Mitchell Jamie, Barbosa German, Tsinberg Michael, Milas Mira, Siperstein Allan, Berber Eren
Endocrinology and Metabolism Institute, Section of Endocrine Surgery A-80, The Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
Surg Endosc. 2009 Feb;23(2):248-54. doi: 10.1007/s00464-008-0189-1. Epub 2008 Nov 27.
Subclinical Cushing's syndrome (SCS) is a well-described phenomenon where abnormalities of the hypothalamic-pituitary-adrenal axis exist in the absence of overt signs and symptoms of classic Cushing's syndrome. While this has been shown to exist in 5-20% of patients with adrenal lesions, no standardized biochemical regimen exists to screen for SCS. Consequently, many of these patients may not be diagnosed prior to adrenalectomy with the risk of postoperative adrenal insufficiency. We began checking morning (a.m.) serum cortisol levels on postoperative day 1 (POD1) following unilateral adrenalectomy for nonfunctioning adrenal lesions to determine the incidence of unrecognized adrenal insufficiency (AI) in these patients.
One hundred and five patients undergoing adrenalectomy at a tertiary care center from 1999 to 2007 were retrospectively evaluated. Patients with Cushing's syndrome, conditions associate with bilateral disease, and those receiving perioperative steroids were excluded, leaving 41 patients for analysis. A.m. serum cortisol levels were obtained in all patients POD1. Multiple factors were analyzed as possible predictors of AI. Analysis of variance (ANOVA), t-test, and chi-square test were used to determine statistical significance.
The 41 patients' diagnoses included 13 pheochromocytomas, 15 nonsecreting adenomas, 5 aldosteronomas, 5 metastatic lesions, 1 adrenocortical carcinoma, and 2 other benign lesions. Three groups were identified based on POD1, a.m. cortisol levels: sufficient (>10 microg/dl; n = 25, 61%), low-normal (3.4-10 microg/dl; n = 7, 17%), and insufficient (<3.4 microg/dl; n = 9, 22%). Tumor size and presence of diabetes, hypertension, and obesity were predictive of postoperative AI (p < 0.05).
AI after unilateral adrenalectomy without evidence of cortisol hypersecretion on preoperative screening was present in a significant number of patients in our series. Patients with diabetes, hypertension, obesity, and larger tumors may be at higher risk for postoperative AI. More thorough screening for cortisol hypersecretion may be warranted in patients with these characteristics, and obtaining routine postoperative cortisol levels may avoid potentially dangerous unrecognized adrenal insufficiency following adrenalectomy.
亚临床库欣综合征（SCS）是一种已被充分描述的现象，即下丘脑 - 垂体 - 肾上腺轴存在异常，但无典型库欣综合征的明显体征和症状。虽然已证明5% - 20%的肾上腺病变患者存在这种情况，但尚无用于筛查SCS的标准化生化方案。因此，许多此类患者在肾上腺切除术前可能未被诊断出来，存在术后肾上腺功能不全的风险。我们开始在单侧肾上腺切除术后第1天（POD1）早晨检查血清皮质醇水平，以确定这些患者中未被识别的肾上腺功能不全（AI）的发生率，该手术用于治疗无功能肾上腺病变。
回顾性评估了1999年至2007年在一家三级医疗中心接受肾上腺切除术的105例患者。排除患有库欣综合征、与双侧疾病相关的病症以及接受围手术期类固醇治疗的患者，留下41例患者进行分析。所有患者在POD1时获取早晨血清皮质醇水平。分析了多个因素作为AI的可能预测指标。使用方差分析（ANOVA）、t检验和卡方检验来确定统计学意义。
41例患者的诊断包括13例嗜铬细胞瘤、15例无分泌性腺瘤、5例醛固酮瘤、5例转移性病变、1例肾上腺皮质癌和2例其他良性病变。根据POD1早晨皮质醇水平分为三组：充足（>10μg/dl；n = 25，61%）、低正常（3.4 - 10μg/dl；n = 7，17%）和不足（<3.4μg/dl；n = 9，22%）。肿瘤大小以及糖尿病、高血压和肥胖的存在可预测术后AI（p < 0.05）。
在我们的系列研究中，大量单侧肾上腺切除术后且术前筛查无皮质醇分泌过多证据的患者存在AI。患有糖尿病、高血压、肥胖和肿瘤较大的患者术后发生AI的风险可能更高。对于具有这些特征的患者，可能需要更全面地筛查皮质醇分泌过多情况，并且常规获取术后皮质醇水平可能避免肾上腺切除术后潜在的危险的未被识别的肾上腺功能不全。
