Cadmore media player playing video SCORE School Adrenal
Video Player
Accessibility
Using forms mode, you can utilize keyboard shortcuts to make usability more efficient.
Space bar will play and pause the video. Pressing escape will close all displays and pressing it again will jump to the end of the player.
You can press A to open the Keyboard Shortcut Dialog which also provides an audio description of the player and all of its features.
Language
1x
Play Speed
Adjust Volume
Transcript
Search
Result Count
of
Click to jump to result
Search
Re-center
Segments
Result Count
of
Click to jump to result
Search
Name:
SCORE School Adrenal
Description:
SCORE School Adrenal
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/c20c463d-77d0-402e-b00d-fde90597da70/thumbnails/c20c463d-77d0-402e-b00d-fde90597da70.png?sv=2019-02-02&sr=c&sig=v%2F%2Fxzr3cRCVvoWB01VPZEZ31HQvmqeyt%2FCr52sz5hZ4%3D&st=2024-12-26T11%3A55%3A37Z&se=2024-12-26T16%3A00%3A37Z&sp=r
Duration:
T00H54M50S
Embed URL:
https://stream.cadmore.media/player/c20c463d-77d0-402e-b00d-fde90597da70
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/c20c463d-77d0-402e-b00d-fde90597da70/SCORE School Adrenal.mp4?sv=2019-02-02&sr=c&sig=6M30StQDwq%2BN9Tpq3eIzL4QXYD1v84vP5n8%2BtuSfBRM%3D&st=2024-12-26T11%3A55%3A38Z&se=2024-12-26T14%3A00%3A38Z&sp=r
Upload Date:
2024-04-10T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER: Hello, everyone. Welcome to SCORE School. It's my pleasure to introduce Dr. Neal Saunders from Emory University School of Medicine, where he is an assistant professor of surgery in the division of general and GI surgery. Dr. Saunders received his medical degree from the University of Illinois College of Medicine in 2008. He completed his general surgery training at Emory, followed by a fellowship at Ohio State University in complex general surgical oncology.
SPEAKER: His clinical specialties are endocrine surgery, including malignancies of the thyroid, adrenal, and parathyroid. And his primary research interests are thyroid cancer, surgical outcomes, and quality improvement. Dr. Saunders has a particular interest in bedside ultrasonography, and currently serves as the program director of the endocrine surgery fellowship.
SPEAKER: I can't think of anyone more capable and an expert in talking about our topic today, which is the adrenal. Thank you, Dr. Saunders, so much for helping us with SCORE School.
NEIL SAUNDERS: Well, thank you for having me here, and today, I'm going to talk about the adrenal. We'll narrow it down to a few topics because kind of all the surgical diseases of the adrenal, it would take many hours of lecture, but we'll narrow it down to a few today. So first, we're going to talk about adrenal incidentalomas. These are extremely common. As we scan more and more people on CT scan as soon as they come into the ER, we're seeing lots of little adrenal neoplasms.
NEIL SAUNDERS: And what do we need to do about that? We'll focus on a particular disease of the adrenal, the primary hyperaldosteronism and its work-up because its work-up's a little bit more nuanced and a little bit more difficult than the other adrenal neoplasms. And then we'll talk about adrenalectomy approaches, and specifically, laparoscopic adrenalectomy because that's what the vast majority of our adrenals need to be removed by.
NEIL SAUNDERS: By the end of the session, we should be able to understand initial evaluation of incidentally identified adrenal tumors. We'll identify the indications for resection of these adrenal incidentalomas. And we'll describe the technique and interpretation for adrenal venous sampling. In particular, I find a lot of residents get confused by this, and I'd like to go over it and its role in primary hyperaldosteronism.
NEIL SAUNDERS: I will also talk about the surgical approaches to the left and right adrenalectomy. So let's start with adrenal incidentaloma. I always like to start with a case, and this is somebody who actually came into my clinic a couple of weeks ago. He's a 42-year-old otherwise healthy male. He came to the emergency room with abdominal pain. He got the standard CT scan, which showed some gallstones without acute cholecystitis.
NEIL SAUNDERS: He was able to eat, so they sent him on his way, and he presents to your clinic a couple of weeks later. Look at 1.8 centimeter left adrenal nodule that I found on the CT. So what do you do about this? Here's his scan. We're at the level just above the left kidney, and you can see here on the left, there's a very small adrenal nodule, like it says, about 1.87 centimeters.
NEIL SAUNDERS: So these incidentalomas are very common. They found it in about 4% to 7% of abdominal CT scans. In patients who are older than 60 years old, it's actually seen on up to 10% of those patients' scans. The differential diagnosis is broad. The most common being benign nonfunctional adenomas, which make up about 80% of these tumors. And then every hormone that the adrenal can make can have a tumor producing that hormone as well.
NEIL SAUNDERS: So aldosteronomas, cortisol-producing tumor is causing Cushing's syndrome, pheochromocytomas, and then of course our malignancy, adrenal cortical carcinoma. And then on the other end of the spectrum, myelolipomas, which are benign and follow a little bit different rule, so which we'll get into later. And then metastatic disease. Most common cancers that metastasized to the adrenal will be lung melanoma, colorectal.
NEIL SAUNDERS: But you can also see renal cancer, and just about any cancer as well. So this is a review from your medical school days, and like I said, there's multiple layers in the adrenal, cortex and the medulla. And the cortex has three sublayers. The cortical cells embryologically come from the intermediate mesoderm. The medulla comes from neural crest cells.
NEIL SAUNDERS: And if you remember the mnemonic from medical school, GFR. Going from outer to inner is zona glomerulosa, fasciculata, and reticularis. And these are the levels which produce aldosterone, corticosteroids, sex hormones, respectively. And then the epinephrine and norepinephrine come from the medulla, which is where we get our pheochromocytomas. A review of these hormones, the cortex hormones come from the cholesterol precursor, as you can see here.
NEIL SAUNDERS: And then all the medullary hormones come from a tyrosine precursor. Normetanephrine and metanephrine will be used in our lab testing for pheochromocytoma, and it's just downstream from the norepineprhine and epinephrine in these processes. Also, briefly review the anatomy. As you probably remember, the left and right adrenals have different anatomy.
NEIL SAUNDERS: The biggest change in the anatomy between the sides is the adrenal vein. The left adrenal vein empties into the left renal vein, and the right adrenal vein directs, or empties, directly into the inferior vena cava. Performing the right adrenalectomy makes it a little bit more high-risk in that area, and the left adrenal vein is a little bit of a lower-risk area when we do the operations.
NEIL SAUNDERS: So like I said, we're going to focus on these benign nonfunctional adenomas, how we're going to follow those, and then we'll talk about the work-up of aldosteronomas as well. So when somebody comes in your office [INAUDIBLE] incidentalomas, you always want to start with a history and physical as with any patient that comes into your office. The history points are going to be focusing primarily on the symptoms associated with hormone excess.
NEIL SAUNDERS: And so if you're thinking about pheochromocytoma, you're talking about patients who are coming with, like, hypertension, headaches, tremors, flushing, palpitations. A lot of them have had multiple trips to the emergency room for hypertensive urgency. Cushing's patients are going to talk about weight gain that they've had, or new acne, muscle weakness, new abdominal fat.
NEIL SAUNDERS: Hyperaldosteronism, usually their symptoms are a little more subtle, but they may tell you about having low potassium, or muscle cramps, or fatigue. I mean, you always want to ask about a personal history of malignancy, like I had mentioned earlier. The adrenals are a relatively common site of metastatic disease, and so that may influence your decision making as well.
NEIL SAUNDERS: And then family history of MEN syndromes-- MEN2, worry about pheochromocytoma, and such. On physical exam, the tumor itself, unless it's really big, you're not going to be able to feel it, and the patient won't be able to feel it either. Something on the order of 4, 5, 6 centimeters, it's in an area of the body that doesn't have a lot of sensation, and so they're not really going to know it's there.
NEIL SAUNDERS: Patients who have tumors who are 10, 15 centimeters, there's a lot of times they will feel that pressure, and they will feel pain in their back from that. But most of the time, when you're seeing patients with these small tumors, they can't feel it. But on physical exam, you may see evidence of Cushing, a striae on the abdomen, increased abdominal obesity, hirsutism, acne, that type of stuff.
NEIL SAUNDERS: Once you are done with your physical exam, the next step will be screening labs if there's a functional tumor. The difference between functional and nonfunctional tumors is it's going to a lot of times determine whether they're going to be an operative candidate, or somebody who you're just going to follow with serial imaging and labs. And so our screen test, I always like to start with the plasma test, basic metabolic panel looking for hypokalemia or primary hyperaldosteronism.
NEIL SAUNDERS: Plasma metanephrines and catecholamines to screen for pheochromocytoma, and then the renin aldosterone to screen for hyperaldosteronism. ACTH, DHEA-sulfate as well. And a random serum cortisol test is not really a good test to screen for Cushing syndrome. And so for this, I'll usually send patients home with a prescription for a single tablet of 1 milligram of dexamethasone.
NEIL SAUNDERS: Have them take that in the evening, and then make sure they come the next morning around 8:00 AM for a morning cortisol drop. If their cortisol level is suppressed, then that's a pretty good screening test that they don't have Cushing's syndrome coming from the adrenal. If it's not depressed, then it may very well be that they have Cushing's from that adrenal tumor.
NEIL SAUNDERS: That was, again, our labs.
SPEAKER: [INAUDIBLE] --that constitutes a low-dose suppression test, correct?
NEIL SAUNDERS: Correct, correct. So that's a low-dose dexamethasone suppression test. And for deciding whether a patient has adrenal Cushing's or not, that's really all you need. We don't need to do a high-dose suppression test. That's really more for pituitary Cushing's. But if they don't suppress and they have an adrenal tumor, it's most likely that that's where it's coming from is the adrenal tumor.
SPEAKER: And the high dose is 4 milligrams?
NEIL SAUNDERS: 8 milligrams, if I remember correctly. Yeah.
SPEAKER: OK. Thanks.
NEIL SAUNDERS: And so the next step, once again, in our labs is getting imaging. And the best thing to start with is adrenal protocol CT. Usually whatever they've come with from the ER, or from the outside, it was probably just a regular CT scan with IV contrast, and none of those timings that they do in the routine ER scans are set up for adrenals. The adrenal protocol CT is actually an algorithmic CT that needs midscan radiology interpretation.
NEIL SAUNDERS: You start with a noncontrast CT of the abdomen. And if that adrenal lesion has low Hounsfield units less than 10, then that's diagnostic of a benign adrenal adenoma. And no contrast is necessary in that situation, so that's the end of the test. If it's greater than 10 Hounsfield units, then you proceed with IV contrast with adrenal timing until what you're looking for is washed out of the contrast from the adrenal gland in those timings.
NEIL SAUNDERS: And if it's more than 60% washout, that's indicative of a benign tumor. If there's less than 60% washout, or the results are indeterminate, sometimes an MRI may be helpful, but the adrenal protocol CT for the majority of adrenal adenomas will be enough. One thing I would like to stress is that we generally do not biopsy adrenal lesions.
NEIL SAUNDERS: Even if it's indeterminate on imaging, the biopsy usually yields little. The small amount of tissue that you get from even a core needle biopsy would not be enough to give a definitive diagnosis of adrenal cortical cancer, or a benign neoplasm. And ACC has a high rate of needle seeding from the biopsy. Until, in general, if you're concerned about that, don't biopsy.
NEIL SAUNDERS: You generally just recommend you take it out. Now, there are exceptions to this, and the biggest exception that we'll run into is a metastatic lesion where a tissue diagnosis from an adrenal will actually change the management of the primary cancer that it's coming from. And this is going to be different for every patient and every situation. There are some metastatic lesions where you're not going to biopsy it because knowing whether it is or is not metastatic disease won't change the management.
NEIL SAUNDERS: For example, one of the common ones we get is somebody with colorectal cancer, and the adrenal is their only site of disease. Or they have all of them as metastatic disease, maybe one or two lesions in the liver, and an adrenal lesion as well. And regardless of whether that biopsy is positive or negative, they're going to want you to take that lesion out. Now, it may be different in somebody, for example, with a lung cancer who has a met to that area, they may need to undergo chemotherapy upfront.
NEIL SAUNDERS: But they may not be starting with therapy without a tissue diagnosis. And in that situation, a biopsy would be indicated. Also, suspected lymphoma and suspected tuberculosis would be indications for a biopsy, and those are incredibly rare. So who meets initial resection criteria? If it's a functional tumor, if it's making an excess of any of those hormones, you can generally cure the patient if you remove it.
NEIL SAUNDERS: And so that would be our first criteria. The second is a size-based criteria. Generally, tumors greater than 4 centimeters, we would recommend come out. Once these tumors get bigger than 4 centimeters, the chance of it being an adrenal cortical cancer starts to become non-zero on the order of a couple of percent. Because adrenal cortical cancer has such a poor prognosis, and its main treatment is surgery, we'd rather take out a few too many benign lesions than miss an early adrenal cortical cancer.
NEIL SAUNDERS: Now, if it's bigger than 4 centimeters, and is clearly a myelolipoma on imaging, which is a very benign fatty-appearing adrenal lesion. You can push the limits a little bit on those. Some people wait till 6 centimeters. Some people wait until they're symptomatic. But if it's very clearly a myelolipoma, it usually doesn't fall into this 4-centimeter criteria. And then any of these lesions that are concerning for malignancy, or indeterminate on imaging, for the same reason that the size [INAUDIBLE],, we'd rather take out a few too many benign lesions than miss an early adrenal cortical cancer.
NEIL SAUNDERS: And so if it's indeterminate on imaging, then you can proceed with resection of the tumor. Most commonly, what happens is because 80% of these are going to be nonfunctional and consistent with a benign lesion on imaging, we end up following most of these. We generally follow them with serial CT scans. You want to do the first one about six months from the first one.
NEIL SAUNDERS: Just to be sure that you didn't happen to catch a fast-growing lesion early, you want that first interval scan to be a little bit closer. And then you can yearly follow them afterwards with CT scan. In the recommendation, generally, two to five years. Patient specific, but at least two years. You want to do an annual H and P, and then serial screening with labs when you see them every year as well. About 6% of nonfunctional adremal-- adrenal tumors will eventually become functional, so if you're not screening them at labs, you're going to miss those patients who will then have an indication for surgery.
NEIL SAUNDERS: The screening for the functional labs is recommended for five years annually. So as we're following these patients along, when do they meet resection criteria on follow-up? Well, if they've had a yearly interval growth of more than a centimeter, or if at that six month scan, it was more than half a centimeter, that growth rate would push them into a category needing resection.
NEIL SAUNDERS: Or if the tumor becomes functional as well.
SPEAKER: Nice description of the adrenal protocol CT. I've never heard of such a nice clarification of that. So I will ask you, let's say, you do have a patient who has a smaller adrenal tumor. Let's say it's 3 centimeters, and your initial CT was the elegant adrenal protocol CT you've described. Do the subsequent CT need to be similarly particlized, or can they be simpler?
NEIL SAUNDERS: So I will order adrenal protocol CT on them every year because most of the time, if they're coming back, their radiologist will see that interval-- even if it was a little bit indeterminate, and our MRI showed that it was benign. On that adrenal protocol CT, if they look at it, and they see that it's exactly the same size, they're not going to order the contrast on it probably. So yeah. So annually, I will get the adrenal particle CT on them.
SPEAKER: I see, that makes sense. To have that [INAUDIBLE],, they can really make the difference.
NEIL SAUNDERS: Yeah, and new to that, noncontrast CT is quick. With the 64-slice scanners, lets 30, 45 seconds running through, and then you kind of have your answer, especially if it stayed in the same size.
SPEAKER: All right. OK. Thank you.
NEIL SAUNDERS: So let's move on to aldosteronomas. One of the more common injury-- one of the more common functional tumors we'll see is aldosteronoma. Even though mostly incidentalomas are nonfunctional, we do see a fair amount of these. Cushing's syndrome would probably number three that we see, and then less commonly, is pheochromocytoma. The work-up for aldosteronoma, as you can see, is a little bit different than most of the other ones, and usually requires an extra step of adrenal venous sampling.
NEIL SAUNDERS: So this is the same patient who came in, 42-year-old gentleman, except his history is a little bit different now. He's had hypertension for the past five years. His primary care physician noted some low potassium levels on his routine annual labs, so he prescribed some oral potassium supplements. And when you get your screening labs, you see that his plasma aldosterone level is 24, and his plasma renin activity is 0.5, which is high and low for those two, respectively.
NEIL SAUNDERS: So this looks like a case of hyperaldosteronism. The screening tests for this disease, the plasma aldosterone concentration and the plasma renin activity, which we're going to get on all of our patients who come to us, depends on the incidentalomas anyway. And then we take the ratio of those as well. And so if the plasma aldosterone concentration is greater than 50 nanograms per deciliter, and the renin activity is suppressed as well, and that ratio's above 20, then that's pretty much diagnostic for hyperaldosteronism.
NEIL SAUNDERS: There's some salt-loading tests that can be done for confirmation if you have a borderline case, but in this particular case, it's pretty clear that this is what he's got with his hypokalemia and his clear serum screening tests. Now, this is an example of a CT that we would see in these patients, and it's actually the same patient we saw in the first case. But I want to look on the right adrenal here, which is a little bit higher than the left adrenal that's why it's kind of split into two slices here.
NEIL SAUNDERS: But this is a relatively normal-looking right adrenal, doesn't really look thickened. And then this is the left adrenal, which has that 1.8-centimeter lesion in it. And now you would think, OK, this patient's got hyperaldosteronism. He's got a clear adrenal lesion on the left. We should just take that out and cure his hyperaldosteronism. But in this disease, that's not quite the case.
NEIL SAUNDERS: This disease is actually pretty common. It's thought that up to 5% to 15% of all patients with hypertension have this as the underlying reason. It is poorly recognized, but is very prevalent out there. The most common phenotype of this is actually bilateral overproduction of aldosterone, and that's why the CT scan may be a little bit of a red herring for us.
NEIL SAUNDERS: An adenoma on the CT scan may not be the source of the excess aldosterone because the bilateral phenotype is so common. The way we sort this out is by adrenal venous sampling, which is going to be the key between differentiating unilateral and bilateral disease even in the presence of a unilateral adenoma. Here's the breakdown of the subtypes of primary hyperaldosteronism with a bilateral hyperplasia being 60% of all of these patients, and adenoma being only 35%.
NEIL SAUNDERS: It's a unilateral hyperplasia as well. And then more rarely are familial syndromes, and cancers producing excess aldosterone. So the reason we want to know if it's coming from one or two is because the only candidates for surgery are those with unilateral disease. If they have one side overproducing aldosterone, we can cure them by removing that one side. Because bilateral disease can be treated well with mineralocorticoids antagonist, like spironolactone, the nonoperative treatment for bilateral hyperplasia is our preferred method.
NEIL SAUNDERS: We don't want to take out both of these patient's adrenal because the medical treatment is actually very good. Similarly, with familial hyperaldosteronism, glucocorticoids are used to treat that. So why do we go through this extra step of adrenal venous sampling in most patients? And this is just an example paper. There's multiple papers with similar results out there, but this is one out of University of Michigan from 2008.
NEIL SAUNDERS: And they had 106 patients, 62 of which went to surgery. But 42 had both CT and a successful adrenal venous sampling. And what they found was that adrenal venous sampling in the patients that had it actually changed the management of these patients 35% of the time, meaning they had somebody with a unilateral adenoma, they did the AVS, and it was actually coming from both sides.
NEIL SAUNDERS: Or they had a patient with what looked like a unilateral adenoma, and when they did the adrenal venous sampling, it actually lateralized to the opposite side. And I'm sure you may have heard cases where patients didn't get adrenal venous sampling, ended up having the wrong adrenal gland removed because it looked like a clear adenoma on CT. And then you had to come back and say, you know, sorry we took the wrong one.
NEIL SAUNDERS: And this is why for, at least at Emory, for all patients with hyperaldosteronism, primary hyperaldosteronism, they're going to get AVS before we proceed with any surgery. So how's this done? This is done by our interventional radiologists. Having somebody who's skilled and specialized in this is actually important. With somebody who does this a lot, it's successful more than 95% of the time.
NEIL SAUNDERS: If you have a radiologist who doesn't do AVS a lot, it's actually only about 75% successful. And we'll talk about the anatomy and why that's the case. They usually use bilateral femoral vein access, and they run the catheters up into the IVC, and then the right and left adrenal veins. You compare aldosterone levels side to side between the adrenal veins. But we're not so much worried about the absolute level of aldosterone, but as ratio with cortisol.
NEIL SAUNDERS: And we'll talk about a hormone gradient in the vein, and why that's important. The cortisol essentially functions as the correction factor for how far in the catheter is. And so this is an example of the setup here. You can see that on the right, it actually takes a-- it's kind of an extreme angle from the cava into the right adrenal vein. It's nearly a 90-degree angle.
NEIL SAUNDERS: Whereas on the left side, it's a little more subtle turns to get in there. And so the left adrenal vein is relatively easy for them to cannulate, but that right adrenal vein is where all the skill comes in. Because of this turn, this is where the experience of kind of advanced IR guy is extremely helpful. This is where almost all the failures in adrenal venous sampling happens is not getting into this vein.
NEIL SAUNDERS: Now, I mentioned that we want to talk about using cortisol as a correction factor. The reason why is if you get this catheter really close to the adrenal and you take a sample, the aldosterone level is going to be really high because it hasn't had much time to mix with the blood on the way out to the cava. And so you may get a level of 10,000 right next to the adrenal, and 1,000 maybe a centimeter away.
NEIL SAUNDERS: And to know really what the correct interpretation is that you actually can use cortisol, which will be similarly following in gradient down that vein as well as a correction factor to make sure we're comparing apples to apples when we compare to side by side. So this is an example of the results that we get. Now, this can be done with cosyntropin stimulation, or without.
NEIL SAUNDERS: We actually do it with both, with and without at Emory. But some places will do it without, and some have a bias to do it with. And there's kind of mixed data on that, so either way is fine. But this is an example of what we get. We'll get measurements of the aldosterone and cortisol from the right and left adrenal veins, and then from the inferior vena cava.
NEIL SAUNDERS: The inferior vena cava numbers are really our control numbers for this test. What we want to do is make sure that we really did get into the adrenal veins, and the way that we confirm that is the cortisol in the adrenal vein samples has to be at least twice as high as the cortisol level in the vena cava. And that confirms that we were in an adrenal vein. In this example, the cortisol is 27, and both the left and the adrenal vein cortisols are clearly higher than that.
NEIL SAUNDERS: If for example, this left adrenal vein cortisol was only 50, then we would know we weren't in the left adrenal vein. Similarly with the right, the same thing would happen. Most commonly it's the right that we fail. Now, unfortunately, a lot of the times you don't get real-time results. And so you only find out after the test is completed, once all the labs come back, that they weren't in the right adrenal vein.
NEIL SAUNDERS: So for interpretations of whether this hyperaldosteronism is coming from the right or left, or both, we need to do a ratio of ratios for the interpretation. The first ratio that we do is the aldosterone to cortisol level, and we do that for both the right and the left adrenal vein. And then we compare those to each other. So we divide one over the other.
NEIL SAUNDERS: If that ratio is less than 3, that's evidence of bilateral disease. If it's greater than 4, then that's pretty clear a unilateral disease, and those patients are surgical candidates If, in fact, the right adrenal vein was cannulated during this, then these samples will be 96% accurate. Now, if the right adrenaline wasn't cannulated, generally, you have to repeat it.
NEIL SAUNDERS: There's some data that if it's extremely high, and extremely high ratios on one side or the other, and you didn't get into the right adrenal vein, you may be able to interpret those results with good success. But in general, if you didn't get into the right adrenal vein, it needs to be repeated. And it's a fairly invasive test to repeat. So let's take a look at an example of a patient here, and we'll go through doing the ratios and getting a final answer here.
NEIL SAUNDERS: So the first thing I want to do is confirm that the right adrenal vein is actually adrenal vein blood. And we look at the cortisol in the inferior vena cava and the right adrenal vein, and clearly, it's at least two times higher. Then, we calculate the ratios of aldosterone to cortisol for both adrenal veins. 1.6 on the right adrenal and 2.8 on the left.
NEIL SAUNDERS: And then we take those, divide them over each other. So 2.8 divided by 1.6, and our ratio is 1.75. And this is an evidence of bilateral disease. So in this patient, we wouldn't operate. They would go back to their endocrinologist, and get treated medically with spironolactone, or one of the other mineralocorticoid antagonists. Here's a second patient. Same thing, we'll look at the cortisol levels in the right adrenal and the inferior vena cava.
NEIL SAUNDERS: Clearly, it's at least two times higher. We'll take the ratio of aldosterone to cortisol for both of them, and the left adrenal is 16.2, and the right adrenal is 1.6. And then when we divide those out into 10 to 1, left to right ratio of ratios. And so this clearly lateralizes to the left, and we'll proceed with the left adrenalectomy in this situation.
NEIL SAUNDERS:
SPEAKER: What a nice review. I have never actually seen such a detail in the adrenal sampling. Are there examples where you do have bilaterally producing glands, but one is so much more active than the other that you would actually proceed with a unilateral?
NEIL SAUNDERS: So we have had that situation, and because the medical therapy is good enough, most of the time, we'll go with that. But we have had some patients, and not even in aldosterone, but we've seen it in patients with Cushing's who have actually bilateral hyperplasia causing Cushing's. And that's the more common that we'll see.
NEIL SAUNDERS: Now, in that situation, if we have one that's a lot higher than the other, I have taken out a unilateral adrenal, even in somebody who's having increased bilateral overproduction of cortisol. And that one side that was making so much more, taking that out, actually gave them a pretty good improvement in their quality of life, and years later is doing great, and have no plans to address the other side.
NEIL SAUNDERS: I don't know that I've personally encountered that in primary hyperaldosteronism, but yes, that could happen.
SPEAKER: OK. And once you do take out a unilateral gland, what do you do for biochemical follow-up afterwards?
NEIL SAUNDERS: So usually, I see most of my patients after those, three or four weeks after. We will check their renin and aldosterone again, and their potassium. The day after surgery, of course, we're checking the potassium, and most of these patients will always stay one night in the hospital. We'll make sure the potassium is OK the next day, and usually, it's normal that next day.
NEIL SAUNDERS: If it still remains abnormal, which thankfully happens 5% of time or less, then they would be treated medically after that. But fortunately with the AVS, we cure this 95% of the time, or more, with surgery.
SPEAKER: Great. Thank you.
NEIL SAUNDERS: So let's talk a little bit about adrenalectomy. There's a few different ways to approach this. Historically, the open approach before laparoscopic techniques. Our standard now, which I would say is laparoscopic transabdominal. Laparoscopic retroperitoneal is commonly done, but that's a little bit more specialized approach. And the robotic-assisted laparoscopic, which is just a variation of laparoscopic transabdominal surgery.
NEIL SAUNDERS: So I'm going to focus on the first two. And we're going to start with laparoscopic because we end up taking nearly 90 plus percent of our adrenals out this way. It's really kind of revolutionized the way we take our adrenals. Laparoscopic surgery for this became basically the standard of care in the early 2000s for small adrenal lesions, and the patient outcomes are just so much better. Now, for a benign nonfunctional disease, or an aldosteronoma, these patients for me are just staying overnight, and potentially, could go on the same day.
NEIL SAUNDERS: But we usually just keep them overnight compared to the historical data where patients were getting laparotomies for these, and they stay in the hospital five to seven days. And also the visualization with laparoscopic surgery for this particular area is actually superior doing it laparoscopically than open. And so this is kind of a perfect disease site for this approach.
NEIL SAUNDERS: For positioning these patients-- now, this is assuming that for whatever disease you're treating for this, whether it be a pheochromocytoma, or Cushing's, or primary hyperaldosteronism, that you've done the preop prep for them. Our pheochromocytoma patients are going to need the alpha blocked ahead of time to the point of orthostatic hypotension.
NEIL SAUNDERS: You're going to want to make sure the patients are well-hydrated before they come in. And if there's any sign of hypertension in the preop area, cancel the case. Try again another day. Cushing's patients they've got hypercortisolism and suppressed HPA axis. Those patients, you want to make sure they get preop steroids, and stress those steroids through the first 24 hours of their operation.
NEIL SAUNDERS: So presuming you've done all that, let's talk about positioning. So these operations are done in the left or right lateral decubitus position. And you put the flex of the bed in between the iliac crest and the costal margin. In that way, you can flex the bed and open the space up. And this is going to be the area where we're going to put our ports.
NEIL SAUNDERS: The left approach is generally a three or four-port operation. If they're relatively skinny and there's not a whole lot of retraction that you need to do, three ports is enough. The fourth port can be added for retraction. And the right side is, generally, always a four-port operation laparoscopically because you need that fourth port for liver retraction. And we'll talk about that a little bit.
NEIL SAUNDERS: To review the anatomy, like we said, the left and right are a little bit different. The right side, you're really focusing along the cava, and that right adrenal vein that's kind of a high-risk part of the operation there. And then the left side is coming off, or going into the left renal vein. So this is the laparoscopic left adrenalectomy positioning. Right lateral decubitus.
NEIL SAUNDERS: Generally, a camera port is in the midclavicular line. I usually put at 10 here, and it'll pop the view in to get into this area. And then ports one and two will generally be the working ports. This optional white assistant port here is if you had to-- if you needed some more retraction, especially holding down the colon mesentery out of the way. And then you can put a fourth port in between the camera port and the most lateral port.
NEIL SAUNDERS: The left laparoscopic technique is described as, or the technique that I use is described as an open-book technique. The first step of the operation is mobilizing the spleen off the diaphragm and the retroperitoneum, moving lateral to medial until you've got it mobilized enough that the spleen hangs immediately under its own weight.
NEIL SAUNDERS: One pitfall of this mobilization is that as you get to the most medial aspect in the superior part of your dissection for this mobilization, the fundus of the stomach will start to peak around the corner of the spleen. And so if you're using energy up there, like Harmonic or LigaSure, you've got to be careful that you're not just resting on the stomach.
NEIL SAUNDERS: And that's one of the key points of dissection here. The tail of the pancreas, as you know, tucks into the hilum of the spleen. It mobilizes medially with the spleen as well. And once the spleen is mobilized enough to hang medially on its own weight, it will pull the pancreas medially as well. Once you've completed the spleen mobilization, the second step is to mobilize a splenic flexure of the colon and its mesentery, and mobilizing that inferiorly.
NEIL SAUNDERS: And once that's done, the adrenals are going to come into view. You're going to notice there's going to be a valley between the pancreas medially, and the adrenal and the kidney laterally. Got a couple of views of that here in a minute. Once you've got all that mobilized, you can identify the left adrenal vein. It's generally in an inferomedial position on the adrenal, and it drains usually into the left renal vein.
NEIL SAUNDERS: When you take the adrenal vein, I always put clips on the stay side, and then use an energy device on the specimen side. You can use Harmonic, LigaSure, or similar instrument, whatever version of a vessel sealer the robotic robot has. And then once the left adrenal vein is taken, that's actually the main blood vessel of the whole operation. All of the other small arteries and such are small enough that can be taken primarily with an energy device.
NEIL SAUNDERS: The adrenal arteries are numerous, and they're all very small. And so it's no problem to take those with LigaSure or Harmonic. There's usually a venous branch going into the phrenic vein. That's a fairly low-pressure vein. You can take that with energy, no problem. And like I said, the adrenal arteries are small and not a problem to take with energy.
NEIL SAUNDERS: We put the specimen in endocatch bag, and pull it out through one of the port sites, and then close up. Now, here's drawings from a nice article from memory from 1999, describing this open-book technique. It's a great article. I think one of the best surgical technique articles out there, and this is how I do laparoscopic and robotic adrenalectomies.
NEIL SAUNDERS: So the first step is mobilizing the spleen here, and also taking down the splenic flexure of the colon. And then here's where it's described as open book, may have actually superimposed the book on the anatomy drawing. And so the stomach and the spleen and the pancreas are all hanging over to the left, with the adrenal and the kidney on the right. And then this nice valley appears, and just inferomedial on the adrenal, you'll see the adrenal vein.
NEIL SAUNDERS: In real life, this is what this looks like, with the splenic flexure of the colon inferiorly, and the kidney hidden here in the retroperitoneum. We mobilize the spleen to the left, and you can see the kidney starting to take shape here. My spleen is starting to move under its own weight, and then when we get it completely mobilized, the pancreas is hanging medially.
NEIL SAUNDERS: The kidney, over here, with the adrenal tumor here. And we can make up a left renal vein at the inferior aspect here, and then the left adrenal vein right here. We circumferentially dissect that left adrenal vein, clip it off, and then divide with energy. The right, like I said, is a four-port operation. Usually, two 10-millimeter ports and two 5-millimeter ports. The first step of this is to mobilize the right lobe of the liver medially, and almost analogous to the spleen, you want it to start hanging a little bit under its own weight.
NEIL SAUNDERS: But if you're not going on to mobilize it enough for that to actually happen, and so that's why we need the delivery tractor to help hold the liver medially. Once it's mobilized medially into one that's called a hockey stick incision, along the inferior aspect of the liver, and then down the lateral side of the IVC. And this is going to expose our retroperitoneum.
NEIL SAUNDERS: You gently dissect along the IVC to find where the right adrenal vein directly dumps into the IVC. Clip on the stay side, energy on the specimen side. Now, this is the area of the dissection that is-- it should be approached very carefully. If that vein tears off to the IVC, you can imagine, you can get into a big bleeding problem. You know, fortunately, that's incredibly rare, but for patients who I'm doing a right adrenal on, I always have a couple of units of blood ready, just in case.
NEIL SAUNDERS: It's extremely rare that we ever need it, but if there's a tear along the IVC, you can get into a big problem really quickly. Once that right adrenal vein is taken out, similar to the left side, there's no significant vessels from there on, and you can take all the remaining attachments with an energy device. The arteries are all very small. There may be an accessory adrenal vein, but generally, it's very small as well.
NEIL SAUNDERS: Then similarly, place an endocatch bag, and pull it out through one of the port sites. This is the positioning, similar to the left side, except for now in the left lateral decubitus. On this diagram, I usually put a 10 millimeter at this camera port, and I usually put a 10 millimeter where this port number one is as well. The other two can be 5.
NEIL SAUNDERS: And the reason why do the two 10's in the middle here is everybody is just a little bit different in their orientation of the IVC and the adrenal, and sometimes the better dissection comes from port one, and sometimes it actually comes from where this camera port is labelled. So I'd like to have the flexibility of being able to move the camera into either one of those ports if that particular patient's anatomy is a little bit better from one or the other.
NEIL SAUNDERS: The other thing is that sometimes, a portion of that right adrenal will tuck very far underneath-- under the liver. And that little tongue of adrenal, sometimes you may have to take with a stapler right next to the liver. And that second 10-millimeter port allows you to get a laparoscopic stapler if you need to do that.
NEIL SAUNDERS: Here's a drawing from that same paper describing the hockey-stick incision that goes along underneath the liver, and then down the lateral side of the vena cava. Once you're inside that peritoneum, be gently dissect along the lateral end of the cava, and identify the right adrenal vein. In real life, this is what this looks like.
NEIL SAUNDERS: You can see the peritoneum tenting up onto the liver. Take this about 2 or 3 millimeters away from the liver, and there's a nice avascular plane underneath. If you just take that one see-through layer, and then things start to move and mobilized. This is what it looks like when that hockey stick mobilization is completed. You can see the right lobe with the liver being mobilized here, all the way along, and then we've mobilized along the lateral portion of the IVC.
NEIL SAUNDERS: Here I've outlined the IVC that's covered in a little bit of fat there, and then the right adrenal vein dumping directly into it. This is what it looks like when you have the adrenal vein tented up about raising the clip, and you can see just how close you are to the vena cava. And if you've got a tear, or some type of trauma in that area, it's going to bleed a lot.
NEIL SAUNDERS: So robotic-assisted laparoscopic operations are very similar to that of the laparoscopic operation. The approach is the same, except you're just using the assist of the robot console. I actually used to do a lot of these. I probably did 30 or 40 of these robotically, and I just found that the laparoscopic approach was actually perfectly set up for both the left and the right adrenal.
NEIL SAUNDERS: And the robot wasn't really adding a lot for me. The angles in straight laparoscopic adrenalectomy are excellent, and I didn't get a lot of benefit out of the wristed instruments. I also found that I had a loss of tactile feedback, which happens with the robot. And especially in retracting that spleen medially, it's nice to be able to feel the weight of the spleen on the instrument that you have your hand on.
NEIL SAUNDERS: But robotic surgery for this is perfectly fine as well. There was a meta-analysis a few years ago comparing robotic adrenalectomy to laparoscopic adrenalectomy, and there were no statistical differences and complications, mortality, blood loss, conversion to open. The lengths of stay were similar. So they're essentially equivalent operations. For open adrenalectomy, we do these more rarely, and we usually just do them for large tumors that are more than 10 centimeters, or for adrenocortical cancers.
NEIL SAUNDERS: Now, for something like myelolipoma, which I said was very benign, some of those can get quite large. And you may push this 10-centimeter limit in something like that. I think the biggest one of those I've taken out of is 12 or 13 centimeters laparoscopically. But in general, 10 centimeters is a good ballpark for when you want to think about doing it open.
NEIL SAUNDERS: Adrenal cortical cancer, you generally want to do open. These tumors are often large because they're aggressive and fast-growing, and they're very fragile. Any capsule tears in the adrenal cancer is going to lead to worse outcomes. Essentially, you can't cure the patient, and their five-year survival is going to be extremely low because they're going to recur within months, essentially.
NEIL SAUNDERS: So making sure not to fracture, or tear, an adrenal cortical cancer is important. The other thing is we recommend a regional lymphadenectomy when we take out adrenal cortical cancer, and an open operation facilitate this as well. There's generally some lymph nodes mixed with the hilum of the kidney, and then along the aorta on the left, and the cava on the right. That's usually a little bit easier to do open.
NEIL SAUNDERS: Now, small adrenal cortical cancers less than 6 centimeters, there is some data that suggest that the laparoscopic approach has equivalent cancer outcomes to the open approach. And sometimes, these patients with these small ACCs, they'll be the ones who are indeterminate on their initial incidentaloma imaging work-up. And then you're taking out a 3 or 4-centimeter indeterminate lesion, and then you find out that it's an ACC.
NEIL SAUNDERS: In that situation, you don't have to go back and do a lymphadenectomy. That is enough if the cancer outcomes are equivalent between that and an open approach. For open adrenalectomies, the steps on the inside are fairly similar to laparoscopic. The same mobilizations are done. For the right adrenal, I generally approach that through an upper midline or right subcostal.
NEIL SAUNDERS: The liver pushes down the adrenal and the kidney, and so the right subcostal incision will work for this as well. You can put a bump underneath the back to extend their back and open up that space. But they don't need to be in a lateral decubitus position, or anything like that. For the left adrenal, I prefer an upper midline incision. We don't have the benefit of the liver pushing the adrenal down further into the abdomen, and so oftentimes you need to get quite high in the abdomen.
NEIL SAUNDERS: And a left subcostal incision just has a little bit poorer of an exposure for that left adrenal, so I would prefer an upper midline in that, especially if you're doing a large adrenal cancer. Oftentimes, if you have a 15-centimeter left adrenal cortical cancer-- in order to do the dissection without disrupting the tumor, oftentimes you'll have to take the distal pancreas and the spleen out just to get access to the medial and superior aspect of the tumor, even if it's not invading the pancreas or the spleen.
NEIL SAUNDERS: It's not worth putting excess retraction on the tumor to reach under those two organs to get the tumor out. Because if you rupture the ACC, the patient's fate is sealed at that point. Now, you can also consider a thoracoabdominal retroperitoneal approaches, which are also feasible. But that incision tend to have a little bit higher morbidity. If you have a large tumor in somebody who's had a lot of abdominal operations, or if there's something on the imaging where it makes it look like that approach might be better, you can do that.
NEIL SAUNDERS: But that would be fairly rare. And we have to do that once every two years to take these tumors out. So in summary, adrenal incidentalomas are very common. You're going to see them on CAT scans all the time, and like I said, if they're over 60 years old, it can be up to 10% of CTs. We have to pick and choose which one of these we're going to take out because most of them are benign and nonfunctional.
NEIL SAUNDERS: So the bare minimum, they should get a functional work-up, and they may need serial imaging. Tumors greater than 4 centimeters, in general, they undergo resection with some caveats, but that's the cutoff that we use. If they're small and nonfunctional, serial CT scans are used to follow them, as well as annual function labs because there's a small portion of these that will initially be nonfunctional, and then turn functional later in the patient's life.
NEIL SAUNDERS: The most common phenotype of primary hyperaldosteronism is bilateral disease. Even in the presence of a unilateral adrenal adenoma, we very commonly see bilateral disease. And so adrenal venous sampling is necessary to differentiate bilateral versus unilateral, and so that you have a high cure rate and you're not taking out the wrong adrenal. Remember, the cortisol correction factor for AVS, and that is a ratio of ratios to get your final comparison.
NEIL SAUNDERS: For small noncancerous adrenal tumors, laparoscopic surgery is the standard, and has actually got better exposure and angles than open surgery, so it's great. For cancers, the board answer's still going to be open adrenalectomy, but like I said, for small tumors less than 6 centimeters, the outcomes between laparoscopic and open for ACCs are equivalent.
NEIL SAUNDERS: But I would say for your board answers, I would-- if it's an ACC, open would be the standard. Well, thank you for your attention. I appreciate the invite to talk today.
SPEAKER: Yeah. Thank you. I do have one question. If you could spend just a little time on retroperitoneal approaches to adrenalectomy, I've certainly seen that described and discussed. Do you do that at all?
NEIL SAUNDERS: So the laparoscopic retroperitoneal-- one of our partners does that, and we tend to shuttle patients that need that to him. And those would be patients who have-- who need a bilateral adrenalectomy, and they've had extensive intra-abdominal surgery, or patients who've just had extensive intra-abdominal surgery. I don't do the laparoscopic retroperitoneal myself. There is one issue with that, especially on the right.
NEIL SAUNDERS: It's that if you get into a situation with bleeding on the cava, to fix that, you would have to basically reposition the patient supine. And when we do these retroperitoneal ones, they're prone, bent over at the waist. And so to go from that prone bent over position to a supine position, to open, to address the cava, you're losing a lot of blood during that time. And there have been patients that have died in that transition.
NEIL SAUNDERS: And so our general approach is to do it transabdominally because if you have to have an emergency conversion to open, you're already late there.
SPEAKER: I'm sorry.
NEIL SAUNDERS: For the open-- go ahead.
SPEAKER: No, go ahead.
NEIL SAUNDERS: Oh, OK. Thanks. For the open retroperitoneal approach, we have, as I'm sure you had at your institutions, patients who have had numerous intra-abdominal operations. And just because of the adhesions, sometimes it's easier to make-- have a thoracoabdominal operation, or incision, like you would approach an aorta, and sneak in that way. And it's a really nice technique because you are in the retroperitoneum.
NEIL SAUNDERS: You can go in that way, and take the tumor out. It's a little bit more morbid incision, but when you're weighing the risk and benefits for certain patients, it makes sense.
SPEAKER: And I guess my last question, and I hate to end on a surgical catastrophe, but what do you do if you've disrupted that IVC on the right side, and you encounter catastrophic bleeding during a laps transabdominal adrenalectomy?
NEIL SAUNDERS: Yeah. If it's, say, something that I can't get control-- sometimes you can get lucky, and put a clip on there and seal it. But say, that failed, and they're hemorrhaging from the cava. The first thing I'm going to try to do is get a laparoscopic sponge in there, and try to hold some kind of pressure there with the laparoscopic instrument while I convert to open.
NEIL SAUNDERS: You know, obviously, when you convert to open, you got blood loss on the skin and stuff. You don't care about it. You just try to get it in as quickly as possible. Usually, as soon as you can get it open, you can get a finger down in there and hold pressure. And then get everybody caught up, get people caught up on blood, get the right instruments, and stuff.
NEIL SAUNDERS: But getting in and getting good pressure on that spot is the key to it, and you gotta do it pretty quickly.
SPEAKER: Yeah. Hopefully, a rare and maybe, never occurrence, but I'm sure if you do enough of them, you know, it's going to happen at some point.
NEIL SAUNDERS: Yeah, fortunately, it's been a while. I think the last time we encountered that was about eight years ago. But it's not zero, we can see it.
SPEAKER: Yeah. But Dr. Saunders, thank you so much. It has been terrific, and thank you so much for lending us your expertise.
NEIL SAUNDERS: Excellent. Well, thank you, and happy to be here.
SPEAKER: OK. Good to hear.
NEIL SAUNDERS: Thanks.
Segment:0 .
SPEAKER: Hello, everyone. Welcome to SCORE School. It's my pleasure to introduce Dr. Neal Saunders from Emory University School of Medicine, where he is an assistant professor of surgery in the division of general and GI surgery. Dr. Saunders received his medical degree from the University of Illinois College of Medicine in 2008. He completed his general surgery training at Emory, followed by a fellowship at Ohio State University in complex general surgical oncology.
SPEAKER: His clinical specialties are endocrine surgery, including malignancies of the thyroid, adrenal, and parathyroid. And his primary research interests are thyroid cancer, surgical outcomes, and quality improvement. Dr. Saunders has a particular interest in bedside ultrasonography, and currently serves as the program director of the endocrine surgery fellowship.
SPEAKER: I can't think of anyone more capable and an expert in talking about our topic today, which is the adrenal. Thank you, Dr. Saunders, so much for helping us with SCORE School.
NEIL SAUNDERS: Well, thank you for having me here, and today, I'm going to talk about the adrenal. We'll narrow it down to a few topics because kind of all the surgical diseases of the adrenal, it would take many hours of lecture, but we'll narrow it down to a few today. So first, we're going to talk about adrenal incidentalomas. These are extremely common. As we scan more and more people on CT scan as soon as they come into the ER, we're seeing lots of little adrenal neoplasms.
NEIL SAUNDERS: And what do we need to do about that? We'll focus on a particular disease of the adrenal, the primary hyperaldosteronism and its work-up because its work-up's a little bit more nuanced and a little bit more difficult than the other adrenal neoplasms. And then we'll talk about adrenalectomy approaches, and specifically, laparoscopic adrenalectomy because that's what the vast majority of our adrenals need to be removed by.
NEIL SAUNDERS: By the end of the session, we should be able to understand initial evaluation of incidentally identified adrenal tumors. We'll identify the indications for resection of these adrenal incidentalomas. And we'll describe the technique and interpretation for adrenal venous sampling. In particular, I find a lot of residents get confused by this, and I'd like to go over it and its role in primary hyperaldosteronism.
NEIL SAUNDERS: I will also talk about the surgical approaches to the left and right adrenalectomy. So let's start with adrenal incidentaloma. I always like to start with a case, and this is somebody who actually came into my clinic a couple of weeks ago. He's a 42-year-old otherwise healthy male. He came to the emergency room with abdominal pain. He got the standard CT scan, which showed some gallstones without acute cholecystitis.
NEIL SAUNDERS: He was able to eat, so they sent him on his way, and he presents to your clinic a couple of weeks later. Look at 1.8 centimeter left adrenal nodule that I found on the CT. So what do you do about this? Here's his scan. We're at the level just above the left kidney, and you can see here on the left, there's a very small adrenal nodule, like it says, about 1.87 centimeters.
NEIL SAUNDERS: So these incidentalomas are very common. They found it in about 4% to 7% of abdominal CT scans. In patients who are older than 60 years old, it's actually seen on up to 10% of those patients' scans. The differential diagnosis is broad. The most common being benign nonfunctional adenomas, which make up about 80% of these tumors. And then every hormone that the adrenal can make can have a tumor producing that hormone as well.
NEIL SAUNDERS: So aldosteronomas, cortisol-producing tumor is causing Cushing's syndrome, pheochromocytomas, and then of course our malignancy, adrenal cortical carcinoma. And then on the other end of the spectrum, myelolipomas, which are benign and follow a little bit different rule, so which we'll get into later. And then metastatic disease. Most common cancers that metastasized to the adrenal will be lung melanoma, colorectal.
NEIL SAUNDERS: But you can also see renal cancer, and just about any cancer as well. So this is a review from your medical school days, and like I said, there's multiple layers in the adrenal, cortex and the medulla. And the cortex has three sublayers. The cortical cells embryologically come from the intermediate mesoderm. The medulla comes from neural crest cells.
NEIL SAUNDERS: And if you remember the mnemonic from medical school, GFR. Going from outer to inner is zona glomerulosa, fasciculata, and reticularis. And these are the levels which produce aldosterone, corticosteroids, sex hormones, respectively. And then the epinephrine and norepinephrine come from the medulla, which is where we get our pheochromocytomas. A review of these hormones, the cortex hormones come from the cholesterol precursor, as you can see here.
NEIL SAUNDERS: And then all the medullary hormones come from a tyrosine precursor. Normetanephrine and metanephrine will be used in our lab testing for pheochromocytoma, and it's just downstream from the norepineprhine and epinephrine in these processes. Also, briefly review the anatomy. As you probably remember, the left and right adrenals have different anatomy.
NEIL SAUNDERS: The biggest change in the anatomy between the sides is the adrenal vein. The left adrenal vein empties into the left renal vein, and the right adrenal vein directs, or empties, directly into the inferior vena cava. Performing the right adrenalectomy makes it a little bit more high-risk in that area, and the left adrenal vein is a little bit of a lower-risk area when we do the operations.
NEIL SAUNDERS: So like I said, we're going to focus on these benign nonfunctional adenomas, how we're going to follow those, and then we'll talk about the work-up of aldosteronomas as well. So when somebody comes in your office [INAUDIBLE] incidentalomas, you always want to start with a history and physical as with any patient that comes into your office. The history points are going to be focusing primarily on the symptoms associated with hormone excess.
NEIL SAUNDERS: And so if you're thinking about pheochromocytoma, you're talking about patients who are coming with, like, hypertension, headaches, tremors, flushing, palpitations. A lot of them have had multiple trips to the emergency room for hypertensive urgency. Cushing's patients are going to talk about weight gain that they've had, or new acne, muscle weakness, new abdominal fat.
NEIL SAUNDERS: Hyperaldosteronism, usually their symptoms are a little more subtle, but they may tell you about having low potassium, or muscle cramps, or fatigue. I mean, you always want to ask about a personal history of malignancy, like I had mentioned earlier. The adrenals are a relatively common site of metastatic disease, and so that may influence your decision making as well.
NEIL SAUNDERS: And then family history of MEN syndromes-- MEN2, worry about pheochromocytoma, and such. On physical exam, the tumor itself, unless it's really big, you're not going to be able to feel it, and the patient won't be able to feel it either. Something on the order of 4, 5, 6 centimeters, it's in an area of the body that doesn't have a lot of sensation, and so they're not really going to know it's there.
NEIL SAUNDERS: Patients who have tumors who are 10, 15 centimeters, there's a lot of times they will feel that pressure, and they will feel pain in their back from that. But most of the time, when you're seeing patients with these small tumors, they can't feel it. But on physical exam, you may see evidence of Cushing, a striae on the abdomen, increased abdominal obesity, hirsutism, acne, that type of stuff.
NEIL SAUNDERS: Once you are done with your physical exam, the next step will be screening labs if there's a functional tumor. The difference between functional and nonfunctional tumors is it's going to a lot of times determine whether they're going to be an operative candidate, or somebody who you're just going to follow with serial imaging and labs. And so our screen test, I always like to start with the plasma test, basic metabolic panel looking for hypokalemia or primary hyperaldosteronism.
NEIL SAUNDERS: Plasma metanephrines and catecholamines to screen for pheochromocytoma, and then the renin aldosterone to screen for hyperaldosteronism. ACTH, DHEA-sulfate as well. And a random serum cortisol test is not really a good test to screen for Cushing syndrome. And so for this, I'll usually send patients home with a prescription for a single tablet of 1 milligram of dexamethasone.
NEIL SAUNDERS: Have them take that in the evening, and then make sure they come the next morning around 8:00 AM for a morning cortisol drop. If their cortisol level is suppressed, then that's a pretty good screening test that they don't have Cushing's syndrome coming from the adrenal. If it's not depressed, then it may very well be that they have Cushing's from that adrenal tumor.
NEIL SAUNDERS: That was, again, our labs.
SPEAKER: [INAUDIBLE] --that constitutes a low-dose suppression test, correct?
NEIL SAUNDERS: Correct, correct. So that's a low-dose dexamethasone suppression test. And for deciding whether a patient has adrenal Cushing's or not, that's really all you need. We don't need to do a high-dose suppression test. That's really more for pituitary Cushing's. But if they don't suppress and they have an adrenal tumor, it's most likely that that's where it's coming from is the adrenal tumor.
SPEAKER: And the high dose is 4 milligrams?
NEIL SAUNDERS: 8 milligrams, if I remember correctly. Yeah.
SPEAKER: OK. Thanks.
NEIL SAUNDERS: And so the next step, once again, in our labs is getting imaging. And the best thing to start with is adrenal protocol CT. Usually whatever they've come with from the ER, or from the outside, it was probably just a regular CT scan with IV contrast, and none of those timings that they do in the routine ER scans are set up for adrenals. The adrenal protocol CT is actually an algorithmic CT that needs midscan radiology interpretation.
NEIL SAUNDERS: You start with a noncontrast CT of the abdomen. And if that adrenal lesion has low Hounsfield units less than 10, then that's diagnostic of a benign adrenal adenoma. And no contrast is necessary in that situation, so that's the end of the test. If it's greater than 10 Hounsfield units, then you proceed with IV contrast with adrenal timing until what you're looking for is washed out of the contrast from the adrenal gland in those timings.
NEIL SAUNDERS: And if it's more than 60% washout, that's indicative of a benign tumor. If there's less than 60% washout, or the results are indeterminate, sometimes an MRI may be helpful, but the adrenal protocol CT for the majority of adrenal adenomas will be enough. One thing I would like to stress is that we generally do not biopsy adrenal lesions.
NEIL SAUNDERS: Even if it's indeterminate on imaging, the biopsy usually yields little. The small amount of tissue that you get from even a core needle biopsy would not be enough to give a definitive diagnosis of adrenal cortical cancer, or a benign neoplasm. And ACC has a high rate of needle seeding from the biopsy. Until, in general, if you're concerned about that, don't biopsy.
NEIL SAUNDERS: You generally just recommend you take it out. Now, there are exceptions to this, and the biggest exception that we'll run into is a metastatic lesion where a tissue diagnosis from an adrenal will actually change the management of the primary cancer that it's coming from. And this is going to be different for every patient and every situation. There are some metastatic lesions where you're not going to biopsy it because knowing whether it is or is not metastatic disease won't change the management.
NEIL SAUNDERS: For example, one of the common ones we get is somebody with colorectal cancer, and the adrenal is their only site of disease. Or they have all of them as metastatic disease, maybe one or two lesions in the liver, and an adrenal lesion as well. And regardless of whether that biopsy is positive or negative, they're going to want you to take that lesion out. Now, it may be different in somebody, for example, with a lung cancer who has a met to that area, they may need to undergo chemotherapy upfront.
NEIL SAUNDERS: But they may not be starting with therapy without a tissue diagnosis. And in that situation, a biopsy would be indicated. Also, suspected lymphoma and suspected tuberculosis would be indications for a biopsy, and those are incredibly rare. So who meets initial resection criteria? If it's a functional tumor, if it's making an excess of any of those hormones, you can generally cure the patient if you remove it.
NEIL SAUNDERS: And so that would be our first criteria. The second is a size-based criteria. Generally, tumors greater than 4 centimeters, we would recommend come out. Once these tumors get bigger than 4 centimeters, the chance of it being an adrenal cortical cancer starts to become non-zero on the order of a couple of percent. Because adrenal cortical cancer has such a poor prognosis, and its main treatment is surgery, we'd rather take out a few too many benign lesions than miss an early adrenal cortical cancer.
NEIL SAUNDERS: Now, if it's bigger than 4 centimeters, and is clearly a myelolipoma on imaging, which is a very benign fatty-appearing adrenal lesion. You can push the limits a little bit on those. Some people wait till 6 centimeters. Some people wait until they're symptomatic. But if it's very clearly a myelolipoma, it usually doesn't fall into this 4-centimeter criteria. And then any of these lesions that are concerning for malignancy, or indeterminate on imaging, for the same reason that the size [INAUDIBLE],, we'd rather take out a few too many benign lesions than miss an early adrenal cortical cancer.
NEIL SAUNDERS: And so if it's indeterminate on imaging, then you can proceed with resection of the tumor. Most commonly, what happens is because 80% of these are going to be nonfunctional and consistent with a benign lesion on imaging, we end up following most of these. We generally follow them with serial CT scans. You want to do the first one about six months from the first one.
NEIL SAUNDERS: Just to be sure that you didn't happen to catch a fast-growing lesion early, you want that first interval scan to be a little bit closer. And then you can yearly follow them afterwards with CT scan. In the recommendation, generally, two to five years. Patient specific, but at least two years. You want to do an annual H and P, and then serial screening with labs when you see them every year as well. About 6% of nonfunctional adremal-- adrenal tumors will eventually become functional, so if you're not screening them at labs, you're going to miss those patients who will then have an indication for surgery.
NEIL SAUNDERS: The screening for the functional labs is recommended for five years annually. So as we're following these patients along, when do they meet resection criteria on follow-up? Well, if they've had a yearly interval growth of more than a centimeter, or if at that six month scan, it was more than half a centimeter, that growth rate would push them into a category needing resection.
NEIL SAUNDERS: Or if the tumor becomes functional as well.
SPEAKER: Nice description of the adrenal protocol CT. I've never heard of such a nice clarification of that. So I will ask you, let's say, you do have a patient who has a smaller adrenal tumor. Let's say it's 3 centimeters, and your initial CT was the elegant adrenal protocol CT you've described. Do the subsequent CT need to be similarly particlized, or can they be simpler?
NEIL SAUNDERS: So I will order adrenal protocol CT on them every year because most of the time, if they're coming back, their radiologist will see that interval-- even if it was a little bit indeterminate, and our MRI showed that it was benign. On that adrenal protocol CT, if they look at it, and they see that it's exactly the same size, they're not going to order the contrast on it probably. So yeah. So annually, I will get the adrenal particle CT on them.
SPEAKER: I see, that makes sense. To have that [INAUDIBLE],, they can really make the difference.
NEIL SAUNDERS: Yeah, and new to that, noncontrast CT is quick. With the 64-slice scanners, lets 30, 45 seconds running through, and then you kind of have your answer, especially if it stayed in the same size.
SPEAKER: All right. OK. Thank you.
NEIL SAUNDERS: So let's move on to aldosteronomas. One of the more common injury-- one of the more common functional tumors we'll see is aldosteronoma. Even though mostly incidentalomas are nonfunctional, we do see a fair amount of these. Cushing's syndrome would probably number three that we see, and then less commonly, is pheochromocytoma. The work-up for aldosteronoma, as you can see, is a little bit different than most of the other ones, and usually requires an extra step of adrenal venous sampling.
NEIL SAUNDERS: So this is the same patient who came in, 42-year-old gentleman, except his history is a little bit different now. He's had hypertension for the past five years. His primary care physician noted some low potassium levels on his routine annual labs, so he prescribed some oral potassium supplements. And when you get your screening labs, you see that his plasma aldosterone level is 24, and his plasma renin activity is 0.5, which is high and low for those two, respectively.
NEIL SAUNDERS: So this looks like a case of hyperaldosteronism. The screening tests for this disease, the plasma aldosterone concentration and the plasma renin activity, which we're going to get on all of our patients who come to us, depends on the incidentalomas anyway. And then we take the ratio of those as well. And so if the plasma aldosterone concentration is greater than 50 nanograms per deciliter, and the renin activity is suppressed as well, and that ratio's above 20, then that's pretty much diagnostic for hyperaldosteronism.
NEIL SAUNDERS: There's some salt-loading tests that can be done for confirmation if you have a borderline case, but in this particular case, it's pretty clear that this is what he's got with his hypokalemia and his clear serum screening tests. Now, this is an example of a CT that we would see in these patients, and it's actually the same patient we saw in the first case. But I want to look on the right adrenal here, which is a little bit higher than the left adrenal that's why it's kind of split into two slices here.
NEIL SAUNDERS: But this is a relatively normal-looking right adrenal, doesn't really look thickened. And then this is the left adrenal, which has that 1.8-centimeter lesion in it. And now you would think, OK, this patient's got hyperaldosteronism. He's got a clear adrenal lesion on the left. We should just take that out and cure his hyperaldosteronism. But in this disease, that's not quite the case.
NEIL SAUNDERS: This disease is actually pretty common. It's thought that up to 5% to 15% of all patients with hypertension have this as the underlying reason. It is poorly recognized, but is very prevalent out there. The most common phenotype of this is actually bilateral overproduction of aldosterone, and that's why the CT scan may be a little bit of a red herring for us.
NEIL SAUNDERS: An adenoma on the CT scan may not be the source of the excess aldosterone because the bilateral phenotype is so common. The way we sort this out is by adrenal venous sampling, which is going to be the key between differentiating unilateral and bilateral disease even in the presence of a unilateral adenoma. Here's the breakdown of the subtypes of primary hyperaldosteronism with a bilateral hyperplasia being 60% of all of these patients, and adenoma being only 35%.
NEIL SAUNDERS: It's a unilateral hyperplasia as well. And then more rarely are familial syndromes, and cancers producing excess aldosterone. So the reason we want to know if it's coming from one or two is because the only candidates for surgery are those with unilateral disease. If they have one side overproducing aldosterone, we can cure them by removing that one side. Because bilateral disease can be treated well with mineralocorticoids antagonist, like spironolactone, the nonoperative treatment for bilateral hyperplasia is our preferred method.
NEIL SAUNDERS: We don't want to take out both of these patient's adrenal because the medical treatment is actually very good. Similarly, with familial hyperaldosteronism, glucocorticoids are used to treat that. So why do we go through this extra step of adrenal venous sampling in most patients? And this is just an example paper. There's multiple papers with similar results out there, but this is one out of University of Michigan from 2008.
NEIL SAUNDERS: And they had 106 patients, 62 of which went to surgery. But 42 had both CT and a successful adrenal venous sampling. And what they found was that adrenal venous sampling in the patients that had it actually changed the management of these patients 35% of the time, meaning they had somebody with a unilateral adenoma, they did the AVS, and it was actually coming from both sides.
NEIL SAUNDERS: Or they had a patient with what looked like a unilateral adenoma, and when they did the adrenal venous sampling, it actually lateralized to the opposite side. And I'm sure you may have heard cases where patients didn't get adrenal venous sampling, ended up having the wrong adrenal gland removed because it looked like a clear adenoma on CT. And then you had to come back and say, you know, sorry we took the wrong one.
NEIL SAUNDERS: And this is why for, at least at Emory, for all patients with hyperaldosteronism, primary hyperaldosteronism, they're going to get AVS before we proceed with any surgery. So how's this done? This is done by our interventional radiologists. Having somebody who's skilled and specialized in this is actually important. With somebody who does this a lot, it's successful more than 95% of the time.
NEIL SAUNDERS: If you have a radiologist who doesn't do AVS a lot, it's actually only about 75% successful. And we'll talk about the anatomy and why that's the case. They usually use bilateral femoral vein access, and they run the catheters up into the IVC, and then the right and left adrenal veins. You compare aldosterone levels side to side between the adrenal veins. But we're not so much worried about the absolute level of aldosterone, but as ratio with cortisol.
NEIL SAUNDERS: And we'll talk about a hormone gradient in the vein, and why that's important. The cortisol essentially functions as the correction factor for how far in the catheter is. And so this is an example of the setup here. You can see that on the right, it actually takes a-- it's kind of an extreme angle from the cava into the right adrenal vein. It's nearly a 90-degree angle.
NEIL SAUNDERS: Whereas on the left side, it's a little more subtle turns to get in there. And so the left adrenal vein is relatively easy for them to cannulate, but that right adrenal vein is where all the skill comes in. Because of this turn, this is where the experience of kind of advanced IR guy is extremely helpful. This is where almost all the failures in adrenal venous sampling happens is not getting into this vein.
NEIL SAUNDERS: Now, I mentioned that we want to talk about using cortisol as a correction factor. The reason why is if you get this catheter really close to the adrenal and you take a sample, the aldosterone level is going to be really high because it hasn't had much time to mix with the blood on the way out to the cava. And so you may get a level of 10,000 right next to the adrenal, and 1,000 maybe a centimeter away.
NEIL SAUNDERS: And to know really what the correct interpretation is that you actually can use cortisol, which will be similarly following in gradient down that vein as well as a correction factor to make sure we're comparing apples to apples when we compare to side by side. So this is an example of the results that we get. Now, this can be done with cosyntropin stimulation, or without.
NEIL SAUNDERS: We actually do it with both, with and without at Emory. But some places will do it without, and some have a bias to do it with. And there's kind of mixed data on that, so either way is fine. But this is an example of what we get. We'll get measurements of the aldosterone and cortisol from the right and left adrenal veins, and then from the inferior vena cava.
NEIL SAUNDERS: The inferior vena cava numbers are really our control numbers for this test. What we want to do is make sure that we really did get into the adrenal veins, and the way that we confirm that is the cortisol in the adrenal vein samples has to be at least twice as high as the cortisol level in the vena cava. And that confirms that we were in an adrenal vein. In this example, the cortisol is 27, and both the left and the adrenal vein cortisols are clearly higher than that.
NEIL SAUNDERS: If for example, this left adrenal vein cortisol was only 50, then we would know we weren't in the left adrenal vein. Similarly with the right, the same thing would happen. Most commonly it's the right that we fail. Now, unfortunately, a lot of the times you don't get real-time results. And so you only find out after the test is completed, once all the labs come back, that they weren't in the right adrenal vein.
NEIL SAUNDERS: So for interpretations of whether this hyperaldosteronism is coming from the right or left, or both, we need to do a ratio of ratios for the interpretation. The first ratio that we do is the aldosterone to cortisol level, and we do that for both the right and the left adrenal vein. And then we compare those to each other. So we divide one over the other.
NEIL SAUNDERS: If that ratio is less than 3, that's evidence of bilateral disease. If it's greater than 4, then that's pretty clear a unilateral disease, and those patients are surgical candidates If, in fact, the right adrenal vein was cannulated during this, then these samples will be 96% accurate. Now, if the right adrenaline wasn't cannulated, generally, you have to repeat it.
NEIL SAUNDERS: There's some data that if it's extremely high, and extremely high ratios on one side or the other, and you didn't get into the right adrenal vein, you may be able to interpret those results with good success. But in general, if you didn't get into the right adrenal vein, it needs to be repeated. And it's a fairly invasive test to repeat. So let's take a look at an example of a patient here, and we'll go through doing the ratios and getting a final answer here.
NEIL SAUNDERS: So the first thing I want to do is confirm that the right adrenal vein is actually adrenal vein blood. And we look at the cortisol in the inferior vena cava and the right adrenal vein, and clearly, it's at least two times higher. Then, we calculate the ratios of aldosterone to cortisol for both adrenal veins. 1.6 on the right adrenal and 2.8 on the left.
NEIL SAUNDERS: And then we take those, divide them over each other. So 2.8 divided by 1.6, and our ratio is 1.75. And this is an evidence of bilateral disease. So in this patient, we wouldn't operate. They would go back to their endocrinologist, and get treated medically with spironolactone, or one of the other mineralocorticoid antagonists. Here's a second patient. Same thing, we'll look at the cortisol levels in the right adrenal and the inferior vena cava.
NEIL SAUNDERS: Clearly, it's at least two times higher. We'll take the ratio of aldosterone to cortisol for both of them, and the left adrenal is 16.2, and the right adrenal is 1.6. And then when we divide those out into 10 to 1, left to right ratio of ratios. And so this clearly lateralizes to the left, and we'll proceed with the left adrenalectomy in this situation.
NEIL SAUNDERS:
SPEAKER: What a nice review. I have never actually seen such a detail in the adrenal sampling. Are there examples where you do have bilaterally producing glands, but one is so much more active than the other that you would actually proceed with a unilateral?
NEIL SAUNDERS: So we have had that situation, and because the medical therapy is good enough, most of the time, we'll go with that. But we have had some patients, and not even in aldosterone, but we've seen it in patients with Cushing's who have actually bilateral hyperplasia causing Cushing's. And that's the more common that we'll see.
NEIL SAUNDERS: Now, in that situation, if we have one that's a lot higher than the other, I have taken out a unilateral adrenal, even in somebody who's having increased bilateral overproduction of cortisol. And that one side that was making so much more, taking that out, actually gave them a pretty good improvement in their quality of life, and years later is doing great, and have no plans to address the other side.
NEIL SAUNDERS: I don't know that I've personally encountered that in primary hyperaldosteronism, but yes, that could happen.
SPEAKER: OK. And once you do take out a unilateral gland, what do you do for biochemical follow-up afterwards?
NEIL SAUNDERS: So usually, I see most of my patients after those, three or four weeks after. We will check their renin and aldosterone again, and their potassium. The day after surgery, of course, we're checking the potassium, and most of these patients will always stay one night in the hospital. We'll make sure the potassium is OK the next day, and usually, it's normal that next day.
NEIL SAUNDERS: If it still remains abnormal, which thankfully happens 5% of time or less, then they would be treated medically after that. But fortunately with the AVS, we cure this 95% of the time, or more, with surgery.
SPEAKER: Great. Thank you.
NEIL SAUNDERS: So let's talk a little bit about adrenalectomy. There's a few different ways to approach this. Historically, the open approach before laparoscopic techniques. Our standard now, which I would say is laparoscopic transabdominal. Laparoscopic retroperitoneal is commonly done, but that's a little bit more specialized approach. And the robotic-assisted laparoscopic, which is just a variation of laparoscopic transabdominal surgery.
NEIL SAUNDERS: So I'm going to focus on the first two. And we're going to start with laparoscopic because we end up taking nearly 90 plus percent of our adrenals out this way. It's really kind of revolutionized the way we take our adrenals. Laparoscopic surgery for this became basically the standard of care in the early 2000s for small adrenal lesions, and the patient outcomes are just so much better. Now, for a benign nonfunctional disease, or an aldosteronoma, these patients for me are just staying overnight, and potentially, could go on the same day.
NEIL SAUNDERS: But we usually just keep them overnight compared to the historical data where patients were getting laparotomies for these, and they stay in the hospital five to seven days. And also the visualization with laparoscopic surgery for this particular area is actually superior doing it laparoscopically than open. And so this is kind of a perfect disease site for this approach.
NEIL SAUNDERS: For positioning these patients-- now, this is assuming that for whatever disease you're treating for this, whether it be a pheochromocytoma, or Cushing's, or primary hyperaldosteronism, that you've done the preop prep for them. Our pheochromocytoma patients are going to need the alpha blocked ahead of time to the point of orthostatic hypotension.
NEIL SAUNDERS: You're going to want to make sure the patients are well-hydrated before they come in. And if there's any sign of hypertension in the preop area, cancel the case. Try again another day. Cushing's patients they've got hypercortisolism and suppressed HPA axis. Those patients, you want to make sure they get preop steroids, and stress those steroids through the first 24 hours of their operation.
NEIL SAUNDERS: So presuming you've done all that, let's talk about positioning. So these operations are done in the left or right lateral decubitus position. And you put the flex of the bed in between the iliac crest and the costal margin. In that way, you can flex the bed and open the space up. And this is going to be the area where we're going to put our ports.
NEIL SAUNDERS: The left approach is generally a three or four-port operation. If they're relatively skinny and there's not a whole lot of retraction that you need to do, three ports is enough. The fourth port can be added for retraction. And the right side is, generally, always a four-port operation laparoscopically because you need that fourth port for liver retraction. And we'll talk about that a little bit.
NEIL SAUNDERS: To review the anatomy, like we said, the left and right are a little bit different. The right side, you're really focusing along the cava, and that right adrenal vein that's kind of a high-risk part of the operation there. And then the left side is coming off, or going into the left renal vein. So this is the laparoscopic left adrenalectomy positioning. Right lateral decubitus.
NEIL SAUNDERS: Generally, a camera port is in the midclavicular line. I usually put at 10 here, and it'll pop the view in to get into this area. And then ports one and two will generally be the working ports. This optional white assistant port here is if you had to-- if you needed some more retraction, especially holding down the colon mesentery out of the way. And then you can put a fourth port in between the camera port and the most lateral port.
NEIL SAUNDERS: The left laparoscopic technique is described as, or the technique that I use is described as an open-book technique. The first step of the operation is mobilizing the spleen off the diaphragm and the retroperitoneum, moving lateral to medial until you've got it mobilized enough that the spleen hangs immediately under its own weight.
NEIL SAUNDERS: One pitfall of this mobilization is that as you get to the most medial aspect in the superior part of your dissection for this mobilization, the fundus of the stomach will start to peak around the corner of the spleen. And so if you're using energy up there, like Harmonic or LigaSure, you've got to be careful that you're not just resting on the stomach.
NEIL SAUNDERS: And that's one of the key points of dissection here. The tail of the pancreas, as you know, tucks into the hilum of the spleen. It mobilizes medially with the spleen as well. And once the spleen is mobilized enough to hang medially on its own weight, it will pull the pancreas medially as well. Once you've completed the spleen mobilization, the second step is to mobilize a splenic flexure of the colon and its mesentery, and mobilizing that inferiorly.
NEIL SAUNDERS: And once that's done, the adrenals are going to come into view. You're going to notice there's going to be a valley between the pancreas medially, and the adrenal and the kidney laterally. Got a couple of views of that here in a minute. Once you've got all that mobilized, you can identify the left adrenal vein. It's generally in an inferomedial position on the adrenal, and it drains usually into the left renal vein.
NEIL SAUNDERS: When you take the adrenal vein, I always put clips on the stay side, and then use an energy device on the specimen side. You can use Harmonic, LigaSure, or similar instrument, whatever version of a vessel sealer the robotic robot has. And then once the left adrenal vein is taken, that's actually the main blood vessel of the whole operation. All of the other small arteries and such are small enough that can be taken primarily with an energy device.
NEIL SAUNDERS: The adrenal arteries are numerous, and they're all very small. And so it's no problem to take those with LigaSure or Harmonic. There's usually a venous branch going into the phrenic vein. That's a fairly low-pressure vein. You can take that with energy, no problem. And like I said, the adrenal arteries are small and not a problem to take with energy.
NEIL SAUNDERS: We put the specimen in endocatch bag, and pull it out through one of the port sites, and then close up. Now, here's drawings from a nice article from memory from 1999, describing this open-book technique. It's a great article. I think one of the best surgical technique articles out there, and this is how I do laparoscopic and robotic adrenalectomies.
NEIL SAUNDERS: So the first step is mobilizing the spleen here, and also taking down the splenic flexure of the colon. And then here's where it's described as open book, may have actually superimposed the book on the anatomy drawing. And so the stomach and the spleen and the pancreas are all hanging over to the left, with the adrenal and the kidney on the right. And then this nice valley appears, and just inferomedial on the adrenal, you'll see the adrenal vein.
NEIL SAUNDERS: In real life, this is what this looks like, with the splenic flexure of the colon inferiorly, and the kidney hidden here in the retroperitoneum. We mobilize the spleen to the left, and you can see the kidney starting to take shape here. My spleen is starting to move under its own weight, and then when we get it completely mobilized, the pancreas is hanging medially.
NEIL SAUNDERS: The kidney, over here, with the adrenal tumor here. And we can make up a left renal vein at the inferior aspect here, and then the left adrenal vein right here. We circumferentially dissect that left adrenal vein, clip it off, and then divide with energy. The right, like I said, is a four-port operation. Usually, two 10-millimeter ports and two 5-millimeter ports. The first step of this is to mobilize the right lobe of the liver medially, and almost analogous to the spleen, you want it to start hanging a little bit under its own weight.
NEIL SAUNDERS: But if you're not going on to mobilize it enough for that to actually happen, and so that's why we need the delivery tractor to help hold the liver medially. Once it's mobilized medially into one that's called a hockey stick incision, along the inferior aspect of the liver, and then down the lateral side of the IVC. And this is going to expose our retroperitoneum.
NEIL SAUNDERS: You gently dissect along the IVC to find where the right adrenal vein directly dumps into the IVC. Clip on the stay side, energy on the specimen side. Now, this is the area of the dissection that is-- it should be approached very carefully. If that vein tears off to the IVC, you can imagine, you can get into a big bleeding problem. You know, fortunately, that's incredibly rare, but for patients who I'm doing a right adrenal on, I always have a couple of units of blood ready, just in case.
NEIL SAUNDERS: It's extremely rare that we ever need it, but if there's a tear along the IVC, you can get into a big problem really quickly. Once that right adrenal vein is taken out, similar to the left side, there's no significant vessels from there on, and you can take all the remaining attachments with an energy device. The arteries are all very small. There may be an accessory adrenal vein, but generally, it's very small as well.
NEIL SAUNDERS: Then similarly, place an endocatch bag, and pull it out through one of the port sites. This is the positioning, similar to the left side, except for now in the left lateral decubitus. On this diagram, I usually put a 10 millimeter at this camera port, and I usually put a 10 millimeter where this port number one is as well. The other two can be 5.
NEIL SAUNDERS: And the reason why do the two 10's in the middle here is everybody is just a little bit different in their orientation of the IVC and the adrenal, and sometimes the better dissection comes from port one, and sometimes it actually comes from where this camera port is labelled. So I'd like to have the flexibility of being able to move the camera into either one of those ports if that particular patient's anatomy is a little bit better from one or the other.
NEIL SAUNDERS: The other thing is that sometimes, a portion of that right adrenal will tuck very far underneath-- under the liver. And that little tongue of adrenal, sometimes you may have to take with a stapler right next to the liver. And that second 10-millimeter port allows you to get a laparoscopic stapler if you need to do that.
NEIL SAUNDERS: Here's a drawing from that same paper describing the hockey-stick incision that goes along underneath the liver, and then down the lateral side of the vena cava. Once you're inside that peritoneum, be gently dissect along the lateral end of the cava, and identify the right adrenal vein. In real life, this is what this looks like.
NEIL SAUNDERS: You can see the peritoneum tenting up onto the liver. Take this about 2 or 3 millimeters away from the liver, and there's a nice avascular plane underneath. If you just take that one see-through layer, and then things start to move and mobilized. This is what it looks like when that hockey stick mobilization is completed. You can see the right lobe with the liver being mobilized here, all the way along, and then we've mobilized along the lateral portion of the IVC.
NEIL SAUNDERS: Here I've outlined the IVC that's covered in a little bit of fat there, and then the right adrenal vein dumping directly into it. This is what it looks like when you have the adrenal vein tented up about raising the clip, and you can see just how close you are to the vena cava. And if you've got a tear, or some type of trauma in that area, it's going to bleed a lot.
NEIL SAUNDERS: So robotic-assisted laparoscopic operations are very similar to that of the laparoscopic operation. The approach is the same, except you're just using the assist of the robot console. I actually used to do a lot of these. I probably did 30 or 40 of these robotically, and I just found that the laparoscopic approach was actually perfectly set up for both the left and the right adrenal.
NEIL SAUNDERS: And the robot wasn't really adding a lot for me. The angles in straight laparoscopic adrenalectomy are excellent, and I didn't get a lot of benefit out of the wristed instruments. I also found that I had a loss of tactile feedback, which happens with the robot. And especially in retracting that spleen medially, it's nice to be able to feel the weight of the spleen on the instrument that you have your hand on.
NEIL SAUNDERS: But robotic surgery for this is perfectly fine as well. There was a meta-analysis a few years ago comparing robotic adrenalectomy to laparoscopic adrenalectomy, and there were no statistical differences and complications, mortality, blood loss, conversion to open. The lengths of stay were similar. So they're essentially equivalent operations. For open adrenalectomy, we do these more rarely, and we usually just do them for large tumors that are more than 10 centimeters, or for adrenocortical cancers.
NEIL SAUNDERS: Now, for something like myelolipoma, which I said was very benign, some of those can get quite large. And you may push this 10-centimeter limit in something like that. I think the biggest one of those I've taken out of is 12 or 13 centimeters laparoscopically. But in general, 10 centimeters is a good ballpark for when you want to think about doing it open.
NEIL SAUNDERS: Adrenal cortical cancer, you generally want to do open. These tumors are often large because they're aggressive and fast-growing, and they're very fragile. Any capsule tears in the adrenal cancer is going to lead to worse outcomes. Essentially, you can't cure the patient, and their five-year survival is going to be extremely low because they're going to recur within months, essentially.
NEIL SAUNDERS: So making sure not to fracture, or tear, an adrenal cortical cancer is important. The other thing is we recommend a regional lymphadenectomy when we take out adrenal cortical cancer, and an open operation facilitate this as well. There's generally some lymph nodes mixed with the hilum of the kidney, and then along the aorta on the left, and the cava on the right. That's usually a little bit easier to do open.
NEIL SAUNDERS: Now, small adrenal cortical cancers less than 6 centimeters, there is some data that suggest that the laparoscopic approach has equivalent cancer outcomes to the open approach. And sometimes, these patients with these small ACCs, they'll be the ones who are indeterminate on their initial incidentaloma imaging work-up. And then you're taking out a 3 or 4-centimeter indeterminate lesion, and then you find out that it's an ACC.
NEIL SAUNDERS: In that situation, you don't have to go back and do a lymphadenectomy. That is enough if the cancer outcomes are equivalent between that and an open approach. For open adrenalectomies, the steps on the inside are fairly similar to laparoscopic. The same mobilizations are done. For the right adrenal, I generally approach that through an upper midline or right subcostal.
NEIL SAUNDERS: The liver pushes down the adrenal and the kidney, and so the right subcostal incision will work for this as well. You can put a bump underneath the back to extend their back and open up that space. But they don't need to be in a lateral decubitus position, or anything like that. For the left adrenal, I prefer an upper midline incision. We don't have the benefit of the liver pushing the adrenal down further into the abdomen, and so oftentimes you need to get quite high in the abdomen.
NEIL SAUNDERS: And a left subcostal incision just has a little bit poorer of an exposure for that left adrenal, so I would prefer an upper midline in that, especially if you're doing a large adrenal cancer. Oftentimes, if you have a 15-centimeter left adrenal cortical cancer-- in order to do the dissection without disrupting the tumor, oftentimes you'll have to take the distal pancreas and the spleen out just to get access to the medial and superior aspect of the tumor, even if it's not invading the pancreas or the spleen.
NEIL SAUNDERS: It's not worth putting excess retraction on the tumor to reach under those two organs to get the tumor out. Because if you rupture the ACC, the patient's fate is sealed at that point. Now, you can also consider a thoracoabdominal retroperitoneal approaches, which are also feasible. But that incision tend to have a little bit higher morbidity. If you have a large tumor in somebody who's had a lot of abdominal operations, or if there's something on the imaging where it makes it look like that approach might be better, you can do that.
NEIL SAUNDERS: But that would be fairly rare. And we have to do that once every two years to take these tumors out. So in summary, adrenal incidentalomas are very common. You're going to see them on CAT scans all the time, and like I said, if they're over 60 years old, it can be up to 10% of CTs. We have to pick and choose which one of these we're going to take out because most of them are benign and nonfunctional.
NEIL SAUNDERS: So the bare minimum, they should get a functional work-up, and they may need serial imaging. Tumors greater than 4 centimeters, in general, they undergo resection with some caveats, but that's the cutoff that we use. If they're small and nonfunctional, serial CT scans are used to follow them, as well as annual function labs because there's a small portion of these that will initially be nonfunctional, and then turn functional later in the patient's life.
NEIL SAUNDERS: The most common phenotype of primary hyperaldosteronism is bilateral disease. Even in the presence of a unilateral adrenal adenoma, we very commonly see bilateral disease. And so adrenal venous sampling is necessary to differentiate bilateral versus unilateral, and so that you have a high cure rate and you're not taking out the wrong adrenal. Remember, the cortisol correction factor for AVS, and that is a ratio of ratios to get your final comparison.
NEIL SAUNDERS: For small noncancerous adrenal tumors, laparoscopic surgery is the standard, and has actually got better exposure and angles than open surgery, so it's great. For cancers, the board answer's still going to be open adrenalectomy, but like I said, for small tumors less than 6 centimeters, the outcomes between laparoscopic and open for ACCs are equivalent.
NEIL SAUNDERS: But I would say for your board answers, I would-- if it's an ACC, open would be the standard. Well, thank you for your attention. I appreciate the invite to talk today.
SPEAKER: Yeah. Thank you. I do have one question. If you could spend just a little time on retroperitoneal approaches to adrenalectomy, I've certainly seen that described and discussed. Do you do that at all?
NEIL SAUNDERS: So the laparoscopic retroperitoneal-- one of our partners does that, and we tend to shuttle patients that need that to him. And those would be patients who have-- who need a bilateral adrenalectomy, and they've had extensive intra-abdominal surgery, or patients who've just had extensive intra-abdominal surgery. I don't do the laparoscopic retroperitoneal myself. There is one issue with that, especially on the right.
NEIL SAUNDERS: It's that if you get into a situation with bleeding on the cava, to fix that, you would have to basically reposition the patient supine. And when we do these retroperitoneal ones, they're prone, bent over at the waist. And so to go from that prone bent over position to a supine position, to open, to address the cava, you're losing a lot of blood during that time. And there have been patients that have died in that transition.
NEIL SAUNDERS: And so our general approach is to do it transabdominally because if you have to have an emergency conversion to open, you're already late there.
SPEAKER: I'm sorry.
NEIL SAUNDERS: For the open-- go ahead.
SPEAKER: No, go ahead.
NEIL SAUNDERS: Oh, OK. Thanks. For the open retroperitoneal approach, we have, as I'm sure you had at your institutions, patients who have had numerous intra-abdominal operations. And just because of the adhesions, sometimes it's easier to make-- have a thoracoabdominal operation, or incision, like you would approach an aorta, and sneak in that way. And it's a really nice technique because you are in the retroperitoneum.
NEIL SAUNDERS: You can go in that way, and take the tumor out. It's a little bit more morbid incision, but when you're weighing the risk and benefits for certain patients, it makes sense.
SPEAKER: And I guess my last question, and I hate to end on a surgical catastrophe, but what do you do if you've disrupted that IVC on the right side, and you encounter catastrophic bleeding during a laps transabdominal adrenalectomy?
NEIL SAUNDERS: Yeah. If it's, say, something that I can't get control-- sometimes you can get lucky, and put a clip on there and seal it. But say, that failed, and they're hemorrhaging from the cava. The first thing I'm going to try to do is get a laparoscopic sponge in there, and try to hold some kind of pressure there with the laparoscopic instrument while I convert to open.
NEIL SAUNDERS: You know, obviously, when you convert to open, you got blood loss on the skin and stuff. You don't care about it. You just try to get it in as quickly as possible. Usually, as soon as you can get it open, you can get a finger down in there and hold pressure. And then get everybody caught up, get people caught up on blood, get the right instruments, and stuff.
NEIL SAUNDERS: But getting in and getting good pressure on that spot is the key to it, and you gotta do it pretty quickly.
SPEAKER: Yeah. Hopefully, a rare and maybe, never occurrence, but I'm sure if you do enough of them, you know, it's going to happen at some point.
NEIL SAUNDERS: Yeah, fortunately, it's been a while. I think the last time we encountered that was about eight years ago. But it's not zero, we can see it.
SPEAKER: Yeah. But Dr. Saunders, thank you so much. It has been terrific, and thank you so much for lending us your expertise.
NEIL SAUNDERS: Excellent. Well, thank you, and happy to be here.
SPEAKER: OK. Good to hear.
NEIL SAUNDERS: Thanks.
Form Title Download
Transcript
Form Title Bookmark
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Share
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Accessibility and Keyboard Shortcuts
The cadmore media player is a professional video and audio player experience designed to deliver media as well as relevant transcript, segmentation, and metadata. On the screen is a traditional html video player with buttons such as play, pause, forward, captioning, language and play speed selection and more. Adjacent to the video player are generally tabs, one of which shows a scrolling transcript of the video and the other shows any segmentation of the media, sometimes referred to as chapters. At the top of the video is a menu bar containing an Explore button and Tools button. The Explore button allows you to dig deeper into the video by opening up an explore dialog which contains tabs for a visual navigation of the video using thumbnails, an about tab which contains rich metadata about the media, a segments tab which contains further information about the video, and a related tab which contains links to other media related to this media. The tools button opens a menu with options for sharing the media on social media, creating bookmarking links, creating embed codes for your website, generating citations, and more.
Keyboard Shortcuts
Keyboard shortcuts only work while you are in forms mode. By entering forms mode, you will be able to quickly access portions of the media player with single key commands.
Spacebar: Play/Pause Toggle
I: Info Menu,
O: Tools Menu
T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
N: Video Only Toggle,
B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus / Exits Player
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Embed Size
-
You Size - Responsive
-
We Size - Responsive
-
Picture Overlay Popup
-
400 x 225
-
512 x 288
-
400 x 700
-
768 x 1024
-
1024 x 512
-
1280 x 608
Form Title Cite
No citation provided.
Info
Segments
Related
Thumbnails
Exit Clip Mode
You have requested to see a portion of the video outside of the clip.
Click OK to switch to the full video or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode