Endocrine Abstracts

Background: Management of ACTH-dependent Cushing's syndrome (ACTH-CS) remains a challenge. In the past 2 decades open bilateral adrenalectomy, associated high morbidity and long post-operative in-patient stay, has usually been reserved for cases of failed transsphenoidal surgery (TpS) and radiotherapy (RT), or where the source of ACTH is not found. Laparoscopic adrenalectomy is a significant advance with low morbidity and mortality.

Aim: To assess the effectiveness and safety of bilateral laparoscopic adrenalectomy (BLA) in ACTH-CS.

Patients: From 1995-2003, in Sheffield, 103 patients underwent laparoscopic adrenalectomy by a single operator (BJH): 41 phaeochromocytoma, 42 Cushing's syndrome, 8 Conn's adenoma, 8 incidentaloma, 4 other. Of these 13 had BLA for ACTH-CS: 8 Cushing's disease (CD), 5 ectopic ACTH (EC), median age 41, range 23-79; mean BMI 29 (range 21-54); mean duration of symptoms 48 months (range 6-89). Of patients with CD, 1 was primary treatment, 1 post TpS, and 6 post TpS and RT.

Results: In one patient conversion to unilateral open adrenalectomy was necessary, but all others had BLA. In 12/13 median post-operative stay in hospital was 6 days (range 3-13), which included stabilisation and assessment of adrenal replacement therapy. 11/13 had undetectable serum cortisol post-operatively, whilst 2 patients had detectable but low values, still requiring full adrenal replacement therapy. There was no mortality, chest or wound infections. One patient with widely disseminated metastatic neuroendocrine tumour and EC developed a peripancreatic abcess requiring percutaneous drainage and an overall patient stay of 41 days.

Conclusions: In this series with severe ACTH-CS, BLA is effective treatment when performed by an experienced operator. Given the low morbidity and short in-patient stay attention should be turned as to whether BLA should be considered as primary therapy for some patients with CD, especially as long term cure by TpS is achieved in only 55-60% of cases.