Suite 12, Level 2, The Women s Hospital (03)

Transcription

1 ADRENAL SURGERY INFORMATION SHEET A/PROFESSOR JULIE MILLER, BA, MD, FRACS Specialist Endcrine Surgen Suite 12, Level 2, The Wmen s Hspital (03) (Including infrmatin frm the SAGES - Sciety f American Gastrintenstinal and Laparscpic Surgens) What are the adrenal glands? The adrenal glands are shaped like small pyramids and sit just abve yur kidneys, under the lwer ribs at the back. They make many imprtant hrmnes that cntrl varius bdily functins including adrenaline fr the fight r flight respnse, crtisl, a stress hrmne, and aldsterne, t help cntrl yur bdy s salt levels and bld pressure. The adrenals als make a small fractin f the bdy s sex hrmnes. Indicatins fr adrenal surgery Tumurs cmmnly frm n the adrenal glands, but mst f them are harmless and d nt need t be remved. Hwever, in sme cases it is recmmended t remve an adrenal tumur. Belw are the mst cmmn reasns: 1. T see if there is cancer: if there are features suspicius fr cancer, like size >4cm r a certain appearance n imaging. Frtunately, malignant adrenal tumurs are rare. 2. Functining tumurs - if the tumur is making t much f a hrmne, like adrenaline (phechrmcytma), crtisl (Cushing s syndrme), r aldsterne (Cnn s syndrme.) 3. Slitary Metastasis - if the adrenal tumur is a metastasis frm anther cancer, and it is the nly lcatin the cancer has spread. 4. Cushing s disease with failed pituitary surgery smetimes yur dctr may recmmend remval f bth adrenals if a pituitary tumur is making them verprduce crtisl and pituitary surgery has failed 1

2 Frequently Asked Questins Hw is an adrenal tumur remved? A general anaesthetic is required, s yu will be fully asleep. There are 3 main appraches t adrenal surgery: OPEN: a large pen incisin is the prcedure f chice fr a very large tumur r a knwn adrenal cancer LAPAROSCOPIC ANTERIOR: Keyhle surgery thrugh the abdminal cavity has smaller incisins and a quicker recvery than pen surgery. It is a safe apprach fr benign (nn-cancerus) tumurs <8cm PRA - POSTERIOR RETROPERITONEOSCOPIC ADRENALECTOMY: This technique is an imprvement ver the laparscpic technique, as it causes less pain than even laparscpic surgery, is safe in bese patients, and is nt affected by scar tissue frm previus abdminal surgery. PRA is safe fr benign tumurs <6cm. In fact, ver half f patients require nthing mre than panadl t relieve discmfrt after PRA! The patient is placed face dwn and the adrenal tumur remved via 3 small incisins in the back, just belw the ribcage. The technique was develped in Eurpe by Prfessr Martin Walz, and mre than 2000 adrenal peratins have been safely cmpleted this way. Dr. Miller learned the prcedure directly frm Dr. Walz and was the first surgen in Victria (and the secnd in Australia) t perfrm it. As f early 2015, she has perfrmed mre PRA adrenal peratins than any ther surgen in Australia, and has mentred mre than ten surgens in fur states successfully perfrm PRA. What are the ptential cmplicatins f adrenal surgery? As with anything in life, there are risks t surgery. These risks are weighed against the risks f nt having surgery. Listed belw are sme f the pssible cmplicatins f surgery. The rate f majr cmplicatins after PRA is less than 2%. Risks include, but are nt limited t: High bld pressure Bleeding Injury t surrunding rgans such as the bwel, r the liver n the right r the spleen r pancreas n the left. Infectin f the incisins Bruising/swelling Incisinal hernia (less cmmn with PRA r laparscpic surgery) Numbness r weakness f the muscles arund the incisin Cllapsed lung (pneumthrax) Other unfreseen risks Yu will require general anaesthetic, given by a specialist anaesthetist. Risk f a serius cmplicatin in a healthy persn is very rare. Ptential risks include, but are nt limited t: Heart prblems (death, heart attack, arrhythmias) Lung prblems (pneumnia, wheezing) Bld clts (strke, clts in leg veins r lungs) Drug reactins (als pssible with lcal anaesthetic) Chipped teeth Other unfreseen risks Yu will meet the anaesthetist befre yur peratin and have the chance t ask any additinal questins. 2

3 What Are The Symptms f Adrenal Gland Tumurs? Patients with adrenal gland tumurs may have n symptms at all. A variety f symptms can result frm excess hrmne prductin by the abnrmal gland. Adrenal tumurs assciated with excess hrmne prductin include phechrmcytmas, aldsterne-prducing tumurs, and crtisl-prducing tumurs. Typical features are described belw. Phechrmcytmas prduce excess hrmnes that can cause episdes f very high bld pressure and peridic spells characterized by severe headaches, excessive sweating, anxiety, palpitatins, and rapid heart rate that may last frm a few secnds t several minutes. These episdes can result in life-threatening strkes r heart attacks. Aldsterne prducing tumurs cause high bld pressure and lw serum (bld) ptassium levels. In sme patients this may result in symptms f weakness, fatigue, and frequent urinatin. Crtisl prducing tumurs cause a syndrme termed Cushing s syndrme that can be characterized by besity (especially f the face and trunk), high bld sugar, high bld pressure, menstrual irregularities, fragile skin, and prminent stretch marks. Mst cases f Cushing s syndrme, hwever, are caused by small pituitary tumurs and are nt treated by adrenal gland remval. Overall, adrenal tumurs accunt fr abut 20% f cases f Cushing s syndrme. An incidentally fund mass in the adrenal may be any f the abve types f tumurs, r may prduce n hrmnes at all. Mst incidentally fund adrenal masses d nt make excess hrmnes, cause n symptms, are benign, and d nt need t be remved. Surgical remval f incidentally discvered adrenal tumurs is indicated nly if: The tumur is fund t make excess hrmnes Is large in size (mre than 4 centimeters in diameter) If there is a suspicin that the tumur culd be malignant. Adrenal gland cancers (adrenal crtical cancer) are rare tumurs that are usually very large at the time f diagnsis. Remval f these tumurs is usually dne by pen adrenal surgery. If an adrenal tumur is suspected based n symptms r has been identified by CT r ther scan, the patient shuld underg bld and urine tests t determine if the tumur is ver-prducing hrmnes. Special tests, such as a CT scan, nuclear medicine scan, MRI, r selective venus sampling are ften used t btain mre infrmatin abut the adrenal tumur. Hw exactly is PRA perfrmed? The surgery is perfrmed under a cmplete general anesthesia, s yu are asleep during the prcedure. 3 small incisins are made in the back and small prts (metal tubes) are placed thrugh them. The space abve the kidney is filled with carbn dixide gas s the surgen can see A laparscpe (a tiny telescpe) cnnected t a special camera is inserted thrugh the prt. This gives the surgen a magnified view f yur internal rgans n a televisin screen. Yur surgen delicately separates the adrenal gland frm its attachments and seals the bld vessels. Once the adrenal gland has been dissected free, it is placed in a small bag and is then remved thrugh ne f the incisins. This incisin may need t be enlarged slightly t remve the tumur. The small incisins are then clsed What happens if the prcedure cannt be perfrmed by PRA? In a small number f patients the PRA methd cannt be perfrmed. The peratin is then cnverted t a laparscpic r pen prcedure. Factrs that may increase the pssibility f chsing r cnverting t the "pen" prcedure may include: Large tumur size r very large patient size A histry f prir abdminal surgery causing dense scar tissue (this affects laparscpy but nt PRA) Inability t visualize the adrenal gland clearly Bleeding during the peratin The decisin t perfrm the pen prcedure is a judgment decisin made by yur surgen either befre r during the actual peratin. When the surgen feels that it is safest t cnvert t an pen prcedure, this is nt a cmplicatin, but rather sund surgical judgment. The decisin t cnvert t an pen prcedure is based strictly n patient safety. 3

4 WHAT SHOULD I EXPECT AFTER ADRENAL SURGERY? After the peratin, it is imprtant t fllw yur dctr's instructins. Althugh many peple feel better in just a few days, remember that yur bdy needs time t heal. Yu shuld expect a ne night stay in hspital, unless yur medical cnditin requires that yu stay lnger. After adrenal gland remval, mst patients can be cared fr n a surgical ward. Occasinally, a patient with a phechrmcytma may g t an intensive care unit after surgery t mnitr bld pressure. Patients with an aldsterne-prducing tumur will need a serum ptassium level checked after surgery and may need t cntinue t take medicatins t cntrl their bld pressure. Patients with crtisl-prducing tumurs and Cushing s syndrme will need t take prednisne r crtisl pills after surgery. The dse is then tapered ver time as the remaining nrmal adrenal gland resumes adequate prductin f crtisl hrmne. Will I have pain after the PRA peratin? Mst patients are surprised at hw cmfrtable they are after PRA surgery. Althugh yu shuld be able t eat and drink nrmally, walk up and dwn stairs, and d light activity. Mst patients take Panadl and/r Nurfen t keep them cmfrtable at hme. Yu will have a prescriptin fr smething strnger fr the first few days in case yu need it, but beware prescriptin pain medicine can make yu drwsy and cnstipated, s d nt drive r perate heavy machinery, and drink lts f water and eat plenty f fruits and vegetables. Hw lng will I be hspitalized? Mst patients are admitted t the hspital n the mrning f surgery and g hme the next day unless yur medical cnditin requires yu t stay lnger. Sme patients feel well enugh t g hme n the day f surgery. When will I knw the findings f the surgery? A final pathlgy reprt requires careful study f the surgical specimen. Therefre, the final reprt is usually nt available until abut ne week after the peratin. Will I have stitches? Yu will have stitches n the inside that disslve n their wn. Yu will have a waterprf Cmfeel dressing s that yu can shwer as usual, but avid baths fr the first week. Leave the dressing in place until yur first pst-perative visit, where it will be remved. Will I have any physical restrictins after my surgery? In general, yur activity level depends n the amunt f discmfrt yu experience. Many patients have resumed glf r tennis within a week after the peratin. Mst patients return t wrk in a week r tw, and yu are able t drive as sn as yu are cmfrtable. Let yur bdy be yur guide and use yur cmmn sense. 4

5 PREPARATION fr SURGERY Preperative preparatin includes bld tests, medical evaluatin, and an ECG depending n yur age and medical cnditin. After yur surgen reviews with yu the ptential risks and benefits f the peratin, yu will need t prvide written cnsent fr surgery. Patients with a phechrmcytma will need special medicatins prir t surgery t cntrl their bld pressure Patients with an aldsterne-prducing tumur may need t take extra ptassium if the level is lw. Patients with Cushing s syndrme will need t receive extra dses f crtisne medicatin n the day f surgery and fr up t ne year afterwards until the remaining adrenal gland has resumed nrmal functin. Please shwer at hme the evening befre r the mrning f surgery. Fr mrning surgery, D Nt Eat r Drink anything after midnight the night befre surgery unless therwise instructed. This includes cffee, tea, water, and juice! Medicatin with a small sip f water is OK. Fr afternn surgery, a small breakfast BEFORE 7AM is OK, and nthing after that. Yur surgery may be cancelled if yu d nt fllw these instructins. D Nt Drink Alchlic beverages 24 hurs prir t yur surgery. D Nt Smke fr 4 weeks befre surgery r yur risk f serius cmplicatins increases. Ask us if yu are permitted t take yur rutine medicatins (such as thse fr heart, bld pressure, r insulin etc.) befre arriving fr surgery. Stp aspirin, warfarin, r any ther bld thinner 5-7 days prir t surgery D Nt bring valuables such as mney, jewelry etc. D nt wear make-up. Bring tiletries and lse fitting, cmfrtable clthing t wear upn discharge. Yu will be required t remve cntact lenses, jewelry, dentures, and wigs Arrange fr a respnsible adult t drive yu hme after discharge. Ntify us there is a change in yur cnditin prir t surgery (such as a cld, cugh, fever r infectin). If severe, yur surgery may need t be pstpned fr yur safety. Stp all herbal medicatins 4 weeks befre surgery unless discussed befrehand. Especially Ginseng, Garlic, and Gingk, Fish Oil, r St. Jhn s Wrt, which increase the risk f bleeding. THE DAY f YOUR SURGERY On the day f yur surgery, reprt t hspital receptin at the appinted time If yu have nt already dne s, yu will meet yur anaesthetist Yu may need a bld test r ECG prir t surgery After the peratin, yu will sme time in the recvery rm befre ging t the ward On the day f discharge, yu are nt permitted t: Drive a Car nr perate pwer equipment Drink Alchlic Beverages Sign imprtant papers The abve are nt permitted n the day f surgery, nr while taking any prescriptin pain medicatin. Instructins regarding safe resumptin f the abve activities will be prvided by yur surgen. 5

6 Pst-Operative Instructins fr Adrenal Surgery Questins: call the ffice n Belw are general instructins fr patients wh have had adrenal surgery. Since individual circumstances may vary, it is imprtant that yu discuss yur individual pst perative care with us. Mnitring Yur Prgress Yu shuld feel imprvement every day after surgery. If yu have any questins regarding yur prgress, call my ffice. Yu shuld make a fllw up appintment apprximately 1-2 weeks after yur surgery. Incisin Pain Yur incisin is cvered with a waterprf prtective dressing. Yu can shwer and pat dry as usual, but d nt sak r scrub the dressing. Yur dressing will be remved at yur first pst-perative visit. If yu experience itching nce the dressing is ff, yu may apply ltin t the scar. Yu might ntice bruising arund yur incisin. In additin, the scar may becme pink and hard. This hardening is temprary and will last sme weeks. Yu may als ntice sme numbness arund the incisin, pain r muscle laxity arund yur abdmen. This will gradually imprve ver time. The main cmplaint fllwing minimally invasive adrenal surgery is minr wund discmfrt. Sme peple experience a dull ache, while thers feel a sharp pain. This shuld nt keep yu frm light activity. Nurfen and/ r Panadl is generally enugh t cntrl this pain. Strnger medicatins are nt necessary fr lng. CONTACT MY OFFICE fr any f the fllwing symptms: Persistent fever >38.5 r chills Persistent nausea r vmiting, unable t keep liquids dwn Increasing pain r redness arund incisin Persistent cugh, shrtness f breath, r difficulty breathing Fainting r increased abdminal swelling AN IMPORTANT WORD ABOUT THE COSTS OF TREATMENT Insurance rebates have nt kept pace with the cst f running a medical practice. As a cnsequence, there will be a gap t pay fr the surgical fee and fr the anaesthetist. Yur insurance cmpany might als charge yu an excess fr a hspital admissin. We will advise yu abut expected ut-f pcket csts nt cvered by insurance. If these csts represent an undue hardship fr yu, please discuss them with us. ASK YOUR DOCTOR We are here t help yu. If yu have any questins, please ask. It is ften helpful t bring a family member with yu t a cnsultatin, r t write questins dwn s yu wn t frget them. 6