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Adrenocorticotropin-independent macronodular adrenal hyperplasia treated by simultaneous bilateral laparoscopic adrenalectomy.

A 61-year-old woman was admitted to our hospital with hypertension and diabetes mellitus, and was found to have Cushing's syndrome. Radiological and endocrinological findings suggested adrenocorticotropic hormone-independent macronodular adrenal hyperplasia. Simultaneous bilateral laparoscopic adrenalectomy was performed, minimizing the number of trocar sites and operation time. Success was attributed to the careful selection of trocar sites to permit safe dissection.

Adrenal Glands↗

Dexamethasone increases adrenalectomy-depressed Na+,K(+)-ATPase mRNA and ouabain binding in spinal cord ventral horn.

The Na+,K(+)-ATPase plays a key role in the regulation of ion fluxes and membrane repolarization in the CNS. We have studied glucocorticoid effects on biosynthesis of the Na+,K(+)-ATPase and on ouabain binding in the ventral horn of the spinal cord using intact rats, adrenalectomized (ADX) rats, and ADX rats receiving dexamethasone (ADX+DEX) during 4 days. Cryostat sections from spinal cords were incubated with a 35S-oligonucleotide coding for the alpha 3-subunit or a 3H-cDNA coding for the beta 1-subunit of the Na+,K(+)-ATPase using in situ hybridization techniques. In ventral horn motoneurons, grain density per cell and grain density per area of soma for both probes were slightly reduced in ADX rats but significantly increased in the ADX+DEX group, using ANOVA and the Bonferroni's test. Statistical analysis of frequency histograms of neuronal densities further indicated a significant shift to the right for intact rats compared with ADX rats for both probes. Concomitantly, [3H]ouabain binding to membrane preparations from ventral horns was reduced in ADX rats and restored to normal by DEX administration. No effect of adrenalectomy or DEX treatment was obtained in the dorsal horn. In conclusion, glucocorticoids positively modulate the mRNA for the alpha 3-subunit and the beta 1-subunit of the Na+,K(+)-ATPase and recover ouabain binding to normal values. The increments of the synthesis and activity of an enzyme affecting membrane repolarization and synaptic neurotransmission are consistent with the alleged stimulatory effect of glucocorticoids on spinal cord function.

Adrenalectomy↗

Laparoscopic adrenalectomy and esophagomyotomy.

Recent improvements in laparoscopic equipment, technique, and skills have contributed to advancement of the laparoscopic approach to even relatively rare pediatric surgical diseases. Two invasive operations that now may be approached laparoscopically are adrenalectomy and esophagomyotomy. Both techniques, initially described in the early 1990s, are particularly well suited for the laparoscopic approach and have become accepted as the preferred technique among general surgeons. Despite infrequent indications for either of these operations in children, pediatric surgeons experienced in minimally invasive techniques may apply the laparoscopic approach in a safe and effective manner. Furthermore, regarding achalasia in the pediatric population specifically, the offering of a less-invasive surgical approach may contribute toward more primary definitive surgical management being offered initially rather than after prolonged supportive medical care. The goal of this article is to familiarize the reader with the current laparoscopic approach to benign pediatric adrenal conditions and esophageal motility disorders in children.

Adenoma↗

Effects of adrenalectomy and hypercorticism on the ACTH content of the anterior and posterior pituitary in rats with inherited diabetes insipidus (Brattleboro strain).

The effects of adrenalectomy (Adx) and hypercorticism on the ACTH content in the anterior (AH) and the neurointermediate lobe (NIL) of the pituitary in Long Evans (+/+), heterozygous (+/DI) and homozygous (DI/DI) Brattleboro rats were determined using dispersed adrenal cells bioassay. Adx decreased the NIL-ACTH content in +/DI and DI/DI rats and left it unchanged in the +/+ rats. Adx increased the AH-ACTH content in the three groups. Hypercorticism had a delayed decreasing effect both in the AH and in the NIL in all rats, with one exception for the NIL in DI/DI rats. Conversely to what appeared in Wistar rats, in Long Evans and Brattleboro rats the corticosterone administered in drinking water was unable to reduce the increase in AH-ACTH activity. These data suggest that Brattleboro, and, to a lesser extent, Long Evans rats from which the former are derived present some particularities in the regulation of their corticotropic function at the AH and the NIL level. We also observed that NaCl (0.9%) added to drinking water and hypercorticism are two factors able to increase diabetes insipidus in homozygous rats without modifying the water intake in Long Evans and heterozygous rats.

Adrenal Glands↗

Studies on the compensatory growth of the adrenal cortex of the male hamster after unilateral adrenalectomy.

The aim of the study was to investigate the cellular aspects of compensatory growth of the adrenal cortex of male hamster after unilateral adrenalectomy. Relative right adrenal gland weight was higher at 24 h after hemiadrenalectomy with no differences--if compared with sham operated hamsters--at 12, 48, 96 and 120 h. In vitro 3H-thymidine incorporation per mg of adrenal after 12 h was higher and 120 h lower in monoadrenalectomised male hamsters than in sham operated animals with no differences in the remaining time-points studied. If 3H-thymidine incorporation was expressed per entire gland, only 120 h after surgery the uptake was lower than in sham operated animals. Five days after hemiadrenalectomy an increase in the average volume of the zona fasciculata cell and no change in the glomerulosa and reticularis zones were observed. At that day solitary adrenal cortex contained similar number of parenchymal cells as the right adrenal gland of sham operated animals. Thus, hemiadrenalectomy in the male hamster leads to a prompt proliferative response of the contralateral gland at 12 h after surgery, followed by decreased proliferative activity at 120 h after surgery. Monoadrenalectomy increased average volume of the zona fasciculata cell and did not change the total number of parenchymal cells in the gland if compared with sham operated animals.

Adrenal Cortex↗

Tissue regenerates of adrenal cortex with a physiological function twelve years after bilateral total adrenalectomy for Cushing's syndrome.

We report about a male patient, who underwent bilateral total adrenalectomy due to ACTH-dependent Cushing's syndrome without pituitary adenoma in his 11th year of life. Symptoms of Cushing's disease were absent during the follow-up period. Height and body weight followed the percentiles 25 and 50 respectively. An endogenous cortisol production was not detected and steroid substitution became necessary. Five years after the surgery, he showed normal cortisol levels, but there was no cortisol increase under ACTH-loading. Nine and 12 years (1993) after surgery, we found normal, physiological levels of cortisol suggestive of normal functioning adrenal glands (day profile of cortisol, Liddle-Test, ACTH-Test, CRH-Test, cortisol excretion in 24-h-urine). Moreover, baseline ACTH and its rise under CRH stimulation were normal. Scintigraphy revealed normal-sized adrenal tissue in orthotopic position on both sides. Steroid supplementation was discontinued. Presently the patient is healthy, active and under no steroid therapy. No evidence of residual or relapsing Cushing's disease or Nelson's syndrome has been found up to this point.

Adrenal Cortex↗

Correction by dexamethasone treatment of the altered lipolytic cascade induced by adrenalectomy in rat adipocytes.

The ability of glucocorticoid-treatment to reverse the metabolic alterations caused by adrenalectomy in rat adipocytes was studied. Correction of the enhanced adenosine antilipolytic effect and of the defect in lipolysis, cyclic AMP and adenylate cyclase responsiveness to guanine nucleotides were all achieved after a 24 h dexamethasone treatment, whereas correction of the defect in beta-adrenoceptor-density required a 48 h treatment. The latter treatment, however, failed to reverse the defect in both the adenylate cyclase catalytic activity and protein content per fat cell. These different kinetics of restoration indicate that correction by dexamethasone of the defective cyclic AMP and lipolytic responses on one hand and of the guanine nucleotide control of adenylate cyclase on the other one are two related phenomenoms.

4-Chloro-7-nitrobenzofurazan↗

Effects of thyroid hormone and adrenalectomy on [Na+ + K+]ATPase in the ob/ob mouse.

The absence of the thyroid stimulation of hepatic [Na+ + K+]ATPase in obese (ob/ob) mice has been investigated. A wide range of tri-iodothyronine (T3) concentrations failed to enhance the hepatic [Na+ + K+]ATPase of ob/ob mice made hypothyroid by methimazole treatment but glycerophosphate dehydrogenase activity was maximally stimulated at low doses of T3. Adrenalectomy increased the basal activity of [Na+ + K+]ATPase to levels found in lean control mice and restored the response of this enzyme to T3. Body weight gain was unaffected by the induction of hypothyroidism in either lean or ob/ob mice. It is concluded that the adrenal steroids play an important role in the expression of [Na+ + K+]ATPase activity in the ob/ob mouse.

Adrenalectomy↗

Time-course of hypothalamic CRH and pituitary ACTH contents, and pituitary responsiveness to CRH stimulation after bilateral adrenalectomy.

The pituitary ACTH and hypothalamic CRH alterations at different periods after adrenalectomy (ADX) or Sham ADX were studied by measurement of ACTH and CRH contents by radioimmunoassay (RIA) in rats. We also studied the corticotroph alterations by immunohistochemistry and the in vitro pituitary responsiveness to CRH. Plasma ACTH presented a triphasic response after ADX. Anterior pituitary (AP) ACTH content decreased 3 h and 1 day after surgery, then rose over this period. Immunohistochemistry demonstrated an initial degranulation of the corticotrophs with a progressive increase in cells immunostained for ACTH and a positive correlation (r = 0.88) with AP ACTH content measured by RIA. Hypothalamic CRH content decreased after ADX, but returned to sham value 3 weeks later. Basal ACTH secretion in incubation medium was correlated with the AP ACTH content observed in vivo. The pituitary responsiveness to CRH was not the same at all times after ADX. It was absent 1 day after, presented an increase of 51%, 117% and 26% when compared with the basal ACTH output 3 h, 3 and 14 days after ADX, respectively. Our data suggest that after ADX the corticotroph undergoes a transitory decrease in ability to secrete ACTH after store depletion. During a later phase, however, there is a relative hyporesponsiveness of the corticotroph to CRH stimulation. These data indicate that CRH may be acting on a down-regulated pituitary or more additional factors play a role in the sensitization of the pituitary after ADX.

Adrenalectomy↗

Mortality in 7B2 null mice can be rescued by adrenalectomy: involvement of dopamine in ACTH hypersecretion.

The serine protease prohormone convertase 2 (PC2), principally involved in the processing of polypeptide hormone precursors in neuroendocrine tissues, requires interaction with the neuroendocrine protein 7B2 to generate an enzymatically active form. 7B2 null mice express no PC2 activity and release large quantities of uncleaved ACTH, resulting in a lethal endocrine condition that resembles pituitary Cushing's (Westphal, C. H., Muller, L., Zhou, A., Bonner-Weir, S., Schambelan, M., Steiner, D. F., Lindberg, I. & Leder, P. (1999) Cell 96, 689). Here, we have compared the 7B2 and PC2 null mouse models to determine why the 7B2 null, but not the PC2 null, exhibits a lethal disease state. Both 7B2 and PC2 nulls contained highly elevated pituitary adrenocorticotropic hormone (ACTH); the neurointermediate lobe content of ACTH in 7B2 nulls was 13-fold higher than in WT mice; that of the PC2 null was 65-fold higher. However, circulating ACTH levels were much higher in the 7B2 null than in the PC2 null. Because hypothalamic inhibitory dopaminergic control represents the major influence on intermediate lobe proopiomelanocortin-derived peptide secretion, dopamine levels were measured, and they revealed that 7B2 null pituitaries contained only one-fourth of WT pituitary dopamine. Adrenalectomized 7B2 null animals survived past the usual time of death at 5 weeks; a month after adrenalectomy, they exhibited normal levels of pituitary dopamine, circulating ACTH, and corticosterone. Elevated corticosterone, therefore, seems to play a central role in the lethal phenotype of the 7B2 null, whereas a 7B2-mediated dopaminergic deficiency state may be involved in the actual ACTH hypersecretion phenomenon. Interestingly, adrenalectomized 7B2 nulls also developed unexpectedly severe obesity.

Adrenal Glands↗

Adrenalectomy or superior cervical ganglionectomy modifies the nocturnal increase in rat pineal type II thyroxine 5'-deiodinase.

We studied the response of type II thyroxine 5'-deiodinase (5'-D) activity to superior cervical ganglionectomy (SCGX) or adrenalectomy (ADX) in the rat pineal gland and other tissues. The results show that no difference was found between controls and SCGX animals during the day, but at night, SCGX modified the day-night cycle of 5'-D activity in the pineal gland. In the same way, ADX did not modify the enzyme activity during the day in pineal gland, harderian gland, hypophysis, or brain frontal cortex (BFC). However, in brown adipose tissue (BAT), where thyroid hormone metabolism is extremely dependent on alpha 1-adrenergic stimulation by blood circulating catecholamines, 5'-D activity is significantly decreased. At the time point of maximal pineal 5'-D activity in controls (02:00 h), ADX animals did not exhibit the nocturnal increase of the enzyme activity that occurs with control rats. Moreover, at 04:00 h ADX did not show any effect on pineal 5'-D activity. These results seem to suggest that the presence of catecholamines in blood is necessary for the pineal 5'-D activity nocturnal increase, although it does not participate in regulating the basal enzyme activity during the day.

Adipose Tissue, Brown↗

Adrenalectomy sensitizes mice to the lethal effects of interleukin 1 and tumor necrosis factor.

To clarify the possible role of TNF and IL-1 in endotoxic shock, the lethality of rTNF (human and murine) and IL-1 in adrenalectomized mice was studied. Adrenalectomy, which has long been known to increase the susceptibility to endotoxin, rendered mice susceptible to TNF and IL-1 in terms of mortality. The lethality of endotoxin, TNF, or IL-1 was totally prevented by pretreatment with dexamethasone (minimal effective dose, 0.3 mg/Kg) but not by ibuprofen (10 mg/Kg).

Adrenal Cortex↗

Laparoscopic adrenalectomy: a cost analysis of three approaches.

Laparoscopic adrenalectomy (LA) is the current standard for treatment of benign adrenal disease and is performed more often now in the setting of malignant disease. Three surgical approaches, the lateral transperitoneal technique, the lateral retroperitoneal technique, and the posterior technique are utilized commonly. While advantages of each approach are advocated, a cost analysis is not available. This article analyzes the operating costs of the three approaches. The operative costs of 51 unilateral LA at the Cleveland Clinic Foundation from 1998 to 2002 were analyzed for comparison. Patients were grouped according to one of the three laparoscopic approaches--transperitoneal (group A), lateral retroperitoneal (group B), and posterior (group C). For each group, n=17. Perioperative characteristics and operative cost were analyzed. The groups were compared using single factor ANOVA analysis. Significance was assigned for P<0.05. The average costs of unilateral LA were $2,885, $3,219, and $2,850 for groups A, B, and C, respectively (P=0.20). Differences were not statistically significant. Six bilateral procedures were performed. There were no significant differences for these six cases. However, the cohort was too small for an appropriate power analysis. LA is commonly performed utilizing one of three surgical approaches. Our data demonstrates no significant difference in operative cost between the respective techniques. Operative costs should not be a factor in choosing a laparoscopic approach for unilateral adrenal disease.

Adrenal Gland Diseases↗

Laparoscopic adrenalectomy via the retroperitoneal approach: first five cases.

Between February and November 1994, we performed laparoscopic retroperitoneal adrenalectomy in five patients with benign adrenal tumors to confirm the efficacy of this operation. Using digital dissection and a balloon, we created a working space in the retroperitoneal cavity before we dissected the adrenal gland and removed it under laparoscopic observation. The adrenal glands of all five patients were removed without any complications. The mean operative time was 3.4 hours, and the mean estimated blood loss was 148 mL. The average postoperative hospital stay was 10 days, and the average full recovery time was 19 days. We concluded that the retroperitoneal approach is an advantageous and safe procedure in the laparoscopic removal of the adrenal gland with benign tumor.

Adrenal Gland Diseases↗

Laparoscopic adrenalectomy for primary hyperaldosteronism during pregnancy.

Laparoscopic adrenalectomy was performed early in the second trimester of pregnancy in a woman with an aldosteronoma causing hypertension (254/154 mm Hg). The patient was later delivered of a healthy baby. With suitable precautions and timing, major laparoscopic surgery can be performed safely during pregnancy.

Adenoma↗

Laparoscopic partial adrenalectomy for recurrent pheochromocytoma in a boy with Von Hippel-Lindau disease.

We describe a case of a boy with Von Hippel-Lindau disease who presented with recurrent right adrenal pheochromocytoma 4.5 years after laparoscopic bilateral partial adrenalectomy. The boy had a second laparoscopic adrenal-sparing removal of the tumor. By this technique, not only the recurrent tumor was successfully removed but also the unaffected adrenal cortex could be preserved for the second time. To our knowledge, this is the first published case of its type.

Adrenal Gland Neoplasms↗

Laparoscopic adrenalectomy.

Laparoscopic adrenalectomy has already been described by various authors. The present series consists of 25 consecutive, nonselected cases operated on in the Department of Surgery, University of Pisa. All operations were carried out using a minimal access technique, and there were no conversions to open surgery. The mean operative time was 109 min. The median postoperative stay was 3 days (range 2-5). There were no complications, and none of the patients required blood transfusion. This technique proved to be as safe as open surgery and caused less distress and allowed more rapid return to normal activity. Increased experience and the development of new laparoscopic equipment are expected to further reduce operative time.

Adrenal Gland Neoplasms↗