Clinical aspects of Adrenalectomy

Abstract: Annual rates of adrenalectomy have doubled in the last 20 years as a consequence of increased detection of adrenal incidentalomas, improved biochemical diagnosis, genetic screening, and minimally invasive surgical techniques. Most adrenal incidentalomas are benign non-functional adrenocortical adenomas. Functional adrenal tumours are associated with high morbidity if left untreated, and this may be the case also for patients with mild hormonal hypersecretion and non-functional adrenocortical adenomas. Malignant tumours may be difficult to diagnose preoperatively, and a significant number of operations are diagnostic procedures. The aim of this thesis was to evaluate the effect and potential value of adrenalectomy, risks of surgery, and health-related quality of life in patients with different adrenal conditions. Data were derived from the validated national quality register; Scandinavian Quality Register for Thyroid Parathyroid and Adrenal Surgery (SQRTPA) and the European quality register for endocrine surgery, Eurocrine®. For evaluation of health-related quality of life (HRQoL) patients were asked to complete the HRQoL-questionnaire SF-36.In paper I risk factors for postoperative complications, conversion from endoscopic to open surgery, and hospital stay for more than 3 days were assessed. Complication rate was low and associated with conversion to open surgery. Prolonged hospital stay was associated with bilateral tumour, conversion, open surgery, and hypersecretion of catecholamines. In paper II, HRQoL was evaluated in patients undergoing adrenalectomy. Patients with adrenal tumours reported lower HRQoL compared with a Swedish referent group and HRQoL improved after adrenalectomy in patients with functional tumours. In paper III the impact of adrenalectomy on specific morbidity in patients with mild and clinically overt hypercortisolism and non-functional adrenocortical adenoma were evaluated and compared with age and sex-matched controls. Approximately 50 per cent of the patients with adrenal tumours, regardless of diagnosis, suffered from hypertension preoperatively. Medication for hypertension decreased after adrenalectomy in all patient groups, which was not the case for controls. In paper IV patients registered in Eurocrine® with clinical and subclinical (without symptoms) phaeochromocytomas were studied. Almost half of the patients with phaeochromocytoma undergoing adrenalectomy were incidentally detected and only 88 per cent were diagnosed preoperatively. Among these patients, 91 per cent were treated preoperatively with alpha-blockade. Complication rate was four per cent and did not differ between indications for surgery or patients treated with preoperative alpha-blockade or not.This thesis shows that adrenalectomy, espcially for patients operated with minimally invasive approach, is a safe procedure with a low rate of surgical complications and rapid recovery regardless of underlying disease. Adrenalectomy has a positive influence on HRQoL in patients with hormonally active adrenal tumours. This thesis also shows that hypertension is common in patients with benign adrenocortical tumour regardless of cortisol secretion. In these patients, adrenalectomy appears to lead to decreased medication for hypertension postoperatively. Complication rate in patients with phaeochromocytoma is not affected by the indication for surgery, and seems not to be higher in patients not treated with preoperative alpha-blockade.