| [BACKGROUND]1.Aldosterone-producing adenoma(APA)is a common subtype of primary hyperaldosteronism(PHA).Conn found and described PHA in 1955,it is also called Conn syndrome.It is reported that PHA in patients with hypertension accounted for 5%to 12%,an average of about 10%,is the most common cause of secondary hypertension.With the continuous improvement of screening and diagnostic methods,APA take the proportion of about 40%to 50%.2.High serum aldosterone concentration is an independent factor of the increasing events of cardiovascular.Patients with aldosterone-producing adenoma usually have sever mineralocorticoid manifestations than those with adrenal hyperplasia.including more sever hypertension.PHA cardiovascular and cerebrovascular disease has higher incidence and mortality than the same degree of essential hypertension.The damage of PHA to the kidney is higher than the same degree of essential hypertension.3.APA can be treated by surgery,the best response to surgical treatment can be expected in patients with APA among various subtypes of PHA.Compared with open surgery,laparoscopic adrenalectomy has significant advantages in reducing perioperative mortality,intraoperative blood loss and postoperative recovery time.For patients with APA,total adrenalectomy usually be used.In recent years,adrenal sparing surgery has been gradually reported both at home and aboard.The indication for ASS or TA for APA remains controversial.[Objective]1.The perioperative safety and postoperative efficacy of aldosterone-producing adenoma in the treatment of laparoscopic adrenal sparing surgery versus total adrenalectomy were been analyzed by the means of evidence-based medicine.2.Collecting the case data of the hospitalized patients with APA treated by adrenal sparing surgery from January 2010 to October 2016 in the Department of Urology,Guangzhou General Hospital of Guangzhou Military of PLA,the clinical curative effects were analyzed.[Methods]1.We systematically searched Pubmed?ScienceDirect?Springerlink?the Cochrane library?CNKI and China Biology Medicine disc for clinical comparative studies published before May 2016,these studies reported the treatment of adrenal sparing surgery(ASS)/partial adrenalectomy(PA)versus total adrenalectomy(TA)for aldosterone-producing adenoma(APA).The selected studies were applied to Revman 5.3 software for meta-analysis.The main analyzed contents were perioperative outcomes(operative time,intra-operative blood loss,length of hospital stay)and postoperative efficacy(cure rate,partial response rate,inefficiency rate).2.A retrospective analysis was made on the data of patients with APA treated by ASS at the Guangzhou General Hospital of Guangzhou Military of PLA from January 2010 to October 2016.The general information of patients(gender,age,duration of disease,adenoma side),disease information(potassium,plasma aldosterone/renin activity,cortisol rhythm,preoperative blood pressure,24-hour catecholamine metabolites),surgical conditions(operative time,intra-operative blood loss)and postoperative pathological types were collected.Through the outpatient review or telephone follow-up to know the prognostic efficacy.Comparing the changes of blood pressure,serum potassium and other indicators of the patients with APA before and after surgery to clear safety,feasibility and postoperative efficacy of ASS.Statistical processing and analysis was performed by using SPSS 20.0 software.The data were measured by mean ± standard deviation(x±s).The comparison of blood pressure before and after operation was based on the statistical method of paired Samples T test,which was considered to be statistically different with P<0.05.[Results]1.A total of 154 Chinese literatures and 168 English literatures were found to be potentially relate to the surgical treatment of aldosterone-producing adenoma by retrieving different databases and reviewing the relevant references attached to the literature.After importing the Endnote software,fingding duplicates,reading the text and abstract,extracting data and comparing each sample size.A total of 9 clinical research studies with 1036 patients were included into the final meta-analysis,three English studies,six Chinese studies,7 of them from China,1 of them from Japan,1 of them from Taiwan,China.544 patients were assigned to ASS group and 492 patients were assigned to TA group.The results demonstrated that:? ASS was similar to TA in perioperative outcomes such as operative time(WMD:-2.09min;95%CI-9.86-5.67;P=0.60),intra-operative blood loss(WMD:1.13ml;95%CI-8.86?11.12;P=0.82),length of hospital stay(WMD:-O.10d;95%CI-0.32?0.12;P=0.36).? In terms of postoperative effect,ASS was also similar to TA in cure rate(OR:1.07;95%CI 0.73?1.58;P=0.72),partial response rate(OR:0.85;95%CI 0.57?1.27;P=0.43),inefficiency rate(OR:2.15;95%CI 0.32?14.34;P=0.43).2.According to the inclusion and exclusion criteria strictly,28 patients with APA treated by adrenal sparing surgery were included in the final clinical efficacy analysis.Including 15 men,13 women,aged 27 to 75 years old,mean(45.1 ±11.0)years old,22 patients with adenoma on the left side and 6 cases on the right side.The mean systolic blood pressure was 115?190 mmHg,mean(154.4 ± 18.2)mmHg,the diastolic blood pressure was 68?134 mmHg,mean(106.5± 16.9)mmHg,the course of disease 1?220 months,mean(37.9 ± 51.1)months.Preoperative biochemical tests showed that 12 cases of hypokalemia,plasma aldosterone/renin activity(ARR)increased in 27 cases,cortical alcohol rhythm abnormalities in 10 cases,11 patients 24 hours of urinary catecholamines(CA)metabolites increased.28 patients underwent retroperitoneoscopic adrenal sparing surgery successfully,25 cases of pathological diagnosis showed adrenal cortical adenoma,3 cases of pathological diagnosis showed adrenal hyperplasia.The follow-up for the 28 patients was 3?60 months,mean(28.2± 16.7)months.28 patients were normal blood potassium after surgery,postoperative hypertensive systolic blood pressure 112?150 mmHg,mean(130.2 ± 9.3)mmHg,diastolic blood pressure 66?115 mmHg,mean(95.4± 11.9)mmHg.The blood pressure before and after surgery was analyzed by Paired sample t test,the statistical result demonstrated that:systolic blood pressure decreased by(24.22±14.4)mmHg(P<0.001),diastolic blood pressure decreased by(11.1 ±8.5)mmHg(P<0.001).According to the efficacy evaluation criteria,15 patients were cured(BP<140/90mmHg,without taking antihypertensive drugs),accounting for 53.6%;11 patients were relieved(BP<140/90mmHg,the type and number of oral antihypertensive drugs decreased),accounting for 39.3%;2 patients were ineffective(BP>140/90mmHg,no significant changes in the type or number of oral antihypertensive drugs).[Conclusions]1.Through evidence-based medicine research methods demonstrates that:in the surgical treatment of aldosterone producing adenoma,ASS is technically safe,and can achieve reliable postoperative efficacy,having a similar therapeutic effect with TA,ASS deserves further application in clinical practice.2.The clinical analysis of strictly selected 28 patients with APA treated by ASS demonstrated that:the treatment of ASS for APA is safe and feasible in terms of perioperative aspect,and postoperative efficacy is satisfactory.ASS deserves further application in clinical practice. |
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