Nghiên cứu đặc điểm bệnh lý, chỉ định và kết quả phẫu thuật nội soi u tuyến thượng thận phát hiện tình cờ tt tieng anh

1 INTRODUCTION Adrenal incidentalomas (AIs) are tumors in the adrenal glands that are discovered by accident by imaging diagnosis (ultrasound, computed tomography, magnetic resonance) because other conditions, with no clinical symptoms related to adrenal gland disease The rate of AIs is about 1.0 - 8.7% of the population Regarding the treatment of randomized benign adrenal adenomas, most authors agree on surgery for patients with hormone-secreting tumors, and tumors ≥ cm For tumors with no increased hormone secretion indicated Surgery or follow-up is controversial Laparoscopic adrenalectomy (LA) to remove adrenal adenoma first performed by Gagner in 1992 LS has great advantages such as: allowing easy access and dissection in remote areas such as adrenal glands, aesthetics, postoperative pain relief, short hospital stay time, patients can soon return to normal activities, reducing the rate of prolapse bulging the abdominal wall after surgery In Vietnam, the studies of Nguyen Duc Tien, On Quang Phong, Do Truong Thanh conclude that laparoscopic adrenalectomy and laparoscopic single incison surgery to remove adrenal glands are safe, feasible and with good results However, there has been no in-depth analysis of AIs by chance, and there is no agreement on surgical indications for tumor resection The big question arises: if you have no symptoms why remove it? On the other hand, many studies show that asymptomatic adrenal adenomas can grow in size, switch to endocrine activity, accompanied by an increased risk of malignancy, making surgery difficult, etc Thus, we carried out this research with two objectives: Description of clinical and subclinical features of adrenal incidentalomas at Viet Duc Friendship Hospital for the period 2015 – 2018 Analysis indications and results of Laparoscopic adrenalectomy to treat adrenal incidentalomas at Viet Duc Friendship Hospital for the period 2015 – 2018 2 THE NEW MAIN SCIENTIFIC CONTRIBUTION OF THE THESIS - Reviews of the pathological features of adrenal incidentalomas include: Clinical and subclinical characteristics (tumor imaging characteristics on computed tomography or magnetic resonance, assess the ability of tumor endocrine activity based on the adrenal hormone test) - Analysis of laparoscopic adrenalectomy indications to treat adrenal incidentalomas based on evidence of tumor progression, including: Switch to endocrine activity, the risk of malignancy, the growth of tumor increases in size, causing difficulties if not indicated for surgery early - From the achieved results, the dissertation contributes to affirm that laparoscopic adrenalectomy is a feasible and safe method in the treatment of adrenal incidentalomas with a low rate of complications and complications and no recurrence was noted during long-distance follow-up STRUCTURE OF THE THESIS This thesis consists of 124 pages: pages of introduction, 34 pages of literature review, 23 pages of research methods, 25 pages of research results, 37 pages of discussion, pages of conclusion, page of recommendation; research works, 46 tables, 08 charts, 20 figures; 109 references, including 14 in Vietnamese and 95 in foreign languages 3 Chapter LITERATURE REVIEW 1.1 Anatomy and physiology of the adrenal glands 1.1.1 Anatomy 1.1.2 Physiology of the adrenal glands 1.1.2.1 Adrenal cortex Hormone secretion controls two types of organic metabolism, inorganic metabolism and sexual steroids 1.1.2.2 Adrenal marrow Clinically synthesized three substances are: dopamine, epinephrine and norepinephrine, which are called catecholamines 1.2 Adrenal incidentalomas Adrenal incidentalomas are tumor in the adrenal glands that are discovered by accident by imaging diagnosis (ultrasound, computed tomography, magnetic resonance) because other conditions, with no clinical symptoms related to adrenal gland disease The rate of AIs is about 1.0 - 8.7% of the population 1.3 Subclinical feature of adrenal incidentalomas 1.3.1 Adrenocortical adenoma Benign adrenocortical adenomas are the most common adrenal tumors found in 4-6% of the population About 6% of adrenal cortex tumors are endocrine activity causing manifestations such as Cushing's syndrome, Conn's syndrome, etc - Computed tomography: Typical benign adrenocortical adenomas often have a well-defined, uniform density 1.3.2 Adrenal myeloma (Pheochromocytoma) Studies on benign adrenal adenomas are found by chance showing that the percentage of Pheochromocytoma is about 7-10% 4 - Computed tomography: The density of Pheochromocytoma can be homogeneous or heterogeneous, may contain intracellular fat or degenerative cyst, leading to a decrease in pre-injection density 1.3.3 Ganglioneuroma Ganglioneuroma are tumors originating from the sympathetic ganglia, about 10% localized in the adrenal gland location On computed tomography images, the lymphoma has a homogeneous solid structure, the size at diagnosis is usually larger than cm 1.3.4 Myelolipoma Myeloma is a benign adrenal adenoma containing fat and hematopoietic organization, a rare tumor with the rate of about 0.08 - 0.2% Most tumors are small and have no clinical symptoms, the size can vary from a few millimeters to 30 centimeters 1.3.5 Other benign adrenal glands 1.4 Treatment for benign Adrenal incidentalomas 1.4.1 Medical monitoring and treatment 1.4.2 Surgery 1.4.2.1 Open surgery 1.4.2.2 Laparoscopic surgery The surgical methods of laparoscopic adrenalectomy include: - Traditional laparoscopic surgery: Use - trocars placed in different positions, with the conventional linear endoscope There are main approaches including retroperitoneal LS and Laparoscopic surgery in the peritoneum - Laparoscopic adrenalectomy for a hole or an incision to remove an adrenal tumor: Create an entry line (single slit) through which a dedicated gate is used to bring one or more trocar in through the designated channels at the gate to perform operations - Robot laparoscopic adrenalectomy 5 1.5 Laparoscopic adrenalectomy indications to treat adrenal incidentalomas According to the Guidelines of the American Society of Endocrinology and Endocrine Surgery (AACE / AAES) in 2009, adenoma of the adrenal cortex with increased aldosteron secretion causing primary aldosteron secretion and adrenal medullary tumors are indicated for surgery Tumor of the adrenal cortex with increased secretion of cortisol causes subclinical Cushing syndrome with only surgical indication in a few cases For tumors < cm and inactive function, visual and endocrine features of the tumor should be monitored If the tumor turns to endocrine activity or an increase of 0.5 cm in months, an increase of > l cm or visual properties suggest malignancy with surgical indication Glazer indicated surgery for solid tumors ≥ - cm in diameter Edgar D Research Staren: Surgical indication is recommended for functional or large ( cm, including secretory and non-secretive tumors LS for large tumors of size ≤ 10cm, and cancer but no invasive signs on preoperative imaging 1.6 Research in the world and Vietnam on laparoscopic adrenalectomy results to treat adrenal incidentalomas 1.6.1 World Most studies have demonstrated that LA in the peritoneum to remove the adrenal gland is a safe technique with rare rates of complications, complications and postoperative mortality The complication rate according to the studies is 9%, ranging from 2.9% to 15.5% 6 In addition, many studies also indicate factors related to the rate of complications, complications and open surgery for laparoscopic adrenal tumor surgery including age, patient's BMI, history previous abdominal surgery, tumor location, In general, the rate of open-switch surgery in laparoscopic adrenalectomy is about 2% of cases, with ranges from 0% to 13% The most common causes of open surgery include damage to blood vessels or nearby organs and technical difficulties The death rate after laparoscopic adrenalectomy ranged from 0% to 0.8% The best causes of death include massive bleeding, pancreatitis, pulmonary embolism, sepsis 1.6.2 Vietnam In Vietnam, laparoscopic adrenalectomy has been carried out for the first time since August 1998 at Viet Duc Hospital Since then, this method has been widely applied in many major surgical centers in the country Studies by Vu Le Chuyen (2004), Nguyen Duc Tien (2006 - 2007), Tran Binh Giang, Do Truong Thanh (2013) and On Quang Phong (2017) show that LS to treat adrenal adenoma is Feasible, safe, good results Chapter SUBJECTS AND METHODS 2.1 Subjects of the research 78 patients diagnosed with adrenal incidentalomas and treated with laparoscopic adrenalectomy at Viet Duc Hospital, from October 2015 to the end of October 2018 Tracking far to May 2019 2.1.1 Selection criteria: - Patient accidentally discovered adrenal adenoma based on one of imaging probes such as ultrasound, computed tomography, magnetic resonance without clinical symptoms of adrenal adenoma - Patients indicated for laparoscopic adrenalectomyin the peritoneum (Including those with LA switching open or adding trocar) - The result of postoperative disease surgery is benign adrenal adenoma - Full medical records, patients agree to participate in the study 2.1.2 Exclusion standard - The result of postoperative disease surgery is adrenal cancer or adrenal metastasis - Patients with severe medical disease, incapable of general anesthesia - Patients with blood clotting disorders or existing systemic infections 2.2 Research Methods 2.2.1 research design: Research, clinical intervention, no control 2.2.2 Sample size and sample selection The sample size is calculated according to the formula, the minimum number of patients is 63 2.2.3 Technical procedure of laparoscopic adrenalectomy 2.2.3.1 Indicated for surgery We recommend LA to remove adrenal adenoma according to the Guidelines of Jung-Min Lee (2017), K Lorenz (2019), AACE / AAES (2009): + Tumors that works with endocrine functions + Tumors that are ≥ cm on diagnostic imaging + Tumors that change size, morphology during tracking + Tumors that are < 4cm (Think of Pheochromocytoma) based on MRI or computed tomography 2.2.3.2 Prepare the patient 2.2.3.3 Prepare surgical tools and facilities 2.2.3.4 Indifference method, patient posture and surgical team position 2.2.3.5 Surgical techniques - Step 1: Open the posterior abdominal wall peritoneum, exposing the adrenal gland and the main adrenal vein - Step 2: Anatomy, control of the main adrenal vein - Step 3: Clamp the middle and upper adrenal artery - Step 4: Control of the lower adrenal artery - Step 5: Check the area of dissection and hemostasis, drainage - Step 6: Remove the specimen, release CO2 gas, close the trocar holes 2.2.4 The research criteria 2.2.4.1 Targets for goal 1: Clinical and subclinical characteristics - Clinical characteristics + Age, sex, reason to visit + History of internal medicine, surgery history of the abdomen - Clinical characteristics + Characteristics of disease anatomy + Image diagnosis: Abdominal ultrasound, computed tomography or magnetic resonance imaging, endocrine activity characteristics of the tumor, + Biochemical tests for Adrenal Hormone 2.2.4.2 Targets for goal 2: Analysis indications and results of laparoscopic adrenalectomy to treat adrenal incidentalomas - Analysis indications of laparoscopic adrenalectomy to treat AIs - Results in surgery: + Surgical methods: Traditional LA/ Single incision laparoscopic + Add trocar / open surgery + Method of handling main adrenal vein, hemodynamic change in surgery + Methods of handling tumors, complications and complications - Early results + Mean time, draining, pain after surgery + Early complications, time in hospital after surgery + Evaluate early results: according to levels: Good, fair, average, poor - Far Result Reviewed at the end of the study (May 2019): + Number of patients re-examined, long-distance follow-up time (months) + Clinical symptoms (if any) + Diagnostic imaging results (ultrasound, computed tomography or MRI) upon re-examination + Biochemistry test results for adrenal hormones + Complications far away, recurrence tumors 2.2.5 Data collection and processing - Information is collected according to pre-designed research records - The data are processed by medical statistical software SPSS 20.0 2.2.6 Research ethics - The research outline has been approved by the Outline Council - Hanoi Medical University to ensure its science and feasibility - The patients participating in the study are carefully explained about the treatment methods and voluntarily participate in the study - Patient information is confidential, only for research purposes Chapter RESEARCH RESULTS 3.1 Clinical, subclinical characteristics of Adrenal incidentalomas 3.1.1 Clinical - Year old: Average age of patients is 45.22 ± 13.39 (13 - 79 years) Gender: female patients accounted for the majority with 64.1% Table 3.1 Reason for admission Number of patients Percentage (n = 78) (%) Periodic health examination 37 47.4 Exam for another disease 26 33.4 Follow-up by appointment 15 19.2 Reason for admission 10 due to the discovery of adrenal adenoma in the past - Medical history: 46 patients (59.0%) with combined medical disease - History of abdominal surgery: patients (9.1%) had a history of abdominal surgery 3.1.2 Subclinical Table 3.2 Characteristics of disease anatomy Pathology Number of patients Percentage(%) Adrenocortical adenoma 52 66.7 Schwannoma 2.6 Pheochromocytoma 15 19.2 Myelolipoma 1.3 Ganglioneuroma 7.7 Lymphanginoma 1.3 1.3 Pheochromocytoma + Phải;Ganglioneuroma 46.15% Trái; 53.85% Comment: The majority of adrenocortical tumors with 52 cases (66.7%) Pheochromocytoma accounts for 19.2% - Abdominal ultrasound: 12 cases (15.4%) did not detect tumors with ultrasound The average tumor size according to ultrasound was 3.4 ± 1.98 cm Chart 3.1 Distribution of the tumor location according to computed tomography Comment: Left adrenal adenoma majority with 53.8% - Tumor size according to computed tomography or magnetic resonance: Average 3.63 ± 1.88 cm - Tests for Adrenal Hormone: The percentage of patients with increased blood cortiol accounted for the most with 29.5%, blood adrenalin increased in 8.9% of cases 11 - Inhibitory therapy (NPUC): 23 patients (29.5%) with increased Cortisol assay, we tested NPUC with low dose mg dexamethasone overnight Of these, 19 were positive (82.6%) - Comment: 69.2% of tumors are endocrine inactive 30.8% of tumors are endocrine activity, of which 24.4% show subclinical Cushing syndrome, 6.4% of tumors have increased secretion of Catecholamin - Pathology and endocrine activity: 19/52 patients (36.5%) functional adrenocortical adenoma with symptoms of subclinical Cushing syndrome 5/15 (33.3%) Pheochromocytoma increased secretion of Catecholamin 3.2 Analysis indications and results of laparoscopic adrenalectomy to treat adrenal incidentalomas 3.2.1 Analysis indicated for surgery Table 3.3 Indications of laparoscopic adrenalectomy Number of Percentage patients (n = 78) (%) Active endocrine tumors 24 30.8 Tumors ≥ cm (inactive endocrine) 34 43.6 Tumors resize 15 19.2 6.4 Indications Tumors think of Pheochromocytoma on computed tomography or magnetic resonance Comment: Indications of laparoscopic adrenalectomy due to tumor > cm (inactive endocrine) accounts for 43.6% 24 cases (30.8%) of surgery due to active endocrine tumors - Indications of laparoscopic adrenalectomy according to tumor size: The average tumor size was 3.68 ± 0.21 3.2.2 The result of LA to treat Adrenal incidentalomas 3.2.2.1 Results in surgery 12 - ASA anesthesia risk factor classification: The majority of patients with ASA II classification score accounted for 64.1% - Comment: 61 patients (78.2%) received traditional laparoscopic surgery - The tumor size indicated for single incision LA (2.54 ± 0.3 cm) is smaller than that of traditional LA (3.92 ± 0.25) The difference is statistically significant with p 4.5 cm is a risk factor that increases the rate of complications in surgery, cyst damage, thereby increasing the rate of adding trocar or changing open surgery, increasing complications after surgery as well as surgery time In addition, we have cases requiring open surgery, accounting for 2.6% In general, the rate of open-switch surgery in laparoscopic adrenalectomy is about 2% of cases, with ranges from 0% to 13% We share a statement with the authors: The most likely causes of open surgery include damage to blood vessels or neighboring organs and technical difficulties, in addition to diagnosis of large Pheochromocytoma or endocrine activity is also a factor in the increase in rates additional rate trocar or open surgery Handling method and hemodynamic change when clamping and resection of the main adrenal vein The authors stated: In laparoscopic adrenalectomy, due to its direct involvement with other major tumor markers, the control of the main adrenal vein should be very cautious In our study, 67.9% of cases of primary adrenal vein treatment with Ligasure, 10.3% clip clip alone and 19.2% combination clip and ligasure; 2.6% of the main adrenal vein forced stitch is cases of open surgery Research results show that the majority of patients have no changes in hemodynamic in surgery, accounting for 93.6% There were cases (6.4%) of hemodynamic changes with major adrenal venous clamping including patients (5.1%) with malignant hypertension (ranging from 200 - 210/100 mmHg) and patient (1.3%) rapid pulse oscillation> 110 times / Mainly 20 group of adrenocortical adenoma (3 patients) and Pheochromocytoma (2 patients) According to Table 3.24, 100% of tumors that are endocrine inactive have no changes in hemodynamic in surgery 2/5 cases (40%) of the tumor increases secretion of catecholamin with increased blood pressure in surgery Treatment method for tumors In our study, 96.1% of all cases had laparoscopic total adrenalectomy Only 3.9% selectively cut tumors Assign to cut the entire gland for tumors larger than the selective tumor group 3.72 ± 0.22 cm compared with 1.88 ± 0.27 (p 0.05) Other studies noted the postoperative hospital stay of the traditional LS group from 3.1 ± 1.2 to 6.9 ± 1.75 days Meanwhile, the single incision surgery group had hospital stay ranged from 2.4 ± 0.70 to ± 2.22 days Evaluate early results The study found that the majority of patients achieved good results, accounting for 94.8% There are 3.9% of patients with fairly good results are patients with complications of surgical wound infection 1.3% on average were patients with postoperative adrenal insufficiency and the poor result was 0% 4.2.2.3 Results are far away At this time, 70/76 patients were re-examined, accounting for 92.1% patients (7.9%) were not examined again due to loss of contact, including foreign patient We recorded average follow-up time since post-surgery to be 24.03 ± 12.04 months, shortest months, longest 42 months The results showed that the majority of patients (70.0%) had no clinical manifestations at the time of re-examination, accounting for 70.0% There were 19 patients with hypertension, these were all patients over 40 years old, had a history of hypertension before and during follow-up there was no exacerbation of hypertension hypertension in these patients was due to a cause other than adrenal cancer 23 The results of our subclinical test on follow-up examination showed no abnormal changes in the adrenal hormone and electrolyte assay, no recurrence or death up to the time of follow-up We share a statement with the authors: Accidentally discovered benign adrenal adenoma is a safe and effective method, especially for tumors that are large or have endocrine activity CONCLUSION Clinical and subclinical features of Adrenal incidentalomas The average age of patients was 45.22 ± 13.39, with the majority female with 64.1% 47.4% accidentally discovered adrenal adenoma during periodic health examination, 33.4% discovered by accident because of other diseases The majority of adrenocorticoma with 66.7%, Pheochromocytoma 19.2%, Ganglioneuroma 7.7%, Schwannoma 2.6%, adipoma Myelolipoma 1.3%, Lymphanginoma 1.3% and Pheochromocytoma + Ganglioneuroma) 1.3% Computerized tomography results: Left adrenal adenoma accounts for 53.8% The average tumor size was 3.63 ± 1.88 cm 30.8% of tumors increased secretory activity, of which 24.4% showed subclinical Cushing syndrome, 6.4% increased catecholamin secretion Analysis indications and results of laparoscopic adrenalectomy to treat AIs Indications for surgery: 43.6% due to tumor ≥ cm (inactive secretion), 30.8% due to active tumor secretion, 19.2% due to the tumor's change in size during follow-up and 6.4% due to tumor of Pheochromocytome on computerized tomography images Surgical results Laparoscopic adrenalectomy is a feasible, safe method in the treatment of adrenal incidentalomas: with 78.2% applied traditional LA and 21.8% single 24 incision surgery; rate of open surgery is low (2.6%); 6.4% had changes in hemodynamic in surgery (5.1% increased blood pressure and 1.3% rapid pulse); the rate of complications was 17.9%, mainly bleeding (14.1%); The rate of postoperative variable is low at 5.2% Evaluate early results: Good 94.8%, fair 3.9%, average 1.3%, less than 0% 92.1% of patients followed up long distances for a mean of 24.03 ± 12.04 months, not recorded any case with distant complications, recurrence or death Tests for Adrenal Hormone and Electrolytes both returned to normal RECOMMENDATION For adrenal incidentalomas