Oops! I have a mass in my adrenal gland!

Endocrine Surgery

The adrenal gland: Adrenal glands are the organs that are situated above the kidneys in the abdomen, which secrete several hormones. The production of these hormones is controlled by the brain. The adrenal gland consists of 2 parts: inner and outer parts. When the hormones are secreted from the inner layer (adrenalin and noradrenalin), the heart rate and blood pressure increases. It affects other body functions as well. Generally, physical and emotional stresses start the secretion of these hormones. A hormone group called corticosteroids is produced by the outer layer. These are three types. One of them is sex hormones that include male hormones (androgen) and female hormones (estrogen). These hormones affect sexual development and fertility. Do not forget that sex hormones are also produced in other parts of the body, testis and ovaries and that both female and male hormones exist either in males or females. Another group is the hydrocortisone group (glucocorticoids). These affect the transformation of starchy foods in glycogen (like sugar storage) in liver. The third type of hormones control the consumption of minerals by the body. The hormone called aldosterone is the principal hormone of this group. Thus, the hormones secreted from the adrenal gland affect all systems of the body. Their effects are rather complicated.

In this complicated system, some disorders and insufficiencies may occur. As may happen in every organ, masses can develop in these adrenals, too. Most of these masses are benign; however, they may require detailed investigation and close monitoring. Some of the adrenal gland masses may cause irrecoverable damages to the body due to excessive hormone secretion.
Surgery is considered if the adrenal gland mass produces excessive hormone, enlarges despite normal level of hormone, reaches a precise extent or has the probability of malignancy.

Cushing’s Syndrome: Cushing’s syndrome occurs by the initiation of secretion of glucocorticoid hormones excessively from the outer layer of the adrenal gland. Although in general it is caused by excessive production of the hormone from the adrenal glands, exposure of long-term steroid medications (cortisone) used to treat another disease may also be responsible.

Symptoms of Cushing’s syndrome:
• Appearance of a round-shaped and red face occurring in months to years.
• Accumulation of fat pads between and over the shoulders looking like a hump.
• Striaes (stretch marks) over the skin on the lower part of the trunk.
• Fatigue and muscle weakness (particularly calf muscles)
• Edema
• Hypertension
• Hirsutism (male-pattern hair growth of the body)
• Psychological shock
• Impotence or cessation of menstruation
• Osteoporosis, particularly in vertebrae and pelvis
• Occurrence of diabetes mellitus
• Very easy occurrence of dental caries
• Difficulty in healing of the wounds

If the symptoms occur as a result of a treatment, dose reduction or interruption of drug use is required.

Pheochromocytoma: This is a rare tumor originating from cells situated in the before-mentioned inner layer of the adrenal gland. It is related to hypertension; however, only 1/1000 of hypertensive patients have pheochromocytoma. Although it is generally benign; dangerous hypertensive attacks, pallor of the skin, headaches, flushing of the face, sweating and nerviness as well as high blood glucose levels may be seen because of the excessive hormone secretion. Hypertension and other effects disappear with the surgical excision of the tumor.

Hyperaldosteronism: Hyperaldosteronism, occurs by the initiation of secretion of the hormone called aldosteron excessively from the outer layer of the adrenal gland.

Symptoms of hyperaldosteronism:
• Hypertension
• Low blood potassium level
• Headache
• Polyuria and polydipsia
• Fatigue and weakness
• Muscle cramps and contractions
• Constipation
• Disturbances of cardiac rhythm
• Psychological agitation

So, when should an adrenal gland patient be operated? Every adrenal gland-originated mass, which is huge or is expanding during the follow-up or is suspicion for cancer or is producing a hormone, should be removed surgically.

Adrenal gland surgery: Adrenal gland-originated masses may be operated either by a standard surgical procedure through an incision by opening the abdomen or by a laparoscopic method without opening the abdomen, according to the structure and patient’s condition. Robotic surgery is one of the laparoscopic methods. Both standard open surgery and laparoscopic surgery interventions include the complete resection of adrenal gland mass with clear borders.

Information regarding surgery:
• Surgery is carried out under general anesthesia.
• The aim of surgery is the total resection of the diseased adrenal gland. The other adrenal gland will take on whole functions of the removed gland. If the adrenal gland is extremely adhesive to the kidney, partial or complete resection of the ipsilateral kidney may be performed. Regarding the laparoscopic and robotic method, the procedure is carried out through 1-cm holes (3, 4 or 5 in total) on the lateral side of the trunk by using appropriate equipments according to the size of the mass and properties of the patient. As an alternative to the laparoscopic method, the same procedure can be performed by a standard open surgical method. The open arroach is carried out through a 25-30 centimeter-sized incision on the front part of the trunk, 2-3 cm below and parallel to the ribs or through an incision lying from the lower part of the ribs to the groin. The chance of success is similar and so the surgery-related complications are. However, cosmetic results are better with the laparoscopic approach; the patient feels less pain, recovers more rapidly and stays shorter in the hospital. Furthermore, a laparoscopic surgery patient returns to her/his active life earlier. In addition to the advantages of laparoscopic surgery, robotic surgery facilitates the operation.
• In some of the laparoscopically-initiated operations (less than 10%), the surgeon may have to convert to open method.
• As may be the case in every operation, complications related to anesthesia may also develop during adrenal gland surgery.
• Spleen or liver injury may develop during the surgery. The rate of this condition is less than 1%. The spleen may have to be resected in case of spleen injury. The risk of this condition is less than 0.1%.
• Vessel reconstruction may be required due to large vessel injuries. The risk is less than 1%.
• Rupture in vessels of kidney or adrenal gland may occur. Blood transfusion may be required in this condition. The risk of this condition is less than 1%. If this happens, the patient’s hospital stay may extend.
• The risk of a possible pancreatic leakage is 1-2% after adrenal surgery. Besides, the risk of bowel injury is less than 1 %. If this happens, bowel repair will be required and a stoma may be performed according the situation.
• The risk of wound complications is under 5%. This rate is a little bit higher in patients who are old, obese or have diabetes mellitus or Cushing’s syndrome.
• Because the hormones secreted from the adrenal glands regulate vital functions, such as blood pressure and heart rate; it is also highly possible that an adrenal gland-originated tumor secretes these hormones excessively. In that case, if such a condition is detected during the preoperative work-up; appropriate drug treatment before surgery is required. Essential drugs should also be kept ready in the surgical ward and suggestions of the endocrinologist should be obeyed. Despite all the cautions, the heart rate may rapidly increase and decrease with rapidly developing hypertension and hypotension.
• Adrenal glands may be resected bilaterally due to the type of disease. In this condition, lifelong drug treatment is required.
• Failure of wound healing or aesthetically bad wound healing may happen due to the nature of some diseases.
• In case of refusal of an advised adrenal surgery, the adrenal gland with tumor continues to stay in your body and may result in functional loss of the affected adrenal gland or complications may occur due to excessive hormone secretion or hormonal insufficiency may exist in time. Some conditions such as, symptoms due to the pressure of an enlarged mass (for example; nausea-vomiting, bowel obstruction, liver and pancreas insufficiency, respiratory distress and pain) to adjacent organs (bowel, pancreas, spleen, liver and lung); or the expansion (spread) of disease to the other organs in your body; or general body fatigue, bone pain and shortening of life expectancy may develop.
• You have to avoid heavy exercise and carrying loads after the first 2 months of the operation. Following the suggested diet and drug treatments is advised.