Advertisement

Surgical Approach to Adrenal Diseases in the Elderly

  • Andrea Valeri
  • Andrea Polistena
  • Carlo Bergamini
  • Nicola Avenia
Chapter

Abstract

A wide spectrum of benign and malignant adrenal diseases are referred to surgery in elderly patients. Adrenal causes of secondary hypertension are primary aldosteronism, hypercortisolism either in the form of adenomas or hyperplasia, pheochromocytoma, and paragangliomas. Standard diagnostic protocols are available for the different endocrine features, and adrenal vein catheterization can be used in case of bilateral lesions. Malignant lesions include some forms of pheochromocytoma, metastases, and primary adrenocortical carcinoma. All these malignancies are usually associated to bad prognosis and often are not radically resectable at diagnosis. Especially pheochromocytoma presents with a wide spectrum of clinical features often with surgical indication to control severe hypertension. Asymptomatic adrenal lesions detected during general radiological or ultrasonographic abdominal examination are defined as incidentalomas. Endocrine activity and malignancy should be screened in all incidentalomas. In the elderly, surgery of adrenal disease is feasible, but the outcomes may be worse due to comorbidities, increased postoperative complications, and slower recovery. The indications for adrenalectomy are functional tumor associated with hormone secretion and nonfunctional tumors associated with a suspicion or evidence of malignancy. The feasibility and the safety of the laparoscopic approach in elderly, although higher conversion rate, has been shown. Laparoscopic adrenalectomy represents the gold standard of treatment even in elderly patients with lateral transabdominal access being the most used worldwide. The open adrenalectomy is generally performed in presence of general contraindications to laparoscopy or in presence of large lesions (>12 cm in diameter) or malignant locally invasive tumors. Patient selection and care in containment of complication and comorbidity are key points of the surgical management.

Keywords

Adrenal surgery Elderly Laparoscopic adrenalectomy Secondary hypertension 

References

  1. 1.
    Taffel M, Haji-Momenian S, Nikolaidis P, Miller FH. Adrenal imaging: a comprehensive review. Radiol Clin N Am. 2012;50:219–43.CrossRefGoogle Scholar
  2. 2.
    Fields LE, Burt VL, Cutler JA, Hughes J, Roccella EJ, Sorlie P. The burden of adult hypertension in the United States 1999 to 2000: a rising tide. Hypertension. 2004;44:398–404.CrossRefGoogle Scholar
  3. 3.
    Rudnick KV, Sackett DL, Hirst S, Holmes C. Hypertension in a family practice. Can Med Assoc J. 1977;117:492–7.PubMedPubMedCentralGoogle Scholar
  4. 4.
    Omura M, Saito J, Yamaguchi K, Kakuta Y, Nishikawa T. Prospective study on the prevalence of secondary hypertension among hypertensive patients visiting a general outpatient clinic in Japan. Hypertens Res. 2004;27:193–202.CrossRefGoogle Scholar
  5. 5.
    Viera AJ, Neutze DM. Diagnosis of secondary hypertension: an age-based approach. Am Fam Physician. 2010;82:1471–8.PubMedGoogle Scholar
  6. 6.
    Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine and Biology; Society of Interventional Radiology; ACC/AHA task force on practice guidelines (writing committee to develop guidelines for the management of patients with peripheral arterial disease); endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic inter-society consensus; vascular disease foundation. Circulation. 2006;113:1474–547.CrossRefGoogle Scholar
  7. 7.
    Wheatley K, Ives N, Gray R, Kalra PA, Moss JG, Baigent C, Carr S, Chalmers N, Eadington D, Hamilton G, Lipkin G, Nicholson A, Scoble J, ASTRAL Investigators. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med. 2009;361:1953–62.CrossRefGoogle Scholar
  8. 8.
    Klein I, Danzi S. Thyroid disease and the heart. Circulation. 2007;116:1725–35.CrossRefGoogle Scholar
  9. 9.
    Prisant LM, Gujral JS, Mulloy AL. Hyperthyroidism: a secondary cause of isolated systolic hypertension. J Clin Hypertens. 2006;8:596–9.CrossRefGoogle Scholar
  10. 10.
    Mulatero P, Stowasser M, Loh KC, Fardella CE, Gordon RD, Mosso L, Gomez-Sanchez CE, Veglio F, Young WF Jr. Increased diagnosis of primary aldosteronism, including surgically correctable forms, in centers from five continents. J Clin Endocrinol Metab. 2004;89:1045–50.CrossRefGoogle Scholar
  11. 11.
    Loh KC, Koay ES, Khaw MC, Emmanuel SC, Young WF Jr. Prevalence of primary aldosteronism among Asian hypertensive patients in Singapore. J Clin Endocrinol Metab. 2000;85:2854–9.PubMedGoogle Scholar
  12. 12.
    Mosso L, Carvajal C, Gonzalez A, Barraza A, Avila F, Montero J, Huete A, Gederlini A, Fardella CE. Primary aldosteronism and hypertensive disease. Hypertension. 2003;42:161–5.CrossRefGoogle Scholar
  13. 13.
    Rossi GP, Bernini G, Caliumi C, Desideri G, Fabris B, Ferri C, Ganzaroli C, Giacchetti G, Letizia C, Maccario M, Mallamaci F, Mannelli M, Mattarello MJ, Moretti A, Palumbo G, Parenti G, Porteri E, Semplicini A, Rizzoni D, Rossi E, Boscaro M, Pessina AC, Mantero F. A prospective study of the prevalence of primary aldosteronism in 1,125 hypertensive patients. J Am Coll Cardiol. 2006;48:2293–300.CrossRefGoogle Scholar
  14. 14.
    Schwartz GL, Turner ST. Screening for primary aldosteronism in essential hypertension: diagnostic accuracy of the ratio of plasma aldosterone concentration to plasma renin activity. Clin Chem. 2005;51:386–94.CrossRefGoogle Scholar
  15. 15.
    Eide IK, Torjesen PA, Drolsum A, Babovic A, Lilledahl NP. Low-renin status in therapy-resistant hypertension: a clue to efficient treatment. J Hypertens. 2004;22:2217–26.CrossRefGoogle Scholar
  16. 16.
    Myint KS, Watts M, Appleton DS, Lomas DJ, Jamieson N, Taylor KP, Coghill S, Brown MJ. Primary hyperaldosteronism due to adrenal microadenoma: a curable cause of refractory hypertension. J Renin-Angiotensin-Aldosterone Syst. 2008;9:103–6.CrossRefGoogle Scholar
  17. 17.
    Funder JW, Carey RM, Fardella C, Gomez-Sanchez CE, Mantero F, Stowasser M, Young WF Jr, Montori VM. Case detection, diagnosis, and treatment of patients with primary aldosteronism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2008;93:3266–81.CrossRefGoogle Scholar
  18. 18.
    Young WF Jr. Clinical practice. The incidentally discovered adrenal mass. N Engl J Med. 2007;356:601–10.CrossRefGoogle Scholar
  19. 19.
    Daunt N. Adrenal vein sampling: how to make it quick, easy, and successful. Radiographics. 2005;25:S143–58.CrossRefGoogle Scholar
  20. 20.
    Magiakou MA, Smyrnaki P, Chrousos GP. Hypertension in Cushing’s syndrome. Best Pract Res Clin Endocrinol Metab. 2006;20:467–82.CrossRefGoogle Scholar
  21. 21.
    Nieman LK, Biller BM, Findling JW, Murad MH, Newell-Price J, Savage MO, Tabarin A, Endocrine Society. Treatment of Cushing’s syndrome: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2015;100:2807–31.CrossRefGoogle Scholar
  22. 22.
    Lenders JW, Eisenhofer G, Mannelli M, Pacak K. Phaeochromocytoma. Lancet. 2005;366:665–75.CrossRefGoogle Scholar
  23. 23.
    Bruynzeel H, Feelders RA, Groenland TH, van den Meiracker AH, van Eijck CH, Lange JF, de Herder WW, Kazemier G. Risk factors for hemodynamic instability during surgery for pheochromocytoma. J Clin Endocrinol Metab. 2010;95:678–85.CrossRefGoogle Scholar
  24. 24.
    Lenders JW, Pacak K, Walther MM, Linehan WM, Mannelli M, Friberg P, Keiser HR, Goldstein DS, Eisenhofer G. Biochemical diagnosis of pheochromocytoma: which test is best? Biochemical diagnosis of pheochromocytoma: which test is best? JAMA. 2002;287:1427–34.CrossRefGoogle Scholar
  25. 25.
    Furuta N, Kiyota H, Yoshigoe F, Hasegawa N, Ohishi Y. Diagnosis of pheochromocytoma using [123I]-compared with [131I]-metaiodobenzylguanidine scintigraphy. Int J Urol. 1999;6:119–24.CrossRefGoogle Scholar
  26. 26.
    Nakatani T, Hayama T, Uchida J, Nakamura K, Takemoto Y, Sugimura K. Diagnostic localization of extra-adrenal pheochromocytoma: comparison of (123)I-MIBG imaging and (131)IMIBG imaging. Oncol Rep. 2002;9:1225–7.PubMedGoogle Scholar
  27. 27.
    Lev I, Kelekar G, Waxman A, Yu R. Clinical use and utility of metaiodobenzylguanidine scintigraphy in pheochromocytoma diagnosis. Endocr Pract. 2010;16:398–407.CrossRefGoogle Scholar
  28. 28.
    Lenders JW, Duh QY, Eisenhofer G, Gimenez-Roqueplo AP, Grebe SK, Murad MH, Naruse M, Pacak K, Young WF Jr, Society E. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2014;99:1915–42.CrossRefGoogle Scholar
  29. 29.
    Srougi V, Chambo JL, Tanno FY, Soares IS, Almeida MQ, Pereira MA, Srougi M, Fragoso MC. Presentation and surgery outcomes in elderly with pheochromocytoma: a comparative analysis with young patients. Int Braz J Urol. 2016;42:671–7.CrossRefGoogle Scholar
  30. 30.
    Zenilman ME. Surgery in the elderly. Curr Probl Surg. 1998;35:99–179.CrossRefGoogle Scholar
  31. 31.
    Novosel A, Heger A, Lohse P, Schmidt H. Multiple pheochromocytomas and paragangliomas in a young patient carrying a SDHD gene mutation. Eur J Pediatr. 2004;163:701–3.CrossRefGoogle Scholar
  32. 32.
    Polistena A, Cavallaro G, Cotesta D, Petramala L, Letizia C, Basile U, Filetti S, Cavallaro A, De Toma G. Surgical management of extra-adrenal abdominal paragangliomas report of three cases and review of the literature. Endocrinologist. 2010;20:63–5.CrossRefGoogle Scholar
  33. 33.
    Polistena A, D’Angeli L, Cavallaro G, Izzo L, Cotesta D, Petramala L, Letizia C, Cavallaro G, De Toma G. Surgical treatment of extra-adrenal abdominal paragangliomas. Am Surg. 2009;75:1153–5.PubMedGoogle Scholar
  34. 34.
    Calissendorff J, Calissendorff F, Falhammar H. Adrenocortical cancer: mortality, hormone secretion, proliferation and urine steroids - experience from a single centre spanning three decades. BMC Endocr Disord. 2016;16:15.CrossRefGoogle Scholar
  35. 35.
    Mantero F, Terzolo M, Arnaldi G, Osella G, Masini AM, Ali A, Giovagnetti M, Opocher G, Angeli A. A survey on adrenal incidentaloma in Italy. J Clin Endocrinol Metab. 2000;85:637–44.PubMedGoogle Scholar
  36. 36.
    Bilimoria KY, Shen WT, Elaraj D, Bentrem DJ, Winchester DJ, Kebebew E, Sturgeon C. Adrenocortical carcinoma in the United States: treatment utilization and prognostic factors. Cancer. 2008;113:3130–6.CrossRefGoogle Scholar
  37. 37.
    Fassnacht M, Terzolo M, Allolio B, Baudin E, Haak H, Berruti A, Welin S, Schade-Brittinger C, Lacroix A, Jarzab B. Combination chemotherapy in advanced adrenocortical carcinoma. N Engl J Med. 2012;366:2189–97.CrossRefGoogle Scholar
  38. 38.
    Lebastchi AH, Kunstman JW, Carling T. Adrenocortical carcinoma: current therapeutic state-of-the-art. J Oncol. 2012;2012:234726.CrossRefGoogle Scholar
  39. 39.
    Erdogan I, Deutschbein T, Jurowich C, Kroiss M, Ronchi C, Quinkler M, Waldmann J, Willenberg HS, Beuschlein F, Fottner C. The role of surgery in the management of recurrent adrenocortical carcinoma. J Clin Endocrinol Metab. 2013;98:181–91.CrossRefGoogle Scholar
  40. 40.
    Weiss LM, Medeiros J, Vickery AL. Pathologic features of prognostic significance in adrenocortical carcinoma. Am J Surg Pathol. 1989;13:202–6.CrossRefGoogle Scholar
  41. 41.
    Lau SK, Weiss LM. The Weiss system for evaluating adrenocortical neoplasms: 25 years later. Hum Pathol. 2009;40:757–68.CrossRefGoogle Scholar
  42. 42.
    Aubert S, Wacrenier A, Leroy X, Devos P, Carnaille B, Proye C, Wemeau JL, Lecomte-Houcke M, Leteurtre E. Weiss system revisited: a clinicopathologic and immunohistochemical study of 49 adrenocortical tumours. Am J Surg Pathol. 2002;26:1612–9.CrossRefGoogle Scholar
  43. 43.
    Lughezzani G, Sun M, Perrotte P, Jeldres C, Alasker A, Isbarn H, Budaus L, Shariat SF, Guazzoni G, Montorsi F. The European network for the study of adrenal tumours staging system is prognostically superior to the international union against cancer-staging system: a North American validation. Eur J Cancer. 2010;46:713–9.CrossRefGoogle Scholar
  44. 44.
    Dhamija E, Panda A, Das CJ, Gupta AK. Adrenal imaging (part 2): medullary and secondary adrenal lesions. Indian J Endocrinol Metab. 2015;19:16–24.CrossRefGoogle Scholar
  45. 45.
    Zheng QY, Zhang GH, Zhang Y, Guo YL. Adrenalectomy may increase survival of patients with adrenal metastases. Oncol Lett. 2012;3:917–20.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Strong VE, D’Angelica M, Tang L, Prete F, Gönen M, Coit D, Touijer KA, Fong Y, Brennan MF. Laparoscopic adrenalectomy for isolated adrenal metastasis. Ann Surg Oncol. 2007;14:3392–400.CrossRefGoogle Scholar
  47. 47.
    Henry JF, Sebag F, Iacobone M, Mirallie E. Results of laparoscopic adrenalectomy for large and potentially malignant tumours. World J Surg. 2002;26:1043–7.CrossRefGoogle Scholar
  48. 48.
    Ippolito E, D’Angelillo RM, Fiore M, Molfese E, Trodella L, Ramella S. SBRT: a viable option for treating adrenal gland metastases. Rep Pract Oncol Radiother. 2015;20:484–90.CrossRefGoogle Scholar
  49. 49.
    Glazer HS, Weyman PJ, Sagel SS, Levitt RG, McClennan BL. Nonfunctioning adrenal masses: incidental discovery on computed tomography. Am J Roengtenol. 1982;139:81–5.CrossRefGoogle Scholar
  50. 50.
    Kloos RT, Gross MD, Francis IR, Korobkin M, Shapiro B. Incidentally discovered adrenal masses. Endocr Rev. 1995;16:460–84.PubMedGoogle Scholar
  51. 51.
    Boland GW, Blake MA, Hahn PF, Mayo-Smith WW. Incidental adrenal lesions: principles, techniques, and algorithms for imaging characterization. Radiology. 2008;249:756–75.CrossRefGoogle Scholar
  52. 52.
    Johnson PT, Horton KM, Fishman EH. Adrenal mass imaging with multidetector CT: pathologic conditions, pearls, and pitfalls. Radiographics. 2009;29:1333–51.CrossRefGoogle Scholar
  53. 53.
    Terzolo M, Stigliano A, Chiodini I, Loli P, Furlani L, Arnaldi G, Reimondo G, Pia A, Toscano V, Zini M, Borretta G, Papini E, Garofalo P, Allolio B, Dupas B, Mantero F, Tabarin A, Italian Association of Clinical Endocrinologists. AME position statement on adrenal incidentaloma. Eur J Endocrinol. 2011;164:851–70.CrossRefGoogle Scholar
  54. 54.
    Damhuis RA, Meurs CJ, Meijer WS. Postoperative mortality after cancer surgery in octogenarians and nonagenarians: results from a series of 5,390 patients. World J Surg Oncol. 2005;3:71.CrossRefGoogle Scholar
  55. 55.
    New classification of physical status. American Society of Anaesthesiologists. Anaesthesiology. 1963;24:111.Google Scholar
  56. 56.
    Chung TL, Van Heerden JA, Grant CS, Soreide JA, Warner MA, Ilstrup DM. Adrenal surgery in the elderly: too risky? World J Surg. 1996;20:368–74.CrossRefGoogle Scholar
  57. 57.
    Prager G, Heinz-Peer G, Passler C, Kaczirek K, Schindl M, Scheuba C, et al. Surgical strategy in adrenal masses. Eur J Radiol. 2002;41:70–7.CrossRefGoogle Scholar
  58. 58.
    Gagner M, Lacroix A, Prinz RA, Bolte E, Albala D, Potvin C. Early experience with laparoscopic approach for adrenalectomy. Surgery. 1993;114:1120–4.PubMedGoogle Scholar
  59. 59.
    Gagner M, Pomp A, Heniford BT, Pharand D, Lacroix A. Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures. Ann Surg. 1997;226:238–46.CrossRefGoogle Scholar
  60. 60.
    Brunt LM, Moley JF, Doherty GM, Lairmore TC, DeBenedetti MK, Quasebarth MA. Outcomes analysis in patients undergoing laparoscopic adrenalectomy for hormonally active adrenal tumors. Surgery. 2001;130:625–9.CrossRefGoogle Scholar
  61. 61.
    Heslin MJ, Winzeler AH, Weingarten JO, Diethelm AG, Urist MM, Bland KI. Laparoscopic adrenalectomy and splenectomy are safe and reduce hospital stay and charges. Am Surg. 2003;69:377–81.PubMedGoogle Scholar
  62. 62.
    Kuriansky J, Sáenz A, Astudillo E, Ardid J, Cardona V, Fernández-Cruz L. Laparoscopic adrenalectomy in the elderly. J Laparoendosc Adv Surg Tech. 1999;9:317–20.CrossRefGoogle Scholar
  63. 63.
    Fried GM, Cías D, Meakins JL. Minimally invasive surgery in the elderly patient. Surg Clin North Am. 1994;74:375–86.PubMedGoogle Scholar
  64. 64.
    Zeiger MA, Thompson GB, Duh QY, Hamrahian AH, Angelos P, Elaraj D, et al. The American Association of Clinical Endocrinologists and American Association of endocrine surgeons medical guidelines for the management of adrenal incidentalomas. Endocr Pract. 2009;15:1–20.CrossRefGoogle Scholar
  65. 65.
    Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma analysis of 1000 autopsied cases. Cancer. 1950;3:74–85.CrossRefGoogle Scholar
  66. 66.
    Thompson GB, Grant CS, van Heerden JA, Schlinkert RT, Young WF Jr, Farley DR, Ilstrup DM. Laparoscopic versus open posterior adrenalectomy: a case-control study of 100 patients. Surgery. 1997;122:1132–6.CrossRefGoogle Scholar
  67. 67.
    Henry JF. Minimally invasive adrenal surgery. Best Pract Res Clin Endocrinol Metab. 2001;15:149–60.CrossRefGoogle Scholar
  68. 68.
    Gumbs AA, Gagner M. Laparoscopic adrenalectomy. Best Pract Res Clin Endocrinol Metab. 2006;20:483–99.CrossRefGoogle Scholar
  69. 69.
    Mercan S, Seven R, Ozarmagan S, et al. Endoscopic retroperitoneal adrenalectomy. Surgery. 1995;118:1071–6.CrossRefGoogle Scholar
  70. 70.
    Walz MK, Alesina PF, Wenger FA, et al. Posterior retroperitoneoscopic adrenalectomy results of 560 procedures in 520 patients. Surgery. 2006;140:943–50.CrossRefGoogle Scholar
  71. 71.
    Perretta S, Campagnacci R, Guerrieri M, Paganini AM, De Sanctis A, Sarnari J, Rimini M, Lezoche E. Sub-mesocolic access in laparoscopic left adrenalectomy. Surg Endosc. 2005;19:977–80.CrossRefGoogle Scholar
  72. 72.
    Lezoche E, Guerrieri M, Crosta F, Lezoche G, Baldarelli M, Campagnacci R. Flank approach versus anterior sub-mesocolic access in left laparoscopic adrenalectomy: a prospective randomized study. Surg Endosc. 2008;22:2373–8.CrossRefGoogle Scholar
  73. 73.
    Lin Y, Li L, Zhu J, Qiang W, Makiyama K, Kubota Y. Experience of retroperitoneoscopic adrenalectomy in 195 patients with primary aldosteronism. Int J Urol. 2007;14:910–3.CrossRefGoogle Scholar
  74. 74.
    Suzuki K, Kageyama S, Hirano Y, Ushiyama T, Rajamahanty S, Fujita K. Comparison of 3 surgical approaches to laparoscopic adrenalectomy: a nonrandomized, background matched analysis. J Urol. 2001;166:437–43.CrossRefGoogle Scholar
  75. 75.
    Terachi T, Yoshida O, Matsuda T, Orikasa S, Chiba Y, Takahashi K, Takeda M, Higashihara E, Murai M, Baba S, Fujita K, Suzuki K, Ohshima S, Ono Y, Kumazawa J, Naito S. Complications of laparoscopic and retroperitoneoscopic adrenalectomies in 370 cases in Japan: a multi-institutional study. Biomed Pharmacother. 2000;54:211s–4s.CrossRefGoogle Scholar
  76. 76.
    Gagner M, Lacroix A, Bolte E, Pomp A. Laparoscopic adrenalectomy: the importance of a flank approach in the lateral decubitus position. Surg Endosc. 1994;8:135–8.CrossRefGoogle Scholar
  77. 77.
    Smith CD, Weber CJ, Amerson JR. Laparoscopic adrenalectomy: new gold standard. World J Surg. 1999;23:389–96.CrossRefGoogle Scholar
  78. 78.
    Parnaby CN, Chong PS, Chisholm L, et al. The role of laparoscopic adrenalectomy for adrenal tumours of 6 cm or greater. Surg Endosc. 2008;22:617–21.CrossRefGoogle Scholar
  79. 79.
    Weismann D, Fassnacht M, Weinberger F, Hamelmann W, Diehl S, Lorenz K, et al. Intraoperative haemodynamic stability in patients with phaeochromocytoma—minimally invasive vs conventional open surgery. Clin Endocrinol. 2006;65:352–8.CrossRefGoogle Scholar
  80. 80.
    Compagna R, Aprea G, De Rosa D, Gentile M, Cestaro G, Vigliotti G, et al. Fast track for elderly patients: is it feasible for colorectal surgery? Int J Surg. 2014;12:S20–2.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Andrea Valeri
    • 1
  • Andrea Polistena
    • 2
  • Carlo Bergamini
    • 1
  • Nicola Avenia
    • 2
  1. 1.General, Emergency and Minimally Invasive Surgery UnitCareggi University HospitalFlorenceItaly
  2. 2.General and Endocrine Surgery UnitS. Maria University Hospital, University of PerugiaTerniItaly

Personalised recommendations