Hormonaktif adrenal kitlelerde farmakolojik ve anestetik yönetim, Replasman tedavisi
Neth J Med. 2006 Sep;64(8):290-5.
Preoperative pharmacological management of phaeochromocytoma.
van der Horst-Schrivers AN, Kerstens MN, Wolffenbuttel BH.
Department of Endocrinology, University Medical Centre Groningen, University of
Groningen, Groningen, the Netherlands. a.na.van.der.horst@int.umcg.nl
Phaeochromocytoma is a rare catecholamine-secreting neuroendocrine tumour with a
high cardiovascular morbidity and mortality if left untreated. Surgical resection
is the only curative therapy. During surgery there is a high risk of massive
release of catecholamines, which can result in potentially fatal hypertensive
crises and cardiac arrhythmias. Administration of vasoactive drugs such as
(non)selective alpha- and beta-antagonists and calcium channel blocking agents
have reduced the operation risk. Guidelines for the preoperative medical
management of the patient with a phaeochromocytoma are mainly based on
retrospective studies and case reports. We reviewed the relevant literature on
this subject. In addition, we compared the several preoperative treatment
protocols of the eight university medical centres in the Netherlands.
J Clin Endocrinol Metab. 2007 Nov;92(11):4069-79.
Preoperative management of the pheochromocytoma patient.
Pacak K.
Section on Medical Neuroendocrinology, National Institute of Child Health and
Human Development, National Institutes of Health, Building 10, CRC, Room 1E-3140,
10 Center Drive MSC-1109, Bethesda, Maryland 20892-1109, USA. karel@mail.nih.gov
Pheochromocytomas are rare neuroendocrine tumors with a highly variable clinical
presentation, but they most commonly present as spells of headaches, sweating,
palpitations, and hypertension. Patients with pheochromocytoma may develop
complicated and potentially lethal cardiovascular and other complications,
especially in the setting of diagnostic or interventional procedures (e.g. upon
induction of anesthesia or during surgery). The serious and potentially lethal
nature of such complications is due to the potent effect of paroxysmal release of
catecholamines. Because this warrants prompt diagnosis and treatment, the
physician should be aware of the clinical manifestations and complications of
catecholamine excess and be able to provide proper preoperative management to
minimize catecholamine-related pre-, intra-, and postoperative adverse events.
The following clinical scenario and discussion aim to enhance the knowledge of
the physician regarding the behavior of pheochromocytoma and to outline current
approaches to comprehensive preoperative management of patients suffering from
this tumor.
Arq Bras Endocrinol Metabol. 2007 Nov;51(8):1339-48.
Pharmacological management of Cushing's syndrome: an update.
Dang CN, Trainer P.
Christie Hospital, Manchester, UK.
The treatment of choice for Cushing's syndrome remains surgical. The role for
medical therapy is twofold. Firstly it is used to control hypercortisolaemia
prior to surgery to optimize patient's preoperative state and secondly, it is
used where surgery has failed and radiotherapy has not taken effect. The main
drugs used inhibit steroidogenesis and include metyrapone, ketoconazole, and
mitotane. Drugs targeting the hypothalamic-pituitary axis have been investigated
but their roles in clinical practice remain limited although PPAR-gamma agonist
and somatostatin analogue som-230 (pasireotide) need further investigation. The
only drug acting at the periphery targeting the glucocorticoid receptor remains
Mifepristone (RU486). The management of Cushing syndrome may well involve
combination therapy acting at different pathways of hypercortisolaemia but
monitoring of therapy will remain a challenge.
Arch Surg. 2006 Aug;141(8):771-4; discussion 774-6.
Selective use of steroid replacement after adrenalectomy: lessons from 331
consecutive cases.
Shen WT, Lee J, Kebebew E, Clark OH, Duh QY.
Department of Surgery, University of California, San Francisco, USA.
HYPOTHESIS: Only selected patients require steroid replacement therapy following
adrenalectomy.
DESIGN: Retrospective review.
SETTINGS: University tertiary care center and veterans' hospital.
PATIENTS: A total of 331 patients who underwent adrenalectomy by 1 surgeon
(Q.-Y.D.) between April 1, 1993, and August 31, 2005.
INTERVENTIONS: Laparoscopic, open, and hand-assisted adrenalectomy. Steroid
replacement therapy was administered using a standardized hydrocortisone taper
protocol.
MAIN OUTCOME MEASURES: Indications for adrenalectomy, operative approach,
requirement for postoperative steroid replacement, and episodes of acute
adrenocortical insufficiency.
RESULTS: Of the 331 adrenalectomies, 304 were laparoscopic, 23 were open, and 4
were hand assisted. There were 299 unilateral adrenalectomies and 32 bilateral
adrenalectomies performed. Fifty-seven (17%) of the 331 patients required steroid
replacement after adrenalectomy. Of the 57 patients requiring steroid
replacement, 52 had Cushing syndrome and 5 had bilateral pheochromocytomas. The
52 patients with Cushing syndrome included 16 with pituitary tumors who had
failed pituitary resection and/or medical therapy, 14 with unilateral adrenal
adenomas, 9 with ectopic corticotropin-secreting tumors who had failed resection
and/or medical therapy, 7 with incidentalomas and subclinical Cushing syndrome, 4
with macronodular hyperplasia, and 2 with adrenocortical carcinoma. No patients
undergoing unilateral adrenalectomy for non-Cushing adrenal disease required
steroid replacement. Four (7%) of the 57 patients receiving steroid replacement
had episodes of acute adrenocortical insufficiency following operation and
required increased steroid supplementation. There were no cases of acute
adrenocortical insufficiency in the 274 patients who did not receive steroid
replacement.
CONCLUSIONS: Steroid replacement therapy after adrenalectomy should be reserved
for patients with Cushing syndrome (overt or subclinical) and patients undergoing
bilateral adrenalectomy. Patients undergoing adrenalectomy for unilateral
non-Cushing adrenal tumors do not require postoperative steroid replacement.
J R Soc Med. 1988 Sep;81(9):514-6.
Corticosteroid replacement therapy: twice or thrice daily?
Groves RW, Toms GC, Houghton BJ, Monson JP.
Medical Unit (Endocrinology), London Hospital (Whitechapel).
Although glucocorticoid replacement is conventionally administered twice daily,
the pharmacokinetics of hydrocortisone would predict very low levels of plasma
cortisol by mid-afternoon. This study compared plasma cortisol day profiles in 7
hypoadrenal patients while on twice daily and thrice daily hydrocortisone
replacement. The twice daily regimen was associated with very low levels of
cortisol at 16.00 and 18.00 h. This was eliminated by administering the same
total dose in a thrice daily regimen. Furthermore, estimates of 'well-being' by
visual analogue scale correlated significantly with simultaneous plasma cortisol
levels and 5 of the patients expressed a preference for the thrice daily regimen.
The findings suggest that thrice daily glucocorticoid replacement therapy should
be adopted routinely.
