Regression of venous thrombus after trans-sphenoidal hypophysectomy for pituitary-dependent hyperadrenocorticism in a dog.

An 8.0-kg 8-year-old male dachshund was presented for surgical treatment of suspected pituitary-dependent hyperadrenocorticism with portal vein thrombosis. Advanced diagnostic imaging revealed a thrombus in the splenic and portal veins. For the portal vein thrombus, CT angiography showed an enhanced timing delay in the lateral right and caudate liver lobes. Blood tests showed a marked increase in the liver panel, including total bile acid. Brain MRI revealed a pituitary mass, suggesting pituitary-dependent hyperadrenocorticism. The mass was completely resected. The preoperative antithrombotic therapy of rivaroxaban (0.66 mg/kg, PO, once per day) and clopidogrel sulphate (1.66 mg/kg, PO, once per day) was continued postoperatively. Six months after resection of the pituitary mass, the thrombus had disappeared. Further studies are required to prove a causal association between the disappearance of the thrombus and the treatments provided.

Safety of outpatient adrenalectomy across 3 minimally invasive approaches at 2 academic medical centers.

BACKGROUND: Outpatient adrenalectomy has the potential to decrease costs, improve inpatient capacity, and decrease patient exposure to hospital-acquired conditions. Still, the practice has yet to be widely adopted and current studies demonstrating the safety of outpatient adrenalectomy are limited by sample size, extensive exclusion criteria, and no comparison to inpatient cases. We aimed to study the characteristics and safety of outpatient adrenalectomy using the largest such sample to date across 2 academic medical centers and 3 minimally invasive approaches. METHODS: All minimally invasive adrenalectomies were identified, starting from the time outpatient adrenalectomy was initiated at each institution. Cases involving removal of other organs, bilateral adrenalectomies, and cases in which a patient was admitted to the hospital before the day of surgery were excluded. Patient, tumor, and case characteristics were compared between outpatient and inpatient cases, and multivariable regression analysis was used to assess odds of 30-day readmission and/or complication. RESULTS: Of 203 patients undergoing minimally invasive adrenalectomy, 49% (n = 99) were performed on an outpatient basis. Outpatient disposition was more likely in the setting of lower estimated blood loss, case completion before 3 pm, and for surgery performed in the setting of nodule/mass and primary hyperaldosteronism versus Cushing's syndrome, pheochromocytoma, and metastasis (P < .05). There were no significant differences in patient age, body mass index, American Society of Anesthesiologists class, procedure performed, or total time under anesthesia between inpatient and outpatient cases. On adjusted analysis, outpatient adrenalectomy was not associated with increased 30-day readmission rate (odds ratio 0.23 [confidence interval 0.04-1.26] P = .09) or 30-day complication rate (odds ratio 0.21 [confidence interval 0.06-0.81] P = .02). CONCLUSION: Outpatient adrenalectomy can be performed safely without increased risk of 30-day complications or readmission in appropriately selected candidates.

Surgical Approach to Endocrine Hypertension in Patients with Adrenal Disorders.

Increased hormonal secretion of aldosterone, cortisol, or catecholamines from an adrenal gland can produce a variety of undesirable symptoms, including hypertension, which may be the initial presenting symptom. Consequences of secondary hypertension can result in potential cardiovascular and cerebrovascular complications at higher rates than in those with essential hypertension. Once a biochemical diagnosis is confirmed, targeted pharmacotherapy can be initiated to improve hypertension and may be corrected with surgical intervention. Adrenalectomy can be curative and can reverse the risk of cardiovascular sequelae once blood pressure control is achieved. This article discusses perioperative and operative considerations of adrenal causes of hypertension.

[Surgical treatment of ACTH-ectopic syndrome]. / Khirurgicheskoe lechenie AKTG-éktopicheskogo sindroma.

ACTH-ectopic syndrome is a severe, multiple-symptom disease characterized by secretion of adrenocorticotropic hormone (ACTH) by ectopic tumor, increased release of adrenal cortical hormones and clinical picture of hypercorticism. Diagnosis and treatment of ACTH-ectopic syndrome is still difficult problem despite the achievements of modern medicine. There are several unresolved issues including optimal diagnostic algorithm, indications for various surgical procedures and their optimal dates. This review is devoted to these questions.

Changes of computed tomography-based body composition after adrenalectomy in patients with endogenous hypercortisolism.

CONTEXT: Data on longitudinal changes of computed tomography (CT)-determined visceral fat area (VFA), skeletal muscle area (SMA) and skeletal muscle radiodensity (SMD) after adrenalectomy are limited in patients with hypercortisolism. OBJECTIVE: To examine the association of severity of cortisol excess and improvement of CT-based muscle and fat parameters after adrenalectomy. DESIGN: Retrospective observational cohort study. PATIENTS: One hundred thirty-four patients with overt Cushing's syndrome (CS; n = 39), mild autonomous cortisol excess (MACE; n = 57), or nonfunctioning adrenal tumour (NFAT; n = 38) at a tertiary endocrinology institution between 2006 and 2017 were included. MEASUREMENTS: Changes in CT-determined VFA, visceral-to-subcutaneous fat ratio (VSR), SMA, skeletal muscle index (SMI), and SMD measured at the third lumbar vertebra (L3). RESULTS: At baseline, CS patients had higher VFA, lower SMA, SMI and SMD values, compared to NFAT or MACE patients. Compared to NFAT, significant decreases in VFA and increases in SMA, SMI and SMD was observed in CS 1 year after adrenalectomy. In MACE, adjusted mean changes of SMD but not VFA, SMA or SMI differ significantly compared to NFAT (+8.9% vs -3.4%, P = 0.032). In a multivariate linear regression model, the increase by 1 µg/dL of post-dexamethasone serum cortisol at baseline was independently associated with greater reduction of VFA (-3.95%), VSR (-3.07%), and increase in SMD (+0.92%, P < 0.05 for all) after adrenalectomy. CONCLUSIONS: The severity of cortisol excess was associated with greater improvement of L3 VFA, VSR and SMD 1 year after adrenalectomy. These CT-based markers may allow more objective assessment of treatment benefit at earlier stage.

Effectiveness of unilateral laparoscopic adrenalectomy in ACTH-independent hypercortisolaemia and subclinical Cushing's syndrome - a retrospective study on a large cohort.

INTRODUCTION: To assess the effectiveness of early unilateral laparoscopic adrenalectomy in ACTH-independent and subclinical hypercor-tisolaemia. MATERIAL AND METHODS: We conducted a unicentric, retrospective study. Between 2010 and 2015, 356 laparoscopic adrenalectomies were performed in the Department of General and Endocrine Surgery of the MUW. Hypercortisolaemia was found in 50 (14%) patients, while overt hypercortisolaemia was found in 31 patients. In the hypercortisolaemia group, ACTH-dependent hypercortisolaemia was diagnosed in five (10%) and ACTH-independent hypercortisolaemia in 25 patients (50%). One patient with overt hypercortisolaemia had cancer of the adrenal cortex. The remaining 19 (38%) patients had subclinical Cushing's syndrome. For our study, we compared patients with ACTH-independent hypercortisolaemia (n = 25) with those with Cushing's syndrome (n = 19). Patients with ACTH-dependent hyper-cortisolaemia (n = 5) and the patient with cancer of the adrenal cortex (n = 1) were excluded. RESULTS: Patients from both groups (n = 44) underwent a unilateral transperitoneal adrenalectomy. Good early outcomes were observed in 42 patients (93.3%). In one patient, an additional laparoscopic surgery was necessary on postoperative day 0 due to bleeding. In another patient, on day 22 post-surgery, we found an abscess in the site of the excised adrenal gland, which was drained under laparoscopic guid-ance. In three patients (6.8%) with substantial obesity, temporary respiratory insufficiency of varying degrees occurred. We did not observe any thromboembolic complications. All patients with overt hypercortisolaemia and nine patients with subclinical hypercortisolaemia had secondary adrenal insufficiency postoperatively. CONCLUSIONS: Transperitoneal unilateral laparoscopic adrenalectomy is an efficient and safe treatment option in patients with ACTH- -independent hypercortisolaemia, both overt and subclinical.

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.

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.

Long-term outcome after adrenalectomy for incidentally diagnosed subclinical cortisol-secreting adenomas.

BACKGROUND: The management of subclinical cortisol-secreting adenomas (SCSAs) is controversial, and available evidence to assess the superiority of an operative versus a nonoperative approach is lacking. The aim of this work was to report the postoperative results and the long-term outcomes for patients with incidentally diagnosed SCSAs and to compare the results with those of patients who underwent an operation for cortisol-secreting adenomas (CSAs). METHODS: From 1994-2011, 107 consecutive patients underwent laparoscopic unilateral adrenalectomy for either an SCSA (n = 39) or a CSA (n = 68). Preoperatively, all patients underwent standardized clinical, hormonal, and imaging assessments. Patients were followed up for ≥2 years with serial assessments of body weight, blood pressure, and glycated hemoglobin, HbA1c. RESULTS: Operative resection of SCSAs and CSAs did not significantly differ regarding operative time, conversion rate, overall operative and medical morbidity, and duration of stay. For SCSAs, the comparison between preoperative status and 2-year assessment showed a median weight loss of 6% (P < .001), a decrease in the median HbA1c of 15% (P < .001), and an improvement or normalization of blood pressure in 50% of the patients. The same significant beneficial metabolic effects of the operation with even greater improvement were observed in patients with CSAs. CONCLUSION: Laparoscopic unilateral adrenalectomy for SCSA is associated with low morbidity, no mortality, and significant improvement of various aspects of metabolic syndrome. Until additional evidence from prospective randomized controlled studies is obtained, laparoscopic unilateral adrenalectomy should be considered a valid option in the care of patients with SCSA.

Collateral circulation in ferrets (Mustela putorius) during temporary occlusion of the caudal vena cava.

OBJECTIVE To determine whether extent of collateral circulation would change during temporary occlusion of the caudal vena cava (CVC) in ferrets (Mustela putorius), a pressure change would occur caudal to the occlusion, and differences would exist between the sexes with respect to those changes. ANIMALS 8 adult ferrets (4 castrated males and 4 spayed females). PROCEDURES Ferrets were anesthetized. A balloon occlusion catheter was introduced through a jugular vein, passed into the CVC by use of fluoroscopy, positioned cranial to the right renal vein, and inflated for 20 minutes. Venography was performed 5 and 15 minutes after occlusion. Pressure in the CVC caudal to the occlusion was measured continuously. A CBC, plasma biochemical analysis, and urinalysis were performed immediately after the procedure and 2 or 3 days later. RESULTS All 8 ferrets survived the procedure; no differences were apparent between the sexes. Vessels providing collateral circulation were identified in all ferrets, indicating blood flow to the paravertebral venous plexus. Complications observed prior to occlusion included atrial and ventricular premature contractions. Complications after occlusion included bradycardia, seizures, and extravasation of contrast medium. Mean baseline CVC pressure was 5.4 cm H2O. During occlusion, 6 ferrets had a moderate increase in CVC pressure (mean, 24.3 cm H2O) and 2 ferrets had a marked increase in CVC pressure to > 55.0 cm H2O. CONCLUSIONS AND CLINICAL RELEVANCE Caval occlusion for 20 minutes was performed in healthy ferrets with minimal adverse effects noted within the follow-up period and no apparent differences between sexes. The CVC pressure during occlusion may be prognostic in ferrets undergoing surgical ligation of the CVC, which commonly occurs during adrenal tumor resection.

A magnetic resonance imaging-based classification system for indication of trans-sphenoidal hypophysectomy in canine pituitary-dependent hypercortisolism.

OBJECTIVES: The objectives of this study were to establish a magnetic resonance imaging-based classification system for canine hyperadrenocorticism according to pituitary gland extension, determine indications for trans-sphenoidal hypophysectomy, and clarify the prognosis for each disease grade. METHODS: A 5-point classification system (Grades 1 to 5) was developed based on tumour extension in dorsal and cranio-caudal directions. Cases were then classified as Type A: no arterial circle of Willis or cavernous sinus involvement and Type B: cases in which these blood vessels were involved. RESULTS: Medical records and magnetic resonance imaging data of 37 cases with hyperadrenocorticism were reviewed. Thirty-three cases underwent surgery; 4 Grade 5 cases did not have appropriate indications for surgery, and other therapies were used. Complete resection was achieved for 3, 3, 22 and 1 Grade 1A, 2A, 3A and 3B cases, respectively. Resection was incomplete in 1, 1 and 2 Grade 3A, 3B and 4B cases, respectively. Remission was achieved in 29 cases. Recurrence occurred in 4 cases, all of which were classified as Grade 3. CLINICAL SIGNIFICANCE: Dogs with Type A, Grade 1 to 3 hyperadrenocorticism had a good prognosis following trans-sphenoidal hypophysectomy. Grade 3B, 4 and 5 cases may not be suitable for this surgery.

Risk of concomitant malignancy in hyperfunctioning adrenal incidentalomas.

BACKGROUND: Adrenal masses are common incidental findings on radiologic imaging. The association between malignancy and hormonal hyperactivity found in incidentally discovered adrenal tumors, however, remains unclear. METHODS: A retrospective analysis of prospectively collected data from patients who underwent adrenalectomy for incidentally discovered adrenal tumors at a single institution. Outcomes and operative data were compared by univariate analysis. Area under the curve was used to analyze the effect of tumor size in predicting malignancy. RESULTS: There were 49 patients who initially presented with adrenal incidentalomas that underwent adrenalectomy. Most patients were Caucasian women with an average age of 51 ± 14 years. Of this group, 24 patients underwent resection for hyperfunctioning adrenal glands. There were no significant differences in malignancy rates between hyperfunctional and nonfunctional tumors (4.1% vs. 12.0%, P = 0.32). On final histopathology, there were four patients with adrenal malignancies: two adrenocortical carcinomas and two metastatic from renal carcinoma. Only one patient with a hyperfunctioning adrenal tumor had underlying malignancy. Overall, invasion of adjacent structures (P < 0.001), presence of lymphadenopathy (P = 0.02), metastasis (P = 0.03), irregular tumor margins (P = 0.01), heterogeneity (P = 0.05), and tumor size >6 cm (P = 0.04) on radiologic imaging were strongly associated with malignancy in adrenal incidentalomas. CONCLUSIONS: The risk of concomitant malignancy and hormonal hyperactivity in adrenal incidentalomas is very low. Tumor size (>6 cm) and radiographic features remain the most important predictors of adrenal malignancy, regardless of tumor function.

Single-incision laparoscopic adrenalectomy at Viet Duc University Hospital.

INTRODUCTION: Laparoscopic adrenalectomy is the technique of choice in the treatment of adrenal tumors. SILS has recently been introduced in this field and applied in Viet Duc University Hospital. Herein, we report our experience with single-incision transperitoneal adrenalectomy. METHODS: Between August 2010 and January 2012, 61 patients (23 men, 38 women) underwent SILS adrenalectomy at our institution. The diagnoses consisted of 20 patients with pheochromocytoma, 17 with nonfunctioning adenoma, 16 with Conn syndrome, 4 with Cushing syndrome and 4 with adrenal cysts. The mean age was 47.8 years (range, 21-68 years). There were 29 right-sided and 32 left-sided tumors; their mean diameter was 30.7 mm (range, 8-59 mm). Patients were in the flank position with the operated side up. A 2.5-cm pararectal incision at the level of the umbilicus was made to insert the SILS Port. RESULTS: The mean operating time was 78 min (range, 50-120 min), and mean blood loss was approximately 70 mL. Left-sided tumors were excised entirely with the SILS technique. Right-sided lesions sometimes required an additional trocar (hybrid technique). No drainage was needed at the operating site. There were no intraoperative or postoperative complications, but one case was converted to the conventional three-port technique. The mean length of hospital stay was 3.4 days (range, 2-6 days). CONCLUSION: Our preliminary results show that SILS adrenalectomy is safe and technically feasible. It should be considered among the surgical managements for selected patients with adrenal tumors.

Severe systemic hypertension in a cat with pituitary-dependent hyperadrenocorticism.

A seven-year-old Burmese cat was presented with sudden onset blindness. On physical examination, the cat had bilateral retinal detachment and severe systemic hypertension. Further clinical investigations revealed pituitary-dependent hyperadrenocorticism. Antihypertensive therapy was discontinued when the hypertension resolved after bilateral adrenalectomy. Systolic blood pressure remained normal until 19 months post-operatively when systemic hypertension recurred and was attributed to chronic kidney disease. The cat was euthanased 47 months after initial presentation. A pituitary adenoma was identified at post-mortem examination. This case illustrates that systemic hypertension can occur secondary to hyperadrenocorticism in the cat.

Successful treatment of acromegaly in a diabetic cat with transsphenoidal hypophysectomy.

UNLABELLED: PATIENT AND SURGICAL TREATMENT: An 11-year-old, castrated male cat was referred for insulin-resistant diabetes mellitus. It had a ravenous appetite, increased body weight, polyuria/polydipsia and a dull hair coat. The cat was receiving 25 IU insulin four times daily but blood glucose concentrations remained elevated. Plasma concentrations of growth hormone (GH) (51 microg/l, reference range 0.8-7.2 microg/l) and insulin-like growth factor 1 (IGF-1) (3871 microg/l, reference range 39-590 microg/l) were highly elevated, whereas those of alpha-melanocyte-stimulating hormone, adrenocorticotropic hormone and cortisol were normal. Computed tomography revealed a thick palatum molle and an enlarged pituitary gland, indicating a pituitary neoplasm. Microsurgical transsphenoidal hypophysectomy was performed and microscopic examination of the surgical specimen revealed an acidophilic, infiltrative pituitary adenoma that showed positive immunostaining for GH. OUTCOME: The clinical signs resolved and 3 weeks after surgery the cat no longer required insulin administration. One year after hypophysectomy the plasma concentrations of GH and IGF-1 were 2.4 microg/l and 113 microg/l, respectively. PRACTICAL RELEVANCE: This is the first report detailing transsphenoidal hypophysectomy as a feasible and effective treatment for feline acromegaly due to a pituitary somatotroph adenoma. Moreover, in this patient, concurrent insulin-resistant diabetes mellitus resolved completely. The surgery is discussed in the context of human and other feline therapies for acromegaly.

Computed tomography and low-field magnetic resonance imaging of the pituitary gland in dogs with pituitary-dependent hyperadrenocorticism: 11 cases (2001-2003).

OBJECTIVE: To compare the results of computed tomography (CT) and magnetic resonance imaging (MRI) of the pituitary gland in dogs with pituitary-dependent hyperadrenocorticism (PDH) caused by histologically confirmed pituitary adenoma. DESIGN: Retrospective case series. ANIMALS: 11 dogs with PDH that underwent transsphenoidal hypophysectomy. PROCEDURES: Medical records of dogs examined between January 2001 and March 2003 were reviewed. Dogs were included in this study if they had clinical signs of hypercortisolism at the time of admission (for which PDH was diagnosed) and underwent transsphenoidal hypophysectomy. Pre- and postcontrast CT and low-field MRI (0.2-Tesla magnet) were performed on the same day as surgery for each dog. RESULTS: An abnormal pituitary gland was found in 7 dogs by use of MRI and in the same 7 dogs by use of CT. Significant differences were found between postcontrast CT and MR images for height, width, and length of the pituitary gland; brain area; and thickness of the sphenoid bone. However, the pituitary gland height-to-brain area ratio determined from postcontrast CT and MR images was not significantly different. The signal-to-noise ratio and contrast-to-noise ratio of pre- and postcontrast MR images were significantly higher than those of the CT images. CONCLUSIONS AND CLINICAL RELEVANCE: Low-field MRI and dynamic CT imaging of the pituitary gland provided comparable information on the presence of pituitary adenomas in dogs with PDH.

Carcinoma suprarenal gigante. Presentación de un caso / Giant adrenal carcinoma. Case report

OBJETIVO: Presentar un caso con carcinoma suprarrenal gigante atendido en el Servicio de Urología Hospital General Universitario Camilo Cienfuegos de Sancti Spíritus, Cuba.MÉTODO: Paciente de 32 años de edad masculino que acudió a consulta de urgencia de Urología por presentar dolor en flanco izquierdo y pérdida de treinta libras de peso en un periodo de tres meses aproximadamente. Los estudios imagenológicos mostraron una gran masa tumoral con desplazamiento e infiltración de estructuras vecinas. En el estudio histológico se comprobó el diagnóstico de carcinoma suprarrenal.RESULTADOS:El tratamiento aplicado fue la cirugía de exéresis por vía toraco-abdominal. La evolución postoperatoria fue satisfactoria. Se presentaron varios parámetros de mal pronóstico, como peso y tamaño elevados, necrosis, patrón de crecimiento difuso e invasión capsular. El fallecimiento se produjo a los 6 meses de la intervención por progresión de la enfermedad.CONCLUSIONES: Las grandes dimensiones del tumor determinaron una cirugía de exéresis amplia, lo cual no impidió la progresión de la enfermedad y el fallecimiento del paciente a los 6 meses de operado(AU)

OBJECTIVE: To present a case of giant su-prarenal carcinoma assisted by the Urology Service of the “Camilo Cienfuegos Gorriarán” General University Hospital of Sancti Spíritus, Cuba.METHODS: 32 - year - old male patient who attended the emergency urology consultation, presenting left flank pain and a thirty - pound loss of weight in a three - month period. The radiological studies showed a great tumoral mass with displacement and infiltration of neighbor structures. Pathological study confirmed the diagnosis of suprarenal carcinoma.RESULTS: The treatment applied was surgical excision surgery via thoracico-abdominal approach. The postoperative evolution was satisfactory. Several parameters of bad prognosis such as weight and elevated size, necrosis, pattern of diffuse growth and capsular invasion were present. Death took place 6 months after intervention due to the progression of the illness.CONCLUSIONS: The big dimensions of the tumor determi-ned a wide excision surgery which didn’t stop the progression of the disease and the death of the patient 6 months after being operated(AU)