Cushing's syndrome surgery

If an adrenal adenoma is identified it may be removed by either laparoscopic or open adrenalectomy. An ACTH-secreting corticotrophic pituitary adenoma should be removed after diagnosis. Regardless of the adenoma’s location, most patients will require steroid replacement postoperatively at least in the interim as long-term suppression of pituitary ACTH and normal adrenal tissue does not recover immediately. Clearly, if both adrenals are removed, replacement with hydrocortisone or prednisolone is imperative.

The following surgical methods are usually used to treat Cushing’s disease.^[1]

1. Transsphenoidal pituitary resection:
   • Transsphenoidal selective tumor resection (TSS) is the initial treatment of Cushing’s disease arising from pituitary adenoma.
2. Laparoscopic adrenalectomy:
   • Minimally invasive unilateral adrenalectomy is the standard of care for cortisol-secreting unilateral adenomas. These procedures are safe, effective, and comparatively less than open adrenalectomy.
3. Bilateral adrenalectomy:
   • Bilateral adrenalectomy is the usual treatment for patients with bilateral adrenal hyperplasia.
4. Open adrenalectomy:
   • Open adrenalectomy is recommended if adrenocortical cancer is suspected.

Regardless of the adenoma’s location, most patients will require steroid replacement postoperatively at least in the interim as long-term suppression of pituitary ACTH and normal adrenal tissue does not recover immediately. Clearly, if both adrenals are removed, replacement with hydrocortisone or prednisolone is imperative.

Removal of the adrenals in the absence of a known tumor is occasionally performed to eliminate the production of excess cortisol. In some occasions, this removes negative feedback from a previously occult pituitary adenoma, which starts growing rapidly and produces extreme levels of ACTH, leading to hyperpigmentation. This clinical situation is known as Nelson’s syndrome.^[2]

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