Friday, May 29, 2009

Bilateral Adrenalectomy for Refractory Cushing Disease: A Safe and Definitive Therapy

Philip W. Smith MDa, Corresponding Author Contact Information, E-mail The Corresponding Author, Kristin C. Turza MDa, Cullen O. Carter MDa, Mary Lee Vance MDc, Edward R. Laws MD, FACSb and John B. Hanks MD, FACSa

aDepartment of Surgery, University of Virginia, Charlottesville VA

bDepartment of Neurological Surgery, University of Virginia, Charlottesville VA

cDepartment of Medicine, University of Virginia, Charlottesville VA

Received 14 October 2008; 

revised 29 January 2009; 

accepted 2 February 2009. 

Available online 24 April 2009.

From http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T91-4W4S38W-2&_user=10&_coverDate=06%2F30%2F2009&_rdoc=11&_fmt=high&_orig=browse&_srch=doc-info(%23toc%235101%232009%23997919993%231116105%23FLA%23display%23Volume)&_cdi=5101&_sort=d&_docanchor=&_ct=46&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=8a88e97748d1e2e6d927094213d964bc

Background

Refractory Cushing disease (CD) is associated with considerable morbidity and mortality. Bilateral adrenalectomy (BA) offers effective permanent treatment. Both open and laparoscopic approaches have been used, but longterm comparisons are few.

Study Design

We reviewed 40 consecutive BA for refractory CD from 1995 through 2007. Surgical results were evaluated. A Short Form-36 Quality-of-Life (QOL) survey was performed.

Results

Eighty-five percent (34 of 40) of patients were women, and median age was 41.9 years (range, 22.2 to 78.3 years). All had persistent CD after transsphenoidal operation (mean, 1.7; range, 1 to 3). Median followup was 5.0 years. Thirty-eight percent (15 of 40) of procedures were performed laparoscopically; 1 was converted to open. There were no operative or 30-day mortalities, and there was 1 90-day mortality. Morbidities occurred in 7 of 40 (18%) patients. Median length of stay was shorter in the laparoscopic group (4 versus 6 days; p < 0.001). All patients achieved clinical reversal of hypercortisolism, including the 5 (13%) with ectopic adrenal tissue. Elevated serum ACTH (> 200 ng/mL) was present during followup in 33% (13 of 40). A QOL survey demonstrated 86% of patients felt good to excellent compared with 1 year pre-BA. Chronic fatigue was present most or all of the time in 46%, and patients were below population norms on 7 of 8 Short Form-36 scales. No difference was evident in QOL between laparoscopic and open adrenalectomy.

Conclusions

Our experience demonstrates excellent survival and clinical results, despite the inherent risk in patients with CD. There are persistent fatigue and QOL deficits that are not ameliorated by laparoscopic compared with open resection.

Abbreviations: BA, bilateral adrenalectomy; CD, Cushing disease; NS, Nelson syndrome; QOL, quality of life; SF-36, Short Form-36 Quality-Life-Survey; TSS, transsphenoidal surgery

Article Outline
Methods
Results
Discussion
Author Contributions
References

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Figure 1. Survival after bilateral adrenalectomy.

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Figure 2. Short Form-36 Quality-of-Life normative-based scoring, summary results.

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Table 1.

Patient and Prior Treatment Characteristics for Study Groups

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BMI, body mass index (calculated as kg/m2); TSS, transsphenoidal surgery; XRT, radiation therapy.

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Table 2.

Operative Characteristics and Outcomes for Patients in Study Groups

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EBL, estimated blood loss; LOS, length of stay.

low asterisk Excludes a single patient from the open adrenalectomy group with 3,700 mL EBL.

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Disclosure Information: Nothing to disclose.

Corresponding Author Contact InformationCorrespondence address: Philip W Smith, MD, Department of Surgery, University of Virginia, Box 800709, Charlottesville, VA 22908