Denver Center for Endocrine , LLC 4700 E Hale Pkwy, Suite 210 ● Denver, CO 80220 ● T 303.407.0280 F 303.407.0284 www.denverendosurgery.com

Adrenal Nodules What are the adrenal glands? The two adrenal glands are part of the body’s and are located just above each kidney in the back of the upper abdomen. Although the adrenal glands are small, they produce several hormones that affect almost every system in the body. Hormones are substances carried through the bloodstream to many parts of the body where they regulate various body functions. You need about one-half of one for adequate hormone function.

Hormones produced by the adrenal glands include: • Aldosterone: Regulates salt balance and blood pressure • Sex Hormones (Androgens and Estrogens) affect physical traits and sex organ function • Catecholamines (Epinephrine, , dopamine, and norepinephrine): Affect heart rate and blood pressure • : Affects the immune system, metabolism, salt balance, and response to other hormones

Why would I need my adrenal gland removed? An (adrenal gland removal) may be done if an adrenal gland contains a tumor or if it makes and secretes too much of one or more hormones. Adrenal tumors are usually benign (not cancerous), but rarely can malignant (cancerous).

How do I know if I need my adrenal gland removed? Blood and urine tests are used to diagnose conditions that may require adrenal removal. Imaging tests (including ultrasound, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans and radioisotope (nuclear medicine) scans) may also be required. Sometimes a procedure to sample the hormones from each adrenal gland (adrenal vein sampling) is needed. Your doctor will let you know if or when adrenal surgery is recommended.

Do I need a biopsy prior to surgery? Biopsy prior to surgery is usually NOT recommended. Rarely, an adrenal biopsy is used to check for spread of cancer from other places (metastatic disease).

What does the name of my adrenal condition mean?

• : An adrenal tumor that secretes catecholamines (a.k.a. adrenaline or epinephrine related hormones). Symptoms include high blood pressure, fast heart rate/palpitations, anxiety, panic attacks, and pounding headaches. Patient’s often have symptomatic “spells” that last less than an hour.

• Hyperaldosteronism: One or both adrenal glands produce too much aldosterone. Patients can experience severe high blood pressure that does not respond to typical medical therapy. Because microscopic tumors and bilateral DCES AdrenalBasics-v3-22-20 (KV) Denver Center for , LLC 4700 E Hale Pkwy, Suite 210 ● Denver, CO 80220 ● T 303.407.0280 F 303.407.0284 www.denverendosurgery.com

adrenal overgrowth can cause excess aldosterone secretion, additional testing to identify the source of aldosterone is needed prior to planning surgery. Treatment with medications that block aldosterone (i.e. Spironoloactone, Eplerenone) may be an alternative to surgery. "Conn’s Syndrome" or Aldosteronoma is the diagnosis given when there is a benign tumor secreting the aldosterone.

• Cushing’s Syndrome: Excessive cortisol. There are many potential causes of excess cortisol, including pituitary tumors, lung tumors, adrenal tumors and certain medications. Extensive testing may be required to make the diagnosis as some patients can have "subclinical" disease where symptoms and blood testing can be within normal range. Testing can sometimes take many months and many rounds of testing. Symptoms may include: weight gain, fatigue, high blood pressure, acne, facial rounding, development of facial hair in women, easy bruising, straie (stretch marks) or “buffalo hump” (fat pad at back of neck). Adrenalectomy may be performed to remove one or both adrenal glands. After surgery most patients require additional medications that may be tapered over several months.

How do you remove the adrenal gland? There are two surgical approaches to removing an adrenal gland: laparoscopic adrenalectomy and open adrenalectomy.

With the laparoscopic approach, three or four small incisions (approximately 1/2 inch) are made in the skin on the abdomen (transabdominal approach) or on the back (retroperitoneal approach). Carbon dioxide gas is used to create space and helps your surgeon see and move instruments in your body. A laparoscope (camera) is inserted into the body which sends a video picture to a television monitor. Long surgical instruments are inserted through the other incisions to perform the procedure. One incision is typically stretched or extended at the end of the procedure to remove the adrenal gland/tumor.

If you have had previous abdominal surgery, the tumor is very large, or if your physician is concerned that the tumor is cancerous or feels that laparoscopic surgery is not safe, you may need an open adrenalectomy. With the open approach, a large incision on the abdomen, side or back is made to access the adrenal gland. In rare cases, your surgeon may feel it is not safe to continue a laparoscopic adrenalectomy once it has begun. If so, the surgeon may convert to an open approach.

Most take about two to four hours, depending on which surgical approach is used.

DCES AdrenalBasics-v3-22-20 (KV) Denver Center for Endocrine Surgery, LLC 4700 E Hale Pkwy, Suite 210 ● Denver, CO 80220 ● T 303.407.0280 F 303.407.0284 www.denverendosurgery.com

What are the risks and complications of an adrenalectomy? Risks are slightly different between the right and left adrenal glands. • Bleeding is the most common risk. It can be life threatening and require a blood transfusion with this surgery, especially on the right side where the adrenal gland is connected to the inferior vena cava (the large vein that drains into the heart from the lower body). • Injury to surrounding organs or structures (Right side: kidney, liver, gallbladder, intestines; Left side: kidney, , spleen, stomach, intestines) • Infection • Anesthesia Related Risks • Major hormone swings related to the underlying disease, the surgery or both. This can affect wound healing, blood pressure fluctuations and risk for heart attack/stroke, and other metabolic problems. • If you have Cushing’s Syndrome, you can be at risk for adrenal insufficiency (low /low cortisol) for months to years after surgery. An “adrenal crisis” can be severe and life-threatening. You should know signs and symptoms of adrenal insufficiency (nausea, vomiting, abdominal pain, weakness, low blood pressure, fever, confusion). Emergency treatment usually involves additional steroids. You may need to wear a medic-alert bracelet.

How do I prepare for surgery? Tell your providers about all prescription and over-the-counter medications you take. Follow your providers’ instructions for taking these medications before surgery.

You may be prescribed additional medications to take in the days or weeks leading up to your surgery. These medications are used to manage the effects of excess hormones (e.g., spells, high blood pressure, low potassium level). It is important that you take the medications as instructed. Taking these medications helps prepare you for surgery and makes surgery safer.

While taking these medications, people sometimes do not feel well. If you have any questions about the medications and their side effects, talk with your provider. Although side effects can be unpleasant, they help us determine how well the medicines are working to block excess hormones.

Sometimes a special diet is recommended during testing or prior to surgery. You may also be asked to record your blood pressure, heart rate and/or blood sugars at home prior to surgery.

What does recovery look like? Recovery depends on the type of surgery and underlying condition (pheochromocytoma or Cushing’s, etc.). Typically, patients spend one to several days in the hospital and continue to recover for several more weeks at home prior to returning to work and usual activities. If you have Cushing’s syndrome, your recovery will likely take additional time.

DCES AdrenalBasics-v3-22-20 (KV) Denver Center for Endocrine Surgery, LLC 4700 E Hale Pkwy, Suite 210 ● Denver, CO 80220 ● T 303.407.0280 F 303.407.0284 www.denverendosurgery.com

DCES AdrenalBasics-v3-22-20 (KV)