Explaining the Options to Your Patient
By Laura Freeman
Sometimes the first sign of trouble is a set of labs that don’t make sense. Or it could be an incidental finding on a scan for something else. The radiologist spots a nodule where a nodule shouldn’t be.
“You may also be trying to find out why a patient with high blood pressure isn’t responding to any combination of medications you’ve prescribed,” Justin Malek, MD with Advanced Surgeons said. “As you rule out possibilities, you see the levels of adrenal hormones in the patient’s blood and then you have a pretty clear idea of what is going on.”
Whether a physician is dealing with an adrenal gland gone rogue and overproducing, or a nodule that could be producing hormones or harboring a budding malignancy, it’s likely the patient will need a surgical consult for input to help decide what should happen next.
“While adrenal surgery isn’t as common as some other endocrine surgeries, it helps to refer the patient to someone who has done enough to be familiar with some of the more subtle factors,” Malek said. “There are several issues to consider. For example, although I usually prefer an abdominal approach using a laparoscope and the DaVinci robot, if the patient has had previous abdominal surgeries, I may consider a more direct approach through the back. It’s a shorter route without the need to move as many organs out of the way, but I know if I cut those particular muscles, the patient may be dealing with back pain that can take a while to heal.
“If there are other factors, a lateral approach is also possible. We don’t usually use open surgery anymore unless there is a strong indication of a malignancy that may have spread, or if an unusual anatomy makes it difficult to visualize both adrenal glands and the surrounding structures.”
When patients hear adrenal disease, they may think about Addison’s, which is treated with medication. However, other adrenal disorders are more typically are treated surgically.
“Cushing’s syndrome, if it is mild, can be managed for a while with medication, but when it becomes severe, surgery may be the best option,” Malek said. “With Cushing’s, there are visible clues and symptoms that help identify the disorder: abdominal weight gain, a fatty lump between the shoulders, fatigue and a dulling of mental acuity. You might also see purple stretch marks on the stomach, hips, thighs, breasts and underarms.”
Cushing’s is caused from having too much cortisol in the body. This can result from a person taking glucocorticoid medicines like Prednisone in which case the provider may try lowering the medication. However, when it results from an adrenal gland that is overproducing cortisol, physicians will perform an adrenalectomy to remove the malfunctioning gland.
In order the ensure that they are removing the right adrenal gland, during surgery Malek’s team can take samples of blood from the veins exiting the adrenals and measure the hormone levels in each one. “Usually the sample taken near the adrenal at fault is noticeably higher,” Malek said. “Only if the patient has only one gland or the health of the other adrenal is questionable would I be likely to try to preserve some of the gland that is malfunctioning.
“Sometimes the excess hormone is coming from a nodule. After we remove the nodule, we test it, and if it tests positive for malignancy, we look closely at the other adrenal and nearby organs including the pancreas. The cancer may originate in an adrenal or adrenal nodule, or it could have spread from the liver or another organ. When malignant cells are found, we bring an oncologist onboard to manage follow-up care.
“If no malignant cells are identified, after laparoscopic surgery patients can go home either the same day or the next day, depending on whether we need to monitor blood pressure changes from shifting hormones.
“Adrenal surgery can be rewarding for me because we’re able to outright cure serious disorders with a minimally invasive procedure in a single day.”
