Division of Endocrine Surgery, University of Pittsburgh, Pennsylvania.
Department of Surgery, University of California, San Francisco.
JAMA Surg. 2022 Oct 1;157(10):870-877. doi: 10.1001/jamasurg.2022.3544.
Adrenalectomy is the definitive treatment for multiple adrenal abnormalities. Advances in technology and genomics and an improved understanding of adrenal pathophysiology have altered operative techniques and indications.
To develop evidence-based recommendations to enhance the appropriate, safe, and effective approaches to adrenalectomy.
A multidisciplinary panel identified and investigated 7 categories of relevant clinical concern to practicing surgeons. Questions were structured in the framework Population, Intervention/Exposure, Comparison, and Outcome, and a guided review of medical literature from PubMed and/or Embase from 1980 to 2021 was performed. Recommendations were developed using Grading of Recommendations, Assessment, Development and Evaluation methodology and were discussed until consensus, and patient advocacy representation was included.
Patients with an adrenal incidentaloma 1 cm or larger should undergo biochemical testing and further imaging characterization. Adrenal protocol computed tomography (CT) should be used to stratify malignancy risk and concern for pheochromocytoma. Routine scheduled follow-up of a nonfunctional adrenal nodule with benign imaging characteristics and unenhanced CT with Hounsfield units less than 10 is not suggested. When unilateral disease is present, laparoscopic adrenalectomy is recommended for patients with primary aldosteronism or autonomous cortisol secretion. Patients with clinical and radiographic findings consistent with adrenocortical carcinoma should be treated at high-volume multidisciplinary centers to optimize outcomes, including, when possible, a complete R0 resection without tumor disruption, which may require en bloc radical resection. Selective or nonselective α blockade can be used to safely prepare patients for surgical resection of paraganglioma/pheochromocytoma. Empirical perioperative glucocorticoid replacement therapy is indicated for patients with overt Cushing syndrome, but for patients with mild autonomous cortisol secretion, postoperative day 1 morning cortisol or cosyntropin stimulation testing can be used to determine the need for glucocorticoid replacement therapy. When patient and tumor variables are appropriate, we recommend minimally invasive adrenalectomy over open adrenalectomy because of improved perioperative morbidity. Minimally invasive adrenalectomy can be achieved either via a retroperitoneal or transperitoneal approach depending on surgeon expertise, as well as tumor and patient characteristics.
Twenty-six clinically relevant and evidence-based recommendations are provided to assist surgeons with perioperative adrenal care.
肾上腺切除术是治疗多种肾上腺异常的明确治疗方法。技术和基因组学的进步以及对肾上腺病理生理学的深入理解改变了手术技术和适应证。
制定循证建议，以增强对肾上腺切除术的适当、安全和有效的方法。
一个多学科小组确定并调查了 7 类与实践外科医生相关的临床关注问题。问题以人群、干预/暴露、比较和结果的框架构建，并对 1980 年至 2021 年期间来自 PubMed 和/或 Embase 的医学文献进行了有指导的审查。建议使用推荐评估、制定与评价（GRADE）方法制定，并在达成共识后进行讨论，并包括患者权益代表。
对于 1 厘米或更大的肾上腺意外瘤患者，应进行生化检测和进一步的影像学特征描述。应使用肾上腺方案 CT 来分层恶性风险和嗜铬细胞瘤的担忧。对于无功能性肾上腺结节，当影像学特征为良性且增强 CT 的 Hounsfield 单位小于 10 时，不建议常规安排随访。当存在单侧疾病时，建议对原发性醛固酮增多症或自主皮质醇分泌的患者进行腹腔镜肾上腺切除术。对于具有肾上腺皮质癌的临床和影像学表现的患者，应在高容量多学科中心进行治疗，以优化结果，包括在可能的情况下，无肿瘤破裂的完全 R0 切除，这可能需要整块根治性切除。选择性或非选择性α阻断剂可用于安全地为副神经节瘤/嗜铬细胞瘤的手术切除做准备。对于明显库欣综合征的患者，应进行经验性围手术期糖皮质激素替代治疗，但对于轻度自主皮质醇分泌的患者，术后第 1 天早晨皮质醇或促皮质素刺激试验可用于确定是否需要糖皮质激素替代治疗。在患者和肿瘤变量适当的情况下，我们建议微创肾上腺切除术优于开放肾上腺切除术，因为前者可降低围手术期发病率。微创肾上腺切除术可通过腹膜后或经腹腔途径实现，具体取决于外科医生的专业知识以及肿瘤和患者的特征。
提供了 26 项具有临床意义和循证的建议，以帮助外科医生进行围手术期肾上腺护理。
