Primary hyperaldosteronism surgery: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Primary hyperaldosteronism}} | {{Primary hyperaldosteronism}} | ||
{{CMG}} | {{CMG}}; {{AE}}{{HK}} | ||
==Overview== | ==Overview== | ||
Surgery is the mainstay of treatment for unilateral adrenal hyperplasia, aldosterone producing adenomas (APAs), adrenal carcinoma, ectopic ACTH, renin, and deoxycorticosterone secreting tumors. | Surgery is the mainstay of treatment for unilateral [[Adrenal gland|adrenal]] [[hyperplasia]], [[aldosterone]] producing [[adenomas]] (APAs), [[adrenal carcinoma]], [[ectopic]] [[Adrenocorticotropic hormone|ACTH]], [[renin]], and [[deoxycorticosterone]] secreting [[Tumor|tumors]]. | ||
==Surgery== | ==Surgery== | ||
Adrenal lesions producing excess aldosterone are treated mainly by | [[Adrenal gland|Adrenal]] lesions producing excess [[aldosterone]] are treated mainly by [[Laparoscopic surgery|laparoscopic adrenalectomy]]. Retroperitoneoscopic removal of [[adrenal glands]] in patients with primary hyperaldosteronism (Conn's syndrome) is a safe, rapidly performed surgical procedure and can thus be considered as first choice option for treatment of both [[solitary]] [[Adrenal gland|adrenal]] [[adenomas]] and [[hyperplasia]] presenting with a clinically predominating [[Nodule (medicine)|nodule]].<ref name="pmid18343972">{{cite journal |vauthors=Walz MK, Gwosdz R, Levin SL, Alesina PF, Suttorp AC, Metz KA, Wenger FA, Petersenn S, Mann K, Schmid KW |title=Retroperitoneoscopic adrenalectomy in Conn's syndrome caused by adrenal adenomas or nodular hyperplasia |journal=World J Surg |volume=32 |issue=5 |pages=847–53 |year=2008 |pmid=18343972 |doi=10.1007/s00268-008-9513-0 |url= |issn=}}</ref> Symptom resolution may take one to six months after the procedure. | ||
=== Indications === | === Indications === | ||
Surgery for primary hyperaldosteronism is indicated in the following:<ref name="pmid32301012">{{cite journal |vauthors=Horsley MG, Bailie GR |title=Effectiveness of theophylline monitoring by the use of serum assays |journal=J Clin Pharm Ther |volume=13 |issue=5 |pages=359–64 |year=1988 |pmid=3230101 |doi= |url= |issn=}}</ref> | Surgery for primary hyperaldosteronism is indicated in the following:<ref name="pmid32301012">{{cite journal |vauthors=Horsley MG, Bailie GR |title=Effectiveness of theophylline monitoring by the use of serum assays |journal=J Clin Pharm Ther |volume=13 |issue=5 |pages=359–64 |year=1988 |pmid=3230101 |doi= |url= |issn=}}</ref> | ||
* Unilateral adrenal hyperplasia | * Unilateral [[Adrenal gland|adrenal]] [[hyperplasia]] | ||
* Aldosterone producing adenoma (APA) | * [[Aldosterone]] producing [[adenoma]] (APA) | ||
* Adrenal carcinoma | * [[Adrenal carcinoma]] | ||
* Ectopic ACTH | * [[Ectopic]] [[Adrenocorticotropic hormone|ACTH]] | ||
* Reninoma | * Reninoma | ||
* Deoxycorticosterone secreting tumors | * [[Deoxycorticosterone]] secreting tumors | ||
Biochemical evidence of primary aldosteronism,. defined as all of the following present<ref name="pmid33370170">{{cite journal| author=Cohen JB, Cohen DL, Herman DS, Leppert JT, Byrd JB, Bhalla V| title=Testing for Primary Aldosteronism and Mineralocorticoid Receptor Antagonist Use Among U.S. Veterans : A Retrospective Cohort Study. | journal=Ann Intern Med | year= 2020 | volume= | issue= | pages= | pmid=33370170 | doi=10.7326/M20-4873 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33370170 }} </ref>: | |||
* plasma aldosterone concentration ≥15 ng/dL | |||
* aldosterone-renin activity ratio ≥30 or aldosterone-renin concentration ratio ≥4.8 | |||
* suppressed renin | |||
=== Contraindications === | === Contraindications === | ||
Surgery is contraindicated in the following situations: | Surgery is contraindicated in the following situations: | ||
* Hemodynamic instability | * [[Hemodynamic instability]] | ||
* Severe hypokalemia | * Severe [[hypokalemia]] | ||
== Post-surgical management == | === Post-surgical management === | ||
Postoperative management of primary hyperaldosteronism includes the following:<ref name="pmid3230101">{{cite journal |vauthors=Horsley MG, Bailie GR |title=Effectiveness of theophylline monitoring by the use of serum assays |journal=J Clin Pharm Ther |volume=13 |issue=5 |pages=359–64 |year=1988 |pmid=3230101 |doi= |url= |issn=}}</ref> | Postoperative management of primary hyperaldosteronism includes the following:<ref name="pmid3230101">{{cite journal |vauthors=Horsley MG, Bailie GR |title=Effectiveness of theophylline monitoring by the use of serum assays |journal=J Clin Pharm Ther |volume=13 |issue=5 |pages=359–64 |year=1988 |pmid=3230101 |doi= |url= |issn=}}</ref> | ||
* PRN use of anti-hypertensives and anti-hypokalemics | * PRN use of [[Antihypertensives|anti-hypertensives]] and anti-[[Hypokalemia|hypokalemics]] | ||
* Anti- | * Anti-hypokalemia can be continued if serum potassium is <3.0 meq/l | ||
* PAC / PRA should be recorded immediately postoperatively on day one, to ensure surgical cure. | * PAC/PRA should be recorded immediately postoperatively on day one, to ensure surgical cure. | ||
* Intra-venous saline load test (SLT) or a fludrocortisone suppression test (FST) can be conducted three months after surgery. | * [[Intravenous|Intra-venous]] [[Saline (medicine)|saline]] load test (SLT) or a [[fludrocortisone]] suppression test (FST) can be conducted three months after surgery. | ||
==Prognosis== | ===Post Surgical Prognosis=== | ||
Good [[prognosis]] after adrenalectomy depends on:<ref name="pmid18552288">{{cite journal |vauthors=Funder JW, Carey RM, Fardella C, Gomez-Sanchez CE, Mantero F, Stowasser M, Young WF, Montori VM |title=Case detection, diagnosis, and treatment of patients with primary aldosteronism: an endocrine society clinical practice guideline |journal=J. Clin. Endocrinol. Metab. |volume=93 |issue=9 |pages=3266–81 |year=2008 |pmid=18552288 |doi=10.1210/jc.2008-0104 |url= |issn=}}</ref> | |||
* Good response to medical therapy with [[spironolactone]] | |||
* Young age | |||
* Decreased duration of [[hypertension]] | |||
* Preoperative use of two or fewer [[antihypertensive]] agents | |||
==References== | ==References== | ||
Latest revision as of 03:06, 4 January 2021
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Primary hyperaldosteronism Microchapters |
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Differentiating Primary Hyperaldosteronism from other Diseases |
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Primary hyperaldosteronism surgery On the Web |
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American Roentgen Ray Society Images of Primary hyperaldosteronism surgery |
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Risk calculators and risk factors for Primary hyperaldosteronism surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]
Overview
Surgery is the mainstay of treatment for unilateral adrenal hyperplasia, aldosterone producing adenomas (APAs), adrenal carcinoma, ectopic ACTH, renin, and deoxycorticosterone secreting tumors.
Surgery
Adrenal lesions producing excess aldosterone are treated mainly by laparoscopic adrenalectomy. Retroperitoneoscopic removal of adrenal glands in patients with primary hyperaldosteronism (Conn's syndrome) is a safe, rapidly performed surgical procedure and can thus be considered as first choice option for treatment of both solitary adrenal adenomas and hyperplasia presenting with a clinically predominating nodule.[1] Symptom resolution may take one to six months after the procedure.
Indications
Surgery for primary hyperaldosteronism is indicated in the following:[2]
- Unilateral adrenal hyperplasia
- Aldosterone producing adenoma (APA)
- Adrenal carcinoma
- Ectopic ACTH
- Reninoma
- Deoxycorticosterone secreting tumors
Biochemical evidence of primary aldosteronism,. defined as all of the following present[3]:
- plasma aldosterone concentration ≥15 ng/dL
- aldosterone-renin activity ratio ≥30 or aldosterone-renin concentration ratio ≥4.8
- suppressed renin
Contraindications
Surgery is contraindicated in the following situations:
Post-surgical management
Postoperative management of primary hyperaldosteronism includes the following:[4]
- PRN use of anti-hypertensives and anti-hypokalemics
- Anti-hypokalemia can be continued if serum potassium is <3.0 meq/l
- PAC/PRA should be recorded immediately postoperatively on day one, to ensure surgical cure.
- Intra-venous saline load test (SLT) or a fludrocortisone suppression test (FST) can be conducted three months after surgery.
Post Surgical Prognosis
Good prognosis after adrenalectomy depends on:[5]
- Good response to medical therapy with spironolactone
- Young age
- Decreased duration of hypertension
- Preoperative use of two or fewer antihypertensive agents
References
- ↑ Walz MK, Gwosdz R, Levin SL, Alesina PF, Suttorp AC, Metz KA, Wenger FA, Petersenn S, Mann K, Schmid KW (2008). "Retroperitoneoscopic adrenalectomy in Conn's syndrome caused by adrenal adenomas or nodular hyperplasia". World J Surg. 32 (5): 847–53. doi:10.1007/s00268-008-9513-0. PMID 18343972.
- ↑ Horsley MG, Bailie GR (1988). "Effectiveness of theophylline monitoring by the use of serum assays". J Clin Pharm Ther. 13 (5): 359–64. PMID 3230101.
- ↑ Cohen JB, Cohen DL, Herman DS, Leppert JT, Byrd JB, Bhalla V (2020). "Testing for Primary Aldosteronism and Mineralocorticoid Receptor Antagonist Use Among U.S. Veterans : A Retrospective Cohort Study". Ann Intern Med. doi:10.7326/M20-4873. PMID 33370170 Check
|pmid=value (help). - ↑ Horsley MG, Bailie GR (1988). "Effectiveness of theophylline monitoring by the use of serum assays". J Clin Pharm Ther. 13 (5): 359–64. PMID 3230101.
- ↑ Funder JW, Carey RM, Fardella C, Gomez-Sanchez CE, Mantero F, Stowasser M, Young WF, Montori VM (2008). "Case detection, diagnosis, and treatment of patients with primary aldosteronism: an endocrine society clinical practice guideline". J. Clin. Endocrinol. Metab. 93 (9): 3266–81. doi:10.1210/jc.2008-0104. PMID 18552288.