带蒂肾上腺背部皮下移位术治疗肾上腺皮髓质增生

Transposition of pedicled adrenal gland for the treatment of adrenocortical and medullary hyperplasia

目的探讨带蒂肾上腺背部皮下移位术治疗肾上腺皮髓质增生的临床疗效。方法。肾上腺增生患者20例。男6例，女14例。平均年龄36岁。高血压病史6个月～5年。临床表现为向心性肥胖、多血质、紫纹等15例，阵发性肌无力、痉挛、多尿等2例，持续性高血压、阵发性加剧3例。20例均行内分泌检查，其中15例24h尿17-羟皮质醇（17-OH）41～96μmol／24h（正常值8～28μmol／24h）、17-酮类固醇（17-KS）98～164μmol／24h（正常值28～76μmol／24h），4例香草基扁桃酸（VMA）90～210μmol／24h（正常值5～45μmol／24h），3例。肾上腺素（E）349～463nmol／24h（正常值O～82nmol／24h）、去甲肾上腺（NE）705～1069nmol／24h（正常值0～591nmol／24h）和多巴胺（DA）2742～4478nmol／24h（正常值424～2612nmol／24h）；3例血醛固酮（Ald）卧位543～720pmol／L（正常值28～139pmol／L）、立位978～1224pmol／L（正常值138～415pmol／L），4例血钾2．6～3．2mmol／L（正常值4．1～5．6mmol／L）。螺旋CT扫描示双侧肾上腺均匀性增大15例，单侧结节3例；MRI检查4例，显示双侧肾上腺弥漫性增大3例；131I-间位碘代苄胍（MIBG）肾上腺髓质显像检查5例，显示肾上腺增大3例。术前诊断库欣综合征11例、原发性醛固酮增多症2例、嗜铬细胞瘤1例、肾上腺髓质增生2例、库欣综合征-儿茶酚胺症4例。20例均采用带蒂肾上腺背部皮下移位术治疗，游离、结扎肾上腺中、下极血管，保留上极血管与膈肌相连形成蒂状结构，牵拉至11肋间皮下固定。结果20例手术均顺利完成，其中行双侧移位3例，单侧移位及对侧肾上腺切除1例。平均手术时间120min，平均出血量40ml，未发生明显外科并发症。术后平均10d出院。病理诊断20例均为肾上腺皮髓质增生。17例术后随访6个月～8年，平均3年。彩色多普勒超声检查示移位的肾上腺1．5～2．0cm×2．O～2．5cm，呈中、低回声，流速0．04～0．07m／s；其中13例患者临床症状消失，24h尿17-OH、17-KS、E、NE、DA和VMA、血钾和Ald均恢复正常；4例血压、17-OH和17-KS仍偏高，再行对侧肾上腺移位或切除后，恢复正常。结论带蒂肾上腺背部皮下移位术是治疗‘肾上腺皮髓质增生的有效方法。

Objective To investigate the clinical efficacy of pedicled adrenal transposition for the treatment of adrenocortical and medullary hyperplasia. Methods Twenty cases of adrenal hyperplasia （6 men and 14 women; mean age,36 years ） had history of hypertension from 0.5 to 5 years. Of all cases, 15 had centripetal obesity and purple striae, 2 had weakness and polyuria, 3 had durative hypertension. Serum potassium and aldosterone were increased in 4 and 3 cases, respectively. Urinary 17-OH and 17-KS were increased in 15 cases. Epinepgrine, norepinephrine and dopamine increased in 3 cases, VMA increased in 4 cases. CT scan and MRI revealed adrenal diffuse enlargement with increased thickness or nodules in 18 and 3 cases, respectively. 131II-MIBG scan showed positive in 3 cases. Preoperative diagnoses were Cushing＇s syndrome in 11 cases, hyperaldosteronism in 2 cases, pheochromocytoma in 1 case, adrenomedullary hyperplasia in 2 cases, Cushing＇s syndrome-cate- cholamine syndrome in 4 cases. All cases were treated with transposition of pedicled adrenal gland into the subcutaneous tissues. Results All operations were successful. The average operation time was 120 min, the average blood loss was 40 ml and the average hospital stay was 10 d. No obvious surgical complications occurred. Pathological studies of all the cases revealed the coexistence of adrenocortical and medullary hyperplasia. Seventeen cases were followed up for 0.5--8 years. Thirteen cases had no symptom and normal biochemical results. Four cases still had hypertension and abnormal biochemical results. They were recovered after adrenal operation of the ther side. Conclusion Transposition of pedicled adrenal gland could be an available option to treat patients with adrenocortical and medullary hyperplasia.