腹腔镜下肾上腺部分切除术治疗库欣综合征肾上腺腺瘤：单中心121例临床分析

Clinical investigation on minimal invasive surgery for Cushing syndrome caused by adrenocortical adenoma： experience of 121 cases in a single center

目的探讨腹腔镜下肾上腺部分切除术治疗库欣综合征（Cushing syndrome，CS）肾上腺腺瘤的有效性和安全性。方法回顾性分析2010年1月至2015年12月收治的121例行腹腔镜下肾上腺部分切除术治疗的cs肾上腺腺瘤患者的临床资料，男10例，女111例。初次就诊年龄17～63岁，平均39岁。腺瘤位于右侧50例，左侧71例。肿瘤直径1．0～5．0cm，平均2．6cm。84例（69．4％）合并高血压，36例（29．8％）合并糖尿病，45例（37．2％）合并肥胖。121例均行腹腔镜下肾上腺部分切除术，62例行经腹膜后腹腔镜手术，59例行经腹腹腔镜手术，围手术期予皮质醇激素规律替代治疗。术后定期随访，观察症状及内分泌检查指标改善情况。结果本组121例手术中1例因出血量较大，转为开放手术，手术成功率为99．2％。中位手术时间50min（30～225min）；中位出血量50ml（20～400m1）；术后平均住院时间（5．0±3．2）d。62例行经腹膜后腹腔镜入路者中位手术时间55min（30—225min），术中出血量50ml（20—400m1），术后平均住院时间（5．0±2．4）d；59例行经腹腹腔镜入路者中位手术时间45min（30～120min），术中出血量60ml（20—300ml），术后平均住院时间（6．0±2．7）d，两种入路上述指标比较差异均无统计学意义（均P〉0．05）。术中并发症：血管损伤2例（发生率1．7％），两种手术入路者中各1例；腹腔脏器损伤2例（脾脏损伤1例，肝脏损伤1例），均发生于经腹腹腔镜手术中。术后并发症：深静脉血栓1例（0．8％），伤151血肿1例（0．8％），伤口感染4例（3．3％）。术后予激素替代治疗2～12个月，平均6．2个月。术前伴发的高血压、糖尿病和肥胖在术后均有不同程度的改善，其术后1年缓解率分别为58．3％（49／84）、30．6％（11／36）和60．O％（30／45）。结论腹腔镜下肾上腺部分切除术治疗CS肾上腺腺瘤效果满意，伴发的高血压、糖尿病、肥胖等疾病在手术后均有不同程度的缓解。经腹膜后腹腔镜入路对腹腔脏器影响小，经腹腹腔镜入路操作空间大。围手术期激素替代治疗是外科治疗的重要组成部分。

Objective To explore the efficacy and safety of minimal invasive adrenal sparing surgery for the treatment of Cushing syndrome caused by adrenocortical adenoma. Methods Patients who underwent minimal invasive adrenal surgery for adrenocortical adenoma in our institution from January 2010 to December 2015 were retrospectively analyzed. Preoperative, intraoperative, and postoperative variables were reviewed from the database. The mean patient age at diagnosis was 39 years and male： female ratio was 10：111. Of the 121 adenomas, 50 were located in the right adrenal and 71 in the left. The mean tumor size was 2. 6 cm. 84 cases had hypertension （69. 4% ） , 36 cases had diabetes mellitus （29.8%） , and 45 cases had obesity （37.2%）. Postoperative follow-up was performed by evaluating adrenal gland function and imaging. Results Mininal invasive partial adrenalectomy was performed in 121 cases and the success rate of operation was 99.2% （120/121）. Sixty-two cases received operation through retroperitoneal approach, and 59 eases were through transperitoneal approach. The median operative time was 50 min with a median blood loss of 50 ml. The mean postoperative hospital stay were （ 5.0 ＋ 3.2） days. The vascular injury occurred in 2 cases （ 1 case in each surgical approach ）, while the abdominal organ injury occurred in 2 cases with 1 case of spleen injury and 1 case of liver injury （ both in transperitoneal approach）. Postoperative complications were observed in 6 cases： 1 case of deep venous thrombosis, 1 case of wound hematoma, 4 cases of wound infection. Cortisol substitution was given in 2 to 12 months （mean 6. 2 months ） postoperatively. One year after operation, the remission rate of hypertension, diabetes and obesity was 58. 3 % （49/84）, 30.6% （11/36） and 60.0% （30/45）, respectively. Conclusions Minimal invasive adrenal surgery using retroperitoneal and transperitoneal laparoscopic technique can be performed with low morbidity and achieve an excellent outcome. The perioperative hormone therapy may also play an important role.