sigmoid adenocarcinoma metastasis

Las glándulas suprarrenales son sitios frecuentes de enfermedad y presentan algún tipo de alteración en 9 por ciento de la población. La detección de lesiones suprarrenales ha aumentado significativamente con el uso cada vez más frecuente de la tomografía axial computarizada y la resonancia magnética. Muchas de ellas son detectadas en forma incidental. Las lesiones más comunes son el adenoma y las metástasis. El adenoma es la enfermedad más frecuente en los pacientes sin antecedente neoplásico. Además, se pueden encontrar feocromocitomas, carcinomas, linfomas, mielolipomas, quistes y pseudoquistes, hemangiomas y hematomas. El objetivo del trabajo es mostrar el resultado del tratamiento quirúrgico de una metástasis en glándula suprarrenal derecha de un adenocarcinoma de sigmoides. La diseminación metastásica de un adenocarcinoma de colon a las glándulas suprarrenales es poco frecuente, muy poco reportado a nivel mundial. Es posible utilizar la vía videoasistida para el tratamiento de lesiones únicas suprarrenales con resultado satisfactorio(AU)

The adrenal glands are frequent sites of disease and present some type of alteration in 9 percent of the population. Its detection has increased significantly with the increasingly frequent use of CT and MRI, in which many of these lesions are detected incidentally. The most common lesions are adenoma and metastasis; Adenoma is the most frequent disease in patients without a neoplastic history. In addition, pheochromocytomas, carcinomas, lymphomas, myelolipomas, cysts and pseudocysts, hemangiomas and hematomas can be found. To show the result of the surgical treatment of a metastasis in the right adrenal gland of a sigmoid adenocarcinoma. A review of the literature, indications and techniques in the treatment of metastases in the adrenal gland was performed and the results of a patient diagnosed and operated at Hermanos Ameijeiras Clinical Surgical Hospital in 2016 are presented. Metastatic dissemination of adenocarcinoma of the colon to the adrenal glands is infrequent, rarely reported worldwide. A video-assisted adrenalectomy technique wasperformed with satisfactory results. There were no complications related to the procedure(AU)

Laparoscopic approach to pheochromocytoma in pregnancy: case report

ABSTRACT A 32-year-old 22-week pregnant hypertensive woman with sporadic episodes of headaches, sweating, and facial flushing was diagnosed with pheochromocytoma through biochemical and imaging tests. Perioperative management included a multidisciplinary approach, symptom stabilization with α blockade followed by β blockade, and tumor resection by laparoscopic adrenalectomy at 24 weeks gestation. The diagnosis was confirmed by histopathological examination and immuno-histochemistry tests. The decision for surgical removal of the tumor was based on maternal symptoms, tumor size, gestational age, the possibility of doing a laparos-copy, and the expertise of the surgical team.

Adrenalectomía laparoscópica / Laparoscopic adrenalectomy

Introducción: desde el año 1997 se comenzó a realizar la adrenalectomía laparoscópica en nuestro centro. Objetivo: analizar los resultados de la adrenalectomía laparoscópica desde su implementación en el servicio de cirugía general del Hospital Clínico Quirúrgico "Hermanos Ameijeiras". Métodos: Se realizó un estudio descriptivo de los resultados obtenidos en 160 pacientes a los que se les realizó adrenalectomía por vía laparoscópica, en el período comprendido desde noviembre de 1997 hasta septiembre del año 2017 en el servicio de cirugía general del Hospital Clínico Quirúrgico Universitario "Hermanos Ameijeiras". Se empleó la técnica laparoscópica con abordaje lateral intraperitoneal en la mayoría de los casos y el abordaje en decúbito supino en 2 casos para la adrenalectomía bilateral. Resultados: se realizaron 162 adrenalectomías laparoscópicas en 160 pacientes, ya que a dos pacientes se les realizó la adrenalectomía bilateral en un tiempo. La edad promedio fue de 44,8 años. La indicación quirúrgica fue el incidentaloma en 68 pacientes (42,5 pòr ciento), el síndrome de Cushing en 27 (16,8 pòr ciento), feocromocitoma en 26 (16,25 pòr ciento), la Enfermedad de Cushing con fracaso del tratamiento neuroquirúrgico en 12 (7,5 pòr ciento), mielolipomas en 7 (4,37 pòr ciento), tumor adrenal en 6 (3,75 pòr ciento), tumor metastásico en 5 (3,1 pòr ciento), quistes adrenales en 4 (2,5 pòr ciento), hiperaldosteronismo primario en 3 (1,87 pòr ciento), tumor virilizante adrenal en 1 paciente y 1 paciente con un Síndrome de secreción ectópica de ACTH que le provocaba un Síndrome de Cushing complicado. Predominaron las lesiones del lado izquierdo en 86 pacientes, 72 del lado derecho y 2 bilaterales. Fueron convertidos a cirugía convencional 2 pacientes (1,25 pòr ciento). El tiempo quirúrgico promedio fue de 82 minutos. La estadía posoperatoria promedio fue de 2.5 días. Conclusiones: la adrenalectomía laparoscópica es una técnica reproducible y segura con las ventajas inherentes a la cirugía laparoscópica(AU)

Introduction: As far as 1997, the performing of laparoscopic adrenalectomy started in our center. Objective: To analyze the results of laparoscopic adrenalectomy since its implementation in the general surgery service of Hermanos Ameijeiras Clinical Surgical Hospital. Methods: A descriptive study was carried out with the results obtained from 160 patients who underwent laparoscopic adrenalectomy, in the period from November 1997 to September 2017, in the general surgery service of Hermanos Ameijeiras University Clinical Surgical Hospital. The laparoscopic technique with intraperitoneal lateral approach was used in the majority of cases and the supine approach was used in two cases for bilateral adrenalectomy. Results: 162 laparoscopic adrenalectomies were performed in 160 patients, since two patients underwent bilateral adrenalectomy at one time. The average age was 44.8 years. Surgical indication cases were incidentalomas, in 68 patients (42.5 percent), Cushing's syndrome in 27 (16.8 percent), pheochromocytomas in 26 (16.25 percent), Cushing's disease with neurosurgical treatment failure in 12 (7.5 percent), myelolipomas in 7 (4.37 percent), adrenal tumor in 6 (3.75 percent), metastatic tumor in 5 (3.1 percent), adrenal cysts in 4 (2.5 percent), primary hyperaldosteronism in 3 (1.87 percent), adrenal virilizing tumor in 1 patient, and 1 patient with an ectopic ACTH secretion syndrome that caused a complicated Cushing's syndrome. Lesions on the left side were predominant in 86 patients, 72 on the right side and two bilateral. Two patients (1.25 percent) were converted to conventional surgery. The average surgical time was 82 minutes. The average postoperative stay was 2.5 days. Conclusions: Laparoscopic adrenalectomy is a reproducible and safe technique with the advantages inherent to laparoscopic surgery(AU)

Adrenalectomía laparoscópica / Laparoscopic adrenalectomy

Introducción: desde el año 1997 se comenzó a realizar la adrenalectomía laparoscópica en nuestro centro. Objetivo: analizar los resultados de la adrenalectomía laparoscópica desde su implementación en el servicio de cirugía general del Hospital Clínico Quirúrgico Hermanos Ameijeiras. Métodos: Se realizó un estudio descriptivo de los resultados obtenidos en 160 pacientes a los que se les realizó adrenalectomía por vía laparoscópica, en el período comprendido desde noviembre de 1997 hasta septiembre del año 2017 en el servicio de cirugía general del Hospital Clínico Quirúrgico Universitario Hermanos Ameijeiras. Se empleó la técnica laparoscópica con abordaje lateral intraperitoneal en la mayoría de los casos y el abordaje en decúbito supino en 2 casos para la adrenalectomía bilateral. Resultados: se realizaron 162 adrenalectomías laparoscópicas en 160 pacientes, ya que a dos pacientes se les realizó la adrenalectomía bilateral en un tiempo. La edad promedio fue de 44,8 años. La indicación quirúrgica fue el incidentaloma en 68 pacientes (42,5 pr ciento), el síndrome de Cushing en 27 (16,8 por ciento), feocromocitoma en 26 (16,25 por ciento), la Enfermedad de Cushing con fracaso del tratamiento neuroquirúrgico en 12 (7,5 por ciento), mielolipomas en 7 (4,37 por ciento), tumor adrenal en 6 (3,75 por ciento), tumor metastásico en 5 (3,1 por ciento), quistes adrenales en 4 (2,5 por ciento), hiperaldosteronismo primario en 3 (1,87 por ciento), tumor virilizante adrenal en 1 paciente y 1 paciente con un Síndrome de secreción ectópica de ACTH que le provocaba un Síndrome de Cushing complicado. Predominaron las lesiones del lado izquierdo en 86 pacientes, 72 del lado derecho y 2 bilaterales. Fueron convertidos a cirugía convencional 2 pacientes (1,25 por ciento). El tiempo quirúrgico promedio fue de 82 minutos. La estadía posoperatoria promedio fue de 2.5 días. Conclusiones: la adrenalectomía laparoscópica es una técnica reproducible y segura con las ventajas inherentes a la cirugía laparoscópica(AU)

Introduction: As far as 1997, the performing of laparoscopic adrenalectomy started in our center. Objective: To analyze the results of laparoscopic adrenalectomy since its implementation in the general surgery service of Hermanos Ameijeiras Clinical Surgical Hospital. Methods: A descriptive study was carried out with the results obtained from 160 patients who underwent laparoscopic adrenalectomy, in the period from November 1997 to September 2017, in the general surgery service of Hermanos Ameijeiras University Clinical Surgical Hospital. The laparoscopic technique with intraperitoneal lateral approach was used in the majority of cases and the supine approach was used in two cases for bilateral adrenalectomy. Results: 162 laparoscopic adrenalectomies were performed in 160 patients, since two patients underwent bilateral adrenalectomy at one time. The average age was 44.8 years. Surgical indication cases were incidentalomas, in 68 patients (42.5 percent), Cushing's syndrome in 27 (16.8 percent), pheochromocytomas in 26 (16.25 percent), Cushing's disease with neurosurgical treatment failure in 12 (7.5 percent), myelolipomas in 7 (4.37 percent), adrenal tumor in 6 (3.75 percent), metastatic tumor in 5 (3.1 percent), adrenal cysts in 4 (2.5 percent), primary hyperaldosteronism in 3 (1.87 percent), adrenal virilizing tumor in 1 patient, and 1 patient with an ectopic ACTH secretion syndrome that caused a complicated Cushing's syndrome. Lesions on the left side were predominant in 86 patients, 72 on the right side and two bilateral. Two patients (1.25 percent) were converted to conventional surgery. The average surgical time was 82 minutes. The average postoperative stay was 2.5 days. Conclusions: Laparoscopic adrenalectomy is a reproducible and safe technique with the advantages inherent to laparoscopic surgery(AU)

Adenoma corticoadrenal, presentándose como un incidentaloma: presentación de un caso y revisión de la literatura / Adrenocortical adenoma, presenting as an incidentaloma: case report and literature review

Resumen Objetivo: Presentamos un caso clínico con diagnóstico de incidentaloma adrenal no funcionante asintomático y analizamos las implicaciones clínicas y el abordaje realizado. Caso clínico: Se reporta el caso de un masculino de 53 años, asintomático, con hallazgo ecográfico accidental de imagen hipoecoica de contornos bien definidos en la glándula suprarrenal derecha que presentó incremento en su tamaño. Su estudio hormonal fue negativo para hiperfunción adrenal. Resultados: Se realizó suprarrenalectomía laparoscópica con técnica de 4 trocares con resección completa de la lesión. El paciente presentó buena evolución posquirúrgica. El estudio anatomopatológico concluyó el diagnóstico de adenoma corticoadrenal no funcionante. Conclusión: Ante el hallazgo de una masa adrenal mayor de 1 cm corresponde realizar una identificación hormonal y una evaluación del riesgo de malignidad en los pacientes, los cuales, junto con parámetros imagenológicos y los síntomas presentados, permitirán definir las complicaciones en el manejo y el pronóstico del paciente. El diagnóstico diferencial de los adenomas adrenales está basado en la identificación hormonal, el conocimiento radiológico y el grado de compromiso de la lesión. El abordaje laparoscópico es de elección en las lesiones pequeñas y sin sospecha de malignidad.

Objective: We present a clinical case with diagnosis of an asymptomatic nonfunctional adrenal incidentaloma, in which we discuss the clinical implications and the approach. Clinical case: Male patient, 53 years old with an accidental sonographic finding, characterized by a hypoechoic image of well-defined contours in the right adrenal gland of less than 2 cm. The hormonal test showed no adrenal hyperfunctioning. Laparoscopic adrenalectomy technique is performed with 4 trocars with complete excision of the lesion. The patient presented good postoperative evolution. Results: The pathology study showed a well-defined and benign tumor lesion of the adrenal gland, being similar to the fascicular zone and cortical hyperplasia next to it. The diagnosis is a non-functioning adenoma of the adrenal gland derived from the fascicular zone. Conclusion: Given the finding of an adrenal mass greater than 1 cm mass corresponds perform a hormonal identification and risk assessment of malignancy in patients, which with imaging parameters (echogenicity, bilateralism and the adjacent commitment) and symptoms presented allow to identify the complications in the management and prognosis of the patient. The differential diagnosis of adrenal adenomas is based on the hormonal evaluation, radiological knowledge and the commitment of the injury.

Experiência de 20 anos em adrenalectomia videolaparoscópica / Twenty-year experience in laparoscopic adrenalectomy

Introdução: As operações na glândula adrenal são realizadas para determinados cânceres, todas as massas biologicamente ativas, metástases, massas com mais de 4-5 cm encontradas incidentalmente e hiperplasia adrenal primária. Métodos: Estudo transversal e descritivo. Foram analisados os prontuários dos pacientes submetidos a adrenalectomia videolaparoscópica entre agosto de 1994 e novembro de 2014. Resultados: Foram realizadas 146 adrenalectomias videolaparoscópicas. Em 134 casos, foi realizada com sucesso, mas em 12 casos (8,2%), o procedimento foi convertido. Foram 97 pacientes do sexo feminino e 49 do sexo masculino, com idade variando de 9 a 81 anos (média de 46,7 anos). Foram removidas 56 adrenais direitas, 75 esquerdas e 15 bilaterais. O tamanho médio das adrenais foi de 5,7 cm, variando de 0,9 a 15 cm. A mediana do tempo de internação hospitalar pós-operatória foi de 4,5 dias. A mediana do tempo de cirurgia foi de 144 minutos. Houve complicações em 22,5% dos casos (maiores ­ casos em que houve conversão para cirurgia aberta, necessidade de reinternação hospitalar e óbito­ e menores), sendo 10,9% complicações intraoperatórias e 11,6% pós-operatórias. Apenas sete (4,7%) pacientes foram considerados complicações maiores. Conclusão: A cirurgia realizada em nosso serviço está de acordo com o descrito na literatura, com taxas aceitáveis de complicações, com motivos de conversão compatíveis e com as indicações totalmente aceitáveis e condizentes. A adrenalectomia videolaparoscópica é a cirurgia de escolha para patologias cirúrgicas da glândula adrenal, exceto em casos de carcinoma adrenal localmente invasivo com comprometimento de outras estruturas (AU)

Introduction: Adrenal gland surgery is performed for some types of cancer, all biologically active masses, metastases, masses larger than 4-5 cm found incidentally, and primary adrenal hyperplasia. Methods: A cross-sectional, descriptive study. Medical records of patients who underwent laparoscopic adrenalectomy from August 1994 to November 2014 were analyzed. Results: A total of 146 laparoscopic adrenalectomies were performed. In 134 cases, laparoscopic adrenalectomy was successfully performed, but in 12 cases (8.2%), the procedure was converted. There were 97 female patients and 49 male patients. Fifty-six right adrenal glands and 75 left adrenal glands were removed, and 15 patients had both of them removed. The average size of adrenal glands was 5.7 cm, ranging from 0.9 to 1.5 cm. The median length of postoperative hospital stay was 4.5 days, ranging from 1 to 55 days. The median surgery time was 144 minutes. There were 22.5% of complications (major ones ­ cases that required conversion to open surgery, hospital readmission, and death ­ and minor ones), of which 10.9% were intraoperative and 11.6% were postoperative. Only seven (4.7%) patients were classified as having major complications. Conclusion: The surgery performed in our department is consistent with the literature, showing acceptable rates of complications, compatible reasons for conversion, and completely acceptable and consistent indications. Laparoscopic adrenalectomy is the surgery of choice for diseases of the adrenal gland, except for locally invasive adrenal carcinoma compromising other structures (AU)

Long-term Results after CT-Guided Percutaneous Ethanol Ablation for the Treatment of Hyperfunctioning Adrenal Disorders

OBJECTIVES: To evaluate the safety and long-term efficacy of computed tomography-guided percutaneous ethanol ablation for benign primary and secondary hyperfunctioning adrenal disorders. METHOD: We retrospectively evaluated the long-term results of nine patients treated with computed tomography-guided percutaneous ethanol ablation: eight subjects who presented with primary adrenal disorders, such as pheochromocytoma, primary macronodular adrenal hyperplasia and aldosterone-producing adenoma, and one subject with Cushing disease refractory to conventional treatment. Eleven sessions were performed for the nine patients. The patient data were reviewed for the clinical outcome and procedure-related complications over ten years. RESULTS: Patients with aldosterone-producing adenoma had clinical improvement: symptoms recurred in one case 96 months after ethanol ablation, and the other patient was still in remission 110 months later. All patients with pheochromocytoma had clinical improvement but were eventually submitted to surgery for complete remission. No significant clinical improvement was seen in patients with hypercortisolism due to primary macronodular adrenal hyperplasia or Cushing disease. Major complications were seen in five of the eleven procedures and included cardiovascular instability and myocardial infarction. Minor complications attributed to sedation were seen in two patients. CONCLUSION: Computed tomography-guided ethanol ablation does not appear to be suitable for the long-term treatment of hyperfunctioning adrenal disorders and is not without risks.

Mielolipoma adrenal gigante: Adrenalectomía derecha laparoscópica / Giant adrenal myelolipoma. Right laparoscopic adrenalectomy

El mielolipoma es un tumor adrenal poco frecuente. Se trata de un tumor benigno no funcionante compuesto por tejido adiposo y hematopoyético. Presentamos el caso de una paciente de 33 años de edad con diagnóstico de incidentaloma adrenal de 14 cm de diámetro no funcionante. Los estudios imagenológicos presentaban características sugestivas de mielolipoma. Debido a la naturaleza benigna del tumor se decidió el abordaje laparoscópico. La anatomía patológica informó un mielolipoma de 444 gramos. La paciente evolucionó favorablemente en el postoperatorio. El abordaje laparoscópico para la resección del mielolipoma gigante fue factible y exitoso.

Adrenal myelolipoma is a rare, benign, non-functioning tumor. It is composed by fat and hematopoietic tissues. We present the case of a 33-year-old woman with diagnosis of a 14 cm diameter non-functioning right adrenal incidentaloma, with imaging features suggestive of myelolipoma. Based on the benign nature of the tumor, laparoscopic resection was performed. Histopathology showed a myelolipoma, weighting 444 grams. The patient evolved with an uneventful postoperative period. Laparoscopic adrenalectomy for a giant myelolipoma was feasible and successful.