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Chapter 53
https://t.me/med1917
Case on Adrenal Insuffi ciency
(Addison Syndrome), After Removal of
an Adenocarcinoma of the Adrenal Gland
Miguel A. Cuesta and H. Jaap Bonjer
Keywords Adrenal carcinoma • Thrombus caval vein • Addison crisis
Diagnosis and Indication for Surgery
A 30-year-old female patient was referred to our department because of a tumor of
the right adrenal with ingrowth in the inferior vena cava. Since 4 months, she had
complaints of tiredness and loss of weight. Recently she had been admitted to the
referral hospital because of thoracic pain, edematous legs, and dyspnoea; her complaints were possibly caused by pulmonary emboli. Pulmonary emboli were not
found, though, but a tumor of 8 × 5 × 7 cm in the right adrenal with ingrowth into the
inferior vena cava (IVC) (Fig. 53.1 ). There were no distance metastases, but on
the CT scan of her abdomen an extensive thrombus was seen in the IVC up to the
right atrium and into the right hepatic vein (Figs. 53.2a, b and 53.3a, b ). During high
fever, a blood culture showed a not-yet specifi ed Streptococcus, but on the endoultrasound there were no signs of endocarditis. Moreover, on the PTC a positive
tumor and thrombus were found with central necrosis (Fig. 53.4a, b ). Hormonal
assessment showed normal aldosterone and epinephrines, but high cortisol
0.5 μmol/L, normal 0.03 and 0.28. Diagnosis was established as cortisol-releasing
adrenal carcinoma on the right side with thrombus in the ICV. At admission, she
was heparinized and an operation plan was made with the cardio surgeon to resect
the tumor and thrombus as radical operation.
M. A. Cuesta , M.D. () • H. J. Bonjer , M.D., Ph.D., F.R.C.S.C.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl; j.bonjer@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_53,
© Springer International Publishing Switzerland 2014
283
284
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Fig. 53.1 CT scan showing
the tumor in the right adrenal
and vena cava
ab
M.A. Cuesta and H.J. Bonjer
Fig. 53.2 ( a , b ) CT scan showing the tumor in contact with the right hepatic vein
Operation
At operation, by subcostal right phrenolaparotomy and sternotomy, a resection was
performed on the right adrenal and the thrombus in the vena cava after control of
the suprahepatic vena cava at the level of the right auricle and proximal of the
hepatic veins. Also a Pringle maneuver was done. The tumor and the thrombus
were resected en bloc. The thrombus was taken out by a cavotomy. Because of
53 Case on Adrenal Insuffi ciency (Addison Syndrome), After Removal of an Adenocarcinoma
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ab
Fig. 53.3 ( a , b ) CT scan showing the tumor with thrombus in the vena cava in direction to right
auricle
ab
285
Fig. 53.4 ( a , b ) PET-CT showing avid spot in the tumor and vena cava
ingrowth in the right hepatic vein, a small part was resected and consequently
occluded. Pathology showed a radical resected adrenocortical carcinoma with high
mitosis index and areas of necrosis and hemorrhage.
Postoperative Course: Identifi cation
and Treatment of Complication
Patient was admitted postoperatively on the IC, where a period of shock occurred
and oliguria was observed. Differential diagnosis was made between (a) sepsis
(started with iv broad spectrum antibiotics), (b) postoperative bleeding,
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(c) thrombosis of the hepatic veins, and (d) presence of Addison crisis (started with
hydrocortisone iv). Blood cultures were negative, US showed permeable hepatic
veins, and hemoglobin was constant. The Addison crisis was treated by an iv hydrocortisone scheme. Patient went home 11 days after operation with hydrocortisone
treatment.
M.A. Cuesta and H.J. Bonjer
Pathology
A 7-cm adrenocortical carcinoma (ACC) was found. The tumor was radically
resected but showed a high mitotic activity and venous invasion.
Discussion
Currently, Addison crises are not frequently found in surgical practice. The cause of
Addison crisis in this patient is that no corticosteroid scheme was given preoperatively. In spite of a precise diagnosis and preparation of the operation, nobody had
taken account of this important point during preparation of patient for surgery. This
was especially important in this case because of corticosteroid production of the
tumor, the other being adrenal and probably atrophic. Functional variants of ACC
have been reported to be more common than the nonfunctional types, and patients
mainly present with Cushing syndrome. Recently data suggest that nonfunctional
ACCs are more common than the functional types. Adrenocortical carcinoma
accounts for approximately 5–10 % of cases of Cushing syndrome and approximately
40 % of patients with both Cushing syndrome and an adrenal mass have an ACC.
Cassinello Ogea et al. described a 70-year-old obese, hypertensive woman taking
angiotensin-converting enzyme (ACE) inhibitors and chlorthalidone but with no
history of corticosteroid treatment. She underwent a nephrectomy and adrenalectomy under combined general and epidural anesthesia [ 1 ]. Severe hypotension with
oliguria developed during surgery and persisted during postoperative recovery, with
anuria, metabolic acidosis, hyponatremia, and hyperpotassemia. The anuria, metabolic acidosis, hyponatremia, and hyperpotassemia led the authors to consider a
diagnosis of an Addison crisis. The patient responded to corticosteroids treatment
and low cortisol levels confi rmed the diagnosis of adrenal insuffi ciency.
Reference
1. Cassinello Ogea C, Giron Nombiela JR, Ruiz Tramazaygues J, et al. Severe perioperative
hypotension after nephrectomy with adrenalectomy. Rev Esp Anestesiol Reanim.
2002;49:213–7.
Chapter 54
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Case on Leakage After Left Pancreatic
Resection
Joris J.G. Scheepers
Keywords Mucinous cystadenoma • Left pancreatectomy • Enucleation •
Pancreatic leakage • Pancreatic stump
First Patient
Diagnosis and Indication for Surgery
A 63-year-old lady was admitted to the hospital and studied by US and CT scan
because of pain in the epigastric region. A tumor was found in the body of the pancreas with aspect of a cyst, possibly mucinous (Fig. 54.1 ). It was proposed to resect
the cyst by laparoscopic approach.
Operation
During laparoscopy, the tumor was considered superfi cial and probably serous.
After laparoscopic US it was enucleated. The tumor was found at distance of 5 mm
from the pancreatic duct (PD). A drain was left along the pancreas.
J. J.G. Scheepers , M.D.
Department of Surgery , Ranier de Graaf Hospital , Delft , The Netherlands
e-mail: j.scheepers@rdgg.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_54,
© Springer International Publishing Switzerland 2014
287
288
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Fig. 54.1 MRI, showing
preoperative tumor in the
pancreas
Fig. 54.2 Postoperative CT
scan. Fluid in lesser sac
drained
J.J.G. Scheepers
Postoperative Course
Postoperatively from the fi rst day a progressive high production of the drain was
observed ranging from 500 cc to 1 L, with amylase rate of 10,000 U/mL. Because
of increasing pain and fever, a CT scan again was performed and a fl uid collection
in the lesser sac percutaneously drained (Fig. 54.2 ). Because of the high production,
it was clear that the leakage could be caused by a leak of the PD or a direct branch;
hence it was decided to stent the duct by means of an ERCP (Fig. 54.3 ). This was
54 Case on Leakage After Left Pancreatic Resection
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Fig. 54.3 Drain in pancreatic
duct
done the ninth postoperative day with success. Production decreased and fi nally the
two drains could be taken out.
Pathology of the cyst showed a pancreatic serous cystadenoma radically resected.
Second Patient
Diagnosis and Indication for Surgery
289
A 58-year-old male butcher was admitted to the hospital because of acute pancreatitis localized in the tail of the pancreas by the CT scan. Complaints disappeared after
3 days and no cause was found for the pancreatitis, neither gallstones nor alcohol
abuse.
After a period of 3 months, pain in the left upper abdomen returned without other
symptoms. Amylase and lipase were normal and on the CT scan a suspected image
for tumor was found in the area between body and tail of pancreas. Imaging was not
typical for chronic pancreatitis or pseudocyst but more for a nonclassifi ed tumor of
3 cm and it was proposed for it to be resected.
Operation
By laparotomy, the tumor was resected along with the spleen without problems and
the stump of the pancreas closed by stitches. A drain was left in the area. After 2
days the drain was taken out. Patient was discharged at the fi fth postoperative day.
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ab
Fig. 54.4 ( a , b ) CT scan showing the leak collection. Transgastric US. First stent along the guide
wire
J.J.G. Scheepers
Postoperative Course: Identifi cation
and Treatment of Complication
At the outpatient clinic at the14th postoperative day, the patient had abdominal pain
and discomfort. The laboratory study showed the amylase to be normal, but CRP
was increased up to 310 mg/L. A CT scan showed a fl uid collection of 8 cm at the
resection area and it was proposed to be drained transgastrically (Fig. 54.4a ).
Through gastroscopy and endoscopic US, fl uid collection was localized retrogastrically (Fig. 54.4b ), being drained transgastrically, leaving three stents between
stomach and fl uid collection (Fig. 54.5a–c ). Complaints did not disappear com-
pletely and because of fever a new CT scan was performed showing a collection at
the pancreatic area (Fig. 54.5d ). A pancreatic duct stent was placed by ERCP and
the collection was percutaneously drained (Fig. 54.5e ). Four days later the patient
could be discharged. Pathology of the tumor showed a mucinous cystadenoma, radically resected.
Discussion
These two cases illustrate the uncertainty the surgeon can experience following
such operations whether or not postoperative leakage is taking place. There are different ways to close the surface of pancreas and—protocols are ongoing to establish
the best way. In the fi rst case, enucleation was done and probably a direct branch of
the PD was damaged. In the case of stump leakage with complaints, there are two
possibilities for drainage, the transgastric and the percutaneous route. If leakage
persists, then the pancreatic duct should be drained (Illustration
54.1 ) [ 1 ].
54 Case on Leakage After Left Pancreatic Resection
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a
b
cd
291
e
Fig. 54.5 ( a – c ) First stent along the guide wire and stents between collection and stomach; control gastric X-ray showing the stents. ( d , e ) Control CT scan showing persisting collection, being
drained by pancreatic duct drainage and percutaneous drainage
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J.J.G. Scheepers
Internal
drainage
Stapler Tachosil
Illustration 54.1 Pancreatic leakage after resection with symptoms can be drained percutaneously or transgastrically depending on the localization. Both approaches are complementary.
Different methods to close the pancreatic stump
or
®
Stitches
External
drainage
Reference
1. Goh BKP, Tan YM, Chung YFA, et al. Critical appraisal of 232 consecutive distal pancreatec-
tomies with emphasis on risk factors, outcome and management of the postoperative pancreatic
fi stula. Arch Surg. 2008;143:956–65.
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