■肾上腺切除术是多发性肾上腺异常的决定性治疗方法。技术和基因组学的进步以及对肾上腺病理生理学的理解已经改变了手术技术和适应症。
■为了制定基于证据的建议,安全,和肾上腺切除术的有效方法。
■一个多学科小组确定并调查了与执业外科医生相关的7类临床问题。问题是在人口框架中构建的,干预/暴露,比较,和结果,并对PubMed和/或Embase从1980年到2021年的医学文献进行了指导性审查。建议是使用建议分级制定的,评估,开发和评估方法,并进行了讨论,直到达成共识,并包括患者倡导代表。
■肾上腺偶发瘤1cm或更大的患者应进行生化检测和进一步的影像学检查。肾上腺方案计算机断层扫描(CT)应用于对嗜铬细胞瘤的恶性风险和关注进行分层。不建议对具有良性影像学特征和Hounsfield单位小于10的未增强CT的无功能肾上腺结节进行常规定期随访。当存在单侧疾病时,对于原发性醛固酮增多症或自主皮质醇分泌的患者,建议进行腹腔镜肾上腺切除术。临床和影像学检查结果与肾上腺皮质癌一致的患者应在高容量多学科中心接受治疗,以优化预后。包括,如果可能,完整的R0切除而没有肿瘤破裂,这可能需要整块根治性切除。选择性或非选择性α阻滞可用于安全地为患者准备副神经节瘤/嗜铬细胞瘤的手术切除。经验性围手术期糖皮质激素替代疗法适用于明显库欣综合征患者,但是对于轻度自主皮质醇分泌的患者,术后第1天早晨皮质醇或协同促蛋白刺激试验可用于确定是否需要糖皮质激素替代治疗.当患者和肿瘤变量合适时,我们推荐微创肾上腺切除术优于开放肾上腺切除术,因为其改善了围手术期的发病率.根据外科医生的专业知识,可以通过腹膜后或腹膜入路进行微创肾上腺切除术。以及肿瘤和患者特征。
■提供了26项临床相关和循证建议,以协助外科医生进行围手术期肾上腺护理。
Adrenalectomy is the definitive treatment for multiple adrenal abnormalities. Advances in technology and genomics and an improved understanding of adrenal pathophysiology have altered operative techniques and indications.
To develop evidence-based recommendations to enhance the appropriate, safe, and effective approaches to adrenalectomy.
A multidisciplinary panel identified and investigated 7 categories of relevant clinical concern to practicing surgeons. Questions were structured in the framework Population, Intervention/Exposure, Comparison, and Outcome, and a guided review of medical literature from PubMed and/or Embase from 1980 to 2021 was performed. Recommendations were developed using Grading of Recommendations, Assessment, Development and Evaluation methodology and were discussed until
consensus, and patient advocacy representation was included.
Patients with an adrenal incidentaloma 1 cm or larger should undergo biochemical testing and further imaging characterization. Adrenal protocol computed tomography (CT) should be used to stratify malignancy risk and concern for
pheochromocytoma. Routine scheduled follow-up of a nonfunctional adrenal nodule with benign imaging characteristics and unenhanced CT with Hounsfield units less than 10 is not suggested. When unilateral disease is present, laparoscopic adrenalectomy is recommended for patients with primary aldosteronism or autonomous cortisol secretion. Patients with clinical and radiographic findings consistent with adrenocortical carcinoma should be treated at high-volume multidisciplinary centers to optimize outcomes, including, when possible, a complete R0 resection without tumor disruption, which may require en bloc radical resection. Selective or nonselective α blockade can be used to safely prepare patients for surgical resection of paraganglioma/
pheochromocytoma. Empirical perioperative glucocorticoid replacement therapy is indicated for patients with overt Cushing syndrome, but for patients with mild autonomous cortisol secretion, postoperative day 1 morning cortisol or cosyntropin stimulation testing can be used to determine the need for glucocorticoid replacement therapy. When patient and tumor variables are appropriate, we recommend minimally invasive adrenalectomy over open adrenalectomy because of improved perioperative morbidity. Minimally invasive adrenalectomy can be achieved either via a retroperitoneal or transperitoneal approach depending on surgeon expertise, as well as tumor and patient characteristics.
Twenty-six clinically relevant and evidence-based recommendations are provided to assist surgeons with perioperative adrenal care.