Elsevier

Surgery

Volume 159, Issue 1, January 2016, Pages 259-266
Surgery

Adrenal
Cosyntropin stimulation testing on postoperative day 1 allows for selective glucocorticoid replacement therapy after adrenalectomy for hypercortisolism: Results of a novel, multidisciplinary institutional protocol

Presented at the 36th Annual Meeting of the American Association of Endocrine Surgeons, May 2015, Nashville, Tennessee.
https://doi.org/10.1016/j.surg.2015.05.034Get rights and content

Background

Secondary adrenal insufficiency (AI) can occur after unilateral adrenalectomy for adrenal-dependent hypercortisolism. Postoperative glucocorticoid replacement (GR), although given routinely, may not be necessary. We sought to identify factors that, in combination with postoperative day 1 cosyntropin stimulation testing (POD1-CST), would predict the need for GR.

Methods

We reviewed 31 consecutive patients who underwent unilateral adrenalectomy for hypercortisolism (study patients) or hyperaldosteronism (control patients). A standard POD1-CST protocol was used. Hydrocortisone was started for clinical evidence of AI, basal plasma cortisol ≤5 (μg/dL), or a stimulated plasma cortisol <18.

Results

A normal POD1-CST was found in all nine control patients and 11 of 22 patients (50%) with Cushing's syndrome; the other 11 study patients (50%) received GR based on the POD1-CST. These patients were younger (51 vs 62 years; P = .017), had a higher body mass index (BMI; 31 vs 29 kg/m2), and smaller adrenal neoplasms (16.9 vs 33.0 g; P = .009) than non–GR study patients.

Conclusion

After unilateral adrenalectomy for hypercortisolism, only 50% of patients received GR. No preoperative biochemical characteristics were associated with postoperative AI, although patients who received GR were younger, and tended to have a higher BMI and smaller adrenal nodules. Use of this novel protocol for postoperative dynamic adrenal function testing prevented unnecessary GR in 50% of patients and allowed for individualized patient care.

Section snippets

Methods

This single institution, institutional review board–approved retrospective review used a prospectively collected database of 34 consecutive patients who underwent unilateral adrenalectomy for hypercortisolism or primary aldosteronism between November 2011 and September 2014. Excluded from the cohort were 3 patients with hypercortisolism who did not have a POD1 cosyntropin stimulation test (CST). Data collected included patient demographics, history of hypertension or diabetes mellitus,

Results

Of the 31 study patients, 22 (71%) had adrenal-dependent hypercortisolism; 9 patients (29%) with primary aldosteronism who had no evidence of cortisol excess served as the control group. The median age of the 31 patients was 58 years (range, 24–72); 23 (74%) were female, and the median body mass index (BMI) was 29.7 kg/m2 (range, 17.2–42.7). For all 31 patients, comorbidities included hypertension in 19 (61%) and diabetes mellitus in 7 (24%). Laparoscopic adrenalectomy was performed in 30

Discussion

Dysregulation of the HPA axis in patients with adrenal-dependent hypercortisolism can result in postoperative secondary AI after even a unilateral adrenalectomy.1, 2, 3, 5 This potential risk has clinically important consequences and has, therefore, resulted in the routine use of postoperative GR despite the many side effects of GR. In this study, we introduced an institutional algorithm to determine the need for GR after adrenalectomy in patients with adrenal-dependent hypercortisolism. Using

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