Laparoscopic bilateral adrenalectomy for occult ectopic ACTH syndrome

Ectopic adrenocorticotropic hormone (ACTH) production is responsible for approximately 15% of the cases of Cushing's syndrome. Bilateral adrenalectomy is the most effective treatment for ectopic ACTH syndrome due to occult or disseminated tumors, but the open approach carries substantial morbidity. In this paper, we review our experience with laparoscopic bilateral adrenalectomy for occult ectopic ACTH syndrome.

Adrenalectomies performed by the authors were identified and the outcomes of laparoscopic bilateral adrenalectomies for ectopic ACTH syndrome were examined. Bilateral adrenalectomies were performed sequentially in full lateral decubitus, with patient repositioning between the sides.

From 2001 to 2006, the authors performed 16 adrenalectomies in 14 patients, with 11 performed laparoscopically. Two women with occult ectopic ACTH syndrome, refractory to medical management, underwent laparoscopic bilateral adrenalectomies. Operative times were 240 and 245 minutes, including repositioning. One patient underwent a simultaneous wedge liver biopsy for a right lobar lesion. There were no complications. Each patient resumed a regular diet on the first postoperative day. Inpatient hospital stays were 3 days each, mainly for steroid-replacement management. Final pathologic diagnoses were diffuse adrenocortical hyperplasia. Both patients noted a quick improvement in Cushing's syndrome symptoms and signs and were maintained on hydrocortisone and fludrocortisone replacement without incident for over 2 years.

Laparoscopic bilateral adrenalectomy for ectopic ACTH syndrome refractory to medical management can be performed with low morbidity. Symptoms and signs of hypercortisolism rapidly improve postoperatively.