Brunicardi F C, Rosman P M, Lesser K L, Andersen D K
Surgery. 1985 Dec;98(6):1127-34.
To evaluate the current use of adrenalectomy in the treatment of Cushing's disease, we reviewed seven consecutive patients who have undergone adrenalectomy for Cushing's disease at this medical center during 1983 to 1984. Seventy-one percent (5/7) had pituitary, or type I, Cushing's disease, while 29% (2/7) had adrenal, or type II, Cushing's disease from either an adenoma or an adrenocortical carcinoma. Presenting signs and symptoms, either initially or at the time of recurrence, were typical of Cushing's syndrome. Four of five patients with type I disease had recurrent disease after transphenoidal hypophysectomy, bilateral adrenalectomy, or unilateral adrenalectomy. In three of five patients, medical therapy of hypercortisolism was abandoned because of adverse side effects. Preoperative evaluation in all patients included cortisol and ACTH levels, dexamethasone suppression tests, and computerized tomography (both abdominal and head). In patients with a prior history of adrenalectomy, radiocholesterol scans were also performed and were useful. Angiographic procedures were not required in these patients. In patients with type I disease, posterior operative approaches were used. In patients with type II disease, an anterolateral approach was used. Posterolateral incisions are preferred over Hugh-Young incisions and provide better exposure with a reduced risk of poor wound healing. Morbidity and mortality included one death and three nonhealing wounds. In the six surviving patients, symptoms resolved with variable frequency. Findings suggestive of Nelson's syndrome (hyperpigmentation) have occurred in two patients; serial computerized tomographic scans fail to reveal evidence of pituitary tumors. We conclude that adrenalectomy remains an essential form of therapy for patients with Cushing's syndrome caused by adrenal tumors or recurrence after previous surgery. The response to the operation is generally good, but long-term surveillance is required for the development of Nelson's syndrome.
为评估目前肾上腺切除术在库欣病治疗中的应用情况，我们回顾了1983年至1984年期间在本医疗中心因库欣病接受肾上腺切除术的7例连续患者。71%（5/7）患有垂体性或I型库欣病，而29%（2/7）患有肾上腺性或II型库欣病，病因分别为腺瘤或肾上腺皮质癌。初发时或复发时的临床表现均为典型的库欣综合征。5例I型疾病患者中有4例在经蝶窦垂体切除术、双侧肾上腺切除术或单侧肾上腺切除术后出现复发性疾病。5例患者中有3例因不良反应而放弃了高皮质醇血症的药物治疗。所有患者的术前评估包括皮质醇和促肾上腺皮质激素水平、地塞米松抑制试验以及计算机断层扫描（腹部和头部）。有肾上腺切除术既往史的患者还进行了放射性胆固醇扫描，且该检查很有用。这些患者无需进行血管造影检查。I型疾病患者采用后入路手术。II型疾病患者采用前外侧入路。后外侧切口优于休 - 扬切口，能提供更好的暴露，且伤口愈合不良风险降低。发病率和死亡率包括1例死亡和3例伤口不愈合。在6例存活患者中，症状以不同频率得到缓解。2例患者出现了提示尼尔森综合征（色素沉着过度）的表现；系列计算机断层扫描未发现垂体肿瘤的证据。我们得出结论，肾上腺切除术仍然是由肾上腺肿瘤引起的库欣综合征患者或既往手术后复发患者的一种重要治疗方式。手术反应总体良好，但需要长期监测以观察尼尔森综合征的发生。
