后腹腔镜手术治疗双侧肾上腺大结节样增生

Retroperitoneal laparoscopic adrenalectomy for bilateral macronodular adrenal hyperplasia

目的探讨后腹腔镜手术治疗双侧肾上腺大结节样增生的可行性和有效性。方法9例双侧肾上腺大结节样增生行后腹腔镜手术治疗。5例有典型库欣综合征表现，4例仅有高血压或高血糖等非特异性症状。体重指数18．8—31．2，平均25．0。血皮质醇平均984（544～1746）nmol／L，尿游离皮质醇（urinary freecortisol，UFC）平均1129（347—1989）nmol／24h。CT示双侧肾上腺弥漫性增大伴多发结节，肾上腺平均8cm×5cm×4cm（6cm×5cm×4cm-10cm×6cm×3cm）。结果行后腹腔镜双侧肾上腺全切＋肾上腺组织阴囊皮下种植1例，右侧。肾上腺全切＋左侧肾上腺次全切除1例；右侧肾上腺全切4例（1例因出血中转开放手术），左侧肾上腺全切3例。平均手术时间116（60～165）min，平均术中估计出血量110（20～600）ml。术中无大血管或脏器损伤等严重并发症发生。病理诊断：肾上腺皮质结节样或腺瘤样增生。术后平均随访58（12～84）个月。5例典型库欣综合征症状均消失，4例体重增加、高血压或高血糖等非特异性症状者体重和血糖恢复正常。2例右侧肾上腺切除分别在术后33和41个月因症状复发行左侧肾上腺切除。结论双侧肾上腺大结节样增生行后腹腔镜肾上腺切除是安全可行的。后腹腔镜单侧肾上腺切除可缓解大部分患者的库欣症状，对症状不缓解或复发者可行双侧肾上腺切除或一侧肾上腺全切、对侧肾上腺次全切除。

Objective To discuss the clinical feasibility and significance of retroperitoneal laparoscopic adrenalectomy for bilateral macronodular adrenal hyperplasia. Methods 9 patients with bilateral macronodular adrenal hyperplasia received retroperitoneal laparoscopic operations. 5 cases had the typical clinical manifestetions of Cushing＇s syndrome and 4 patients presented hypertension or diabetes mellitus without any sign of Cushing＇s syndrome. Body mass index was 18. 8-31.2, with 25.0 as the average. Serum cortisol was 544-1746 nmol/L, with 984 nmol/L as the average. Urinary free cortisol （UFC） was 347-1989 nmol/24h with 1129 nmol/24h as the average. CT scan showed bilateral enlargement of the adrenal glands with multiple macronodules. The size of the adrenal glandwas6cm×5cm×4cmto10cm×6cm×3cm, with8cm×5cm×4cmastheaverage. Results Onepatient underwent retroperitoneal laparoscopic bilateral adrenalectomy with replantation of adrenal gland tissue in scrotum, 1 patient underwent right lateral adrenalectomy combined with left subtotal adrenalectomy, 4 patients underwent right lateral adrenalectomy （1 case was converted to open surgery due to hemorrhage）, and 3 patients underwent left lateral adrenalectomy. The average operation duration was 116 min, ranging from 60 to 165 min. The estimated average intraoperative blood loss was 110 ml, ranging from 20 to 600 ml. No severe complications like injury in great vessels or organs happened during the operation. Pathological diagnosis showed nodular or adenomatoid hyperplasia of adrenal cortex. The average postoperative follow-up was 58 months, ranging from 12 to 84 months. Clinical symptoms of Cushing＇s syndrome disappeared after surgery in the 5 cases with typical clinical features of Cushing＇s syndrome. Body weight and blood glucose recovered to normal level for those 4 cases presenting body weight increasement, hypertension or diabetes mellitus. 2 cases with right lateral adrenalectomy received left adrenalectomy 33 and 41 months after the first operation due to recurrence of Cushing＇s syndrome. Conclusions Retroperitoneal laparoscopic adrenalectomy for bilateral macronodular adrenal hyperplasia is technically feasible in experinced hands. Unilateral adrenalectomy can relieve most of the Cushing＇s symptoms. Bilateral adrenalectomy or unilateral adrenalectomy com-bined with contralateral subtotal adrenalectomy can be performed if the symptoms are not improved or recurred after unilateral adrenalectomy.