PAPER Selective Use of Steroid Replacement After Adrenalectomy Lessons From 331 Consecutive Cases Wen T. Shen, MD; James Lee, MD; Electron Kebebew, MD; Orlo H. Clark, MD; Quan-Yang Duh, MD Hypothesis: Only selected patients require steroid re- tomy. Of the 57 patients requiring steroid replacement, placement therapy following adrenalectomy. 52 had Cushing syndrome and 5 had bilateral pheochro- mocytomas. The 52 patients with Cushing syndrome in- Design: Retrospective review. cluded 16 with pituitary tumors who had failed pitu- itary resection and/or medical therapy, 14 with unilateral Settings: University tertiary care center and veterans’ adrenal adenomas, 9 with ectopic corticotropin- hospital. secreting tumors who had failed resection and/or medi- cal therapy, 7 with incidentalomas and subclinical Cush- Patients: A total of 331 patients who underwent adre- ing syndrome, 4 with macronodular hyperplasia, and 2 nalectomy by 1 surgeon (Q.-Y.D.) between April 1, 1993, with adrenocortical carcinoma. No patients undergoing and August 31, 2005. unilateral adrenalectomy for non-Cushing adrenal dis- ease required steroid replacement. Four (7%) of the 57 Interventions: Laparoscopic, open, and hand-assisted patients receiving steroid replacement had episodes of adrenalectomy. Steroid replacement therapy was admin- istered using a standardized hydrocortisone taper pro- acute adrenocortical insufficiency following operation and tocol. required increased steroid supplementation. There were no cases of acute adrenocortical insufficiency in the 274 Main Outcome Measures: Indications for adrenal- patients who did not receive steroid replacement. ectomy, operative approach, requirement for postopera- tive steroid replacement, and episodes of acute adreno- Conclusions: Steroid replacement therapy after adre- cortical insufficiency. nalectomy should be reserved for patients with Cushing syndrome (overt or subclinical) and patients undergo- Results: Of the 331 adrenalectomies, 304 were laparo- ing bilateral adrenalectomy. Patients undergoing adre- scopic, 23 were open, and 4 were hand assisted. There nalectomy for unilateral non-Cushing adrenal tumors do were 299 unilateral adrenalectomies and 32 bilateral ad- not require postoperative steroid replacement. renalectomies performed. Fifty-seven (17%) of the 331 patients required steroid replacement after adrenalec- Arch Surg. 2006;141:771-776 HE PRACTICE OF PROVIDING roid replacement needed to provide ad- perioperative glucocorti- equate coverage for perioperative stress; coid replacement therapy to the concept and practice of administer- prevent adrenal insuffi- ing supraphysiologic, or “stress-dose,” ste- ciency in patients receiv- roids has been called into question by sev- ing steroids for inflammatory conditions eral investigators,5-8 and new guidelines for T 1,2 is well established. Since the early 1950s steroid-dependent patients undergoing op- when the first articles3,4 describing the dan- erations have been proposed and used.5-8 gers of postoperative adrenal insuffi- Another population of patients who may ciency in steroid-dependent patients were require perioperative steroid supplementa- published, the standard of care has been tion consists of patients undergoing adre- to treat these patients with physiologic or nalectomy for the spectrum of primary ad- Author Affiliations: supraphysiologic doses of steroids dur- renal tumors or, less commonly, adrenal Department of Surgery, ing the perioperative period. Within the metastases or extra-adrenal hypersecre- University of California, past 2 decades, there has been consider- tory conditions. However, few published San Francisco. able debate regarding the amount of ste- guidelines exist for identifying precisely (REPRINTED) ARCH SURG/ VOL 141, AUG 2006 WWW.ARCHSURG.COM 771 ©2006 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/23/2021 RESULTS Table 1. Comparison of Patients Who Required Postoperative Steroid Supplementation vs Patients Who Did Not Require Postoperative Steroids Between April 1, 1993, and August 31, 2005, 331 pa- tients underwent adrenalectomy by 1 surgeon (Q.-Y.D.) Patients Patients Requiring Not Requiring at the University of California, San Francisco, or one of Postoperative Postoperative its affiliated institutions. Of these 331 patients, 304 un- Steroids Steroids derwent laparoscopic adrenalectomy, 23 underwent open Characteristic (n = 57) (n = 274) adrenalectomy, and 4 underwent hand-assisted laparo- Episodes of adrenal insufficiency, No. 4 0* scopic adrenalectomy. Of the 23 open adrenalectomies, Infectious complications, No. 4 0* 4 were initially attempted laparoscopically but were con- Length of hospital stay, mean ± SEM, d 2.6 ± 0.3 1.5 ± 0.1* verted to open adrenalectomy because of difficult dis- section or intraoperative findings that may have been in- PϽ.05. * dicative of malignancy. The indications for operation for the 331 patients included aldosteronomas in 108 pa- tients, pheochromocytomas in 71 patients (including bi- which patients undergoing adrenalectomy require peri- lateral pheochromocytomas in 5 patients), Cushing syn- operative steroids. Not all patients undergoing adrenalec- drome in 52 patients, nonfunctioning cortical adenomas tomy are at risk for postoperative adrenal insufficiency, and in 34 patients, isolated adrenal metastases in 29 pa- unnecessary steroid administration is associated with a host tients, adrenocortical carcinoma (not causing Cushing of deleterious effects, including poor wound healing, blood syndrome) in 5 patients, and a virilizing adrenal tumor glucose level abnormalities, and other metabolic derange- in 1 patient. The remaining 31 patients who underwent ments. We therefore reviewed our experience with pa- adrenalectomy during this period had other types of uni- tients who underwent adrenalectomy during the past de- lateral nonfunctioning adrenal tumors (including my- cade, with the goal of identifying which patients required elolipomas, adrenal cysts, and adrenal hemorrhages). perioperative steroid replacement. We aimed to provide ra- Fifty-seven (17%) of 331 patients required steroid re- tional guidelines for the administration of steroids in pa- placement following adrenalectomy; the remaining 274 tients undergoing adrenalectomy and to highlight the sub- patients did not require or receive any form of postop- groups of patients who are at highest risk for postoperative erative steroid supplementation. The 57 patients receiv- adrenal insufficiency. ing steroids included 52 patients with Cushing syn- drome and 5 with bilateral pheochromocytomas who underwent bilateral adrenalectomies. All of the 52 pa- METHODS tients with Cushing syndrome were diagnosed preop- eratively by biochemical testing either because of clini- We reviewed the medical records of all of the patients who un- cal features of hypercortisolism or as part of the routine derwent adrenalectomy by 1 surgeon (Q.-Y.D.) between April workup of an incidentally discovered adrenal mass. The 1, 1993, and August 31, 2005. Patients who underwent open, cause of glucocorticoid excess in the 52 patients with laparoscopic, or hand-assisted adrenalectomy were included. The clinical presentation and indications for operation were re- Cushing syndrome included functioning pituitary tu- corded for each patient. All of the operations were performed mors in 16 patients who had failed pituitary resection at the University of California, San Francisco, Medical Center, and/or medical therapy; functioning unilateral adrenal the San Francisco Veterans Affairs Medical Center, the Uni- cortical adenomas in 14 patients; ectopic corticotropin- versity of California, San Francisco/Mt Zion Medical Center, secreting tumors in 9 patients who had failed resection or the San Francisco General Hospital. and/or medical therapy; subclinical Cushing syndrome All of the patients requiring postoperative steroid supple- in 7 patients who had been diagnosed during biochemi- mentation were identified, and their indications for and dura- cal workup of an incidentaloma; bilateral adrenal mac- tion of steroid therapy were recorded. Steroid supplementa- ronodular hyperplasia in 4 patients; and functioning ad- tion was administered using a standardized protocol established renocortical carcinoma in 2 patients. The 5 patients with in conjunction with medical endocrinologists at our institu- tion. Postoperative complications were noted, including all epi- bilateral pheochromocytomas included 3 with multiple sodes of adrenal insufficiency requiring additional steroid supple- endocrine neoplasia type 2A or 2B, 1 with Osler-Weber- mentation and any complications related to hypercortisolism Rendu syndrome, and 1 with neurofibromatosis. (including wound infections and other infectious complica- A comparison of postoperative complications in pa- tions). Episodes of adrenal insufficiency following operation tients who received steroid supplementation and pa- were documented by either serum or urinary testing in pa- tients who did not receive steroids is provided in Table 1. tients with symptoms or signs of hypocortisolism. The dura- The 57 patients who underwent steroid replacement in- tion of hospitalization was recorded. In our practice, all of the cluded 4 who required additional steroid therapy be- patients are seen for follow-up by the surgeon between 2 and cause of signs and symptoms of addisonian crisis. Infec- 4 weeks after operation. If there are no persistent postopera- tious complications developed