| Objective and Background:Cushing’s syndrome is one of the most common disease of adrenal gland. The hypercortisolism is most caused by Cushing’s disease and adrenocortical adenoma, resulted in a series of symptoms. Currently, laparoscopic adrenalectomy is a standard treatment for most of adrenocortical adenoma, and transsphenoidal tumor resection is the first treatment for Cushing’s disease, adrenalectomy is an importment treatment for pituitary tumors who had failed pituitary resection or without lesions in medical imaging.During the perioperative period of adrenalectomy, the secretion of adrenal cortex hormone will dramatically changed, patient will suffered from adrenal insufficiency, even can menace the life. but, it can be protected against the risk by the use of supraphysiologic dosage steroid replacement following adrenalectomy. However, At present, there are few reports about steroid replacement at home and abroad, and there has been considerable debate regarding the steroid replacement.In this study, the plasma cortisol and24h urine cortisol concentration were intermittently measured after operation to find out its dynamic changing trend, and to supply the evidence for the use of steroid replacement, and will be helpful for adjusting the dosages of steroid replacemen. Follow was made to observe the clinical symptoms improved and the use of steroid by telephone and questionnaire, in order to evaluate the treatment and effect of perioperative endocrine therapy, and to provide a safe and effective practical scheme of steroid replacement for Cushing’s syndrome.Material and Methods:This study included20cases of Cushing’s syndrome which diagnosed by clinical and endocrinological inspections at our hospital during2010—2011. All patients were performed by laparoscopic adrenalectomy, and were given a new and brief method of endocrine therapy after operation:No steroid was used before the operation, but during removal of adrenal adenoma,100mg hydrocortisone should be given by intravenous injection, another200mg hydrocortisone given on the surgery day, then 100mg Q12h, and100mg hydrocortisone given on the next two days after operation, oral prednisolone10mg three times one day. From on the second day, then, followed by a reduction of5mg every one week until a maintenance dosage (5mg) was reached. The clinical symptoms, blood pressure and heart rate were observed, the concentration of plasma cortisol and24h urine cortisol were intermittently measured on1st,2nd,6th,7th day and on1st,3rd,6th month after operation by radioimmuno--assay to find out its dynamic changing trend.Results:1.All adrenocortical adenoma were undergone laparoscopic adrenalectomy, In which9cases were adrenal adenoma resection,5cases adrenal gland tumour excision adds with the unilateral adrenalectomy;4cases of pituitary tumors who had failed pituitary resection were undergone laparoscopic adrenalectomy, one case was unilateral subtotal adrenatectomy,3cases were adrenalectomy and transplantation, in which2case was planting in the scrotum and one case was planting in left arm. Another2cases of pituitary tumors without lesions in medical imaging, one case was undergone bilateral subtotal excisions, another was unilateral adrenalectomy. All operations were successfully without convertion to open surgery, no blood, without mortality. The operation time was70～230min (mean,107.8min), the amount of bleeding was10～200ml(mean,38.33ml).2.19cases of the plasma cortisol concentration was17.03±8.58ug/ml during the perioperative period, only one case less than normal (3.5ug/ml); It was6.01±5.02ug/ml on1st month,10cases were were within the normal range,10cases were less than normal; It was4.31±3.25ug/ml on3rd month,8cases were were within the normal range,12cases were less than normal; It was2.90±1.35ug/ml on6th month,7cases were were within the normal range,13cases were less than normal.3. The24h urine cortisol concentration was372.83±243.01ug/24h during the perioperative period, all cases were higher comparing to its usual value or within the normal range. It was161.62±68.50on1st month,14cases were more than the normal range,6cases were within the normal range; It was115.40±59.40ug/24h on3rd month,4cases were more than the normal range,16cases were within the normal range; It was88.71±23.38ug/24h on6th month,2cases were more than the normal range,18cases were within the normal range.4. Three cases of bilateral adrenalectomy and adrenal transplantation(4pieces of adrenal gland about1cm), respectively have color flow signal in2、3and3pieces of adrenal gland on1st month, but all have color flow signal in2pieces of adrenal gland on6th month. At present,2case of plasma cortisol concentration was within the normal range, respectively was5.4and9.4ug/ml, one case was less than normal (3.5ug/ml), and the24h urine cortisol concentration were all within the normal range. They all only oral prednisolone5mg Qd,But, Nelson syndrome occurrence in2patients.5. During the follow up six months, nineteen patients experienced weight loss after operation about6months, with a mean decrease in BMI from25.5to23.0. Facial fullness and edema returned to normal respectively was47.06%and62.5%.9patients of serum potassium and40%blood glucose recovered after operation.81.2%hypertension also returned to normal after operation. Other symptoms were all improved to some degree. In a word,60.0%patients reported a significant improvement in their symptoms, and30.0%experienced moderate improvement,55%patients were either satisfied or very satisfied with their currently quality of life.83.33%patients were either satisfied or very satisfied with their operation.6. The acute adrenal hypofunction were not distinct in the perioperative period for all patients, but the24h urine cortisol concentration was less than normal in3cases of adenoma during steroid tapering respectively on15th、35th and75th day,but all symptoms recovered by adjusting the dosage of prednisolone. During the follow up six months,14cases of adenoma stop prednisolone after operation about1～5monthes,3case of Cushing’s disease stop it after operation about1～3monthes,3cases of adrenal transplantation are still necessary to oral prednisolone.Conclusions:1.No steroid was used before the adrenalectomy is safe and feasible for Cushing’s syndrome.2.This method of steroid supplement is brief, safe and effective. It is a kind of practical scheme for Cushing’s syndrome.3.The24h urine cortisol concentration can better reflect adrenocortical function than the plasma cortisol concentration.4. Bilateral adrenalectomy and adrenal transplantation is one kind of trentment for Cushing’s disease. Its short effect was remarkable, despite can oral less prednisolone, it is easy to occurrent Nelson syndrome, and its long effect remains to further study. |
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