J.Jpn. Surg. Soc.. 61(8): 1021-1050, 1960
宿題報告
SURGERY OF ADRENALS
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2nd Department of Surgery, Nagoya University School of Medicine Ryoji NAGAI |
1. Adrenal tumor and hyperplasia of the adrenal cortex.
2. Other diseases which are expected to be betterment if we give operative invasion to the adrenal cortex.
Up to date, I have given operative invasion to the adrenal glands of 48 patients who were suposed to be above mentioned groups.
Among the first group, adrenal tumor with hormone activity and hyperplasia will draw our attention and interest. I have experienced seven cases of them which were Cushing's syndrome, adrenogenital syndrome and pheochromocytoma. About this group, I will not report in detail here.
To the diseases of the second group which are far advanced breast cancer, prostatic cancer, other far advanced malignant tumor, severe ascites, severe diabetes and essential hypertension, adrenalectomy had been tried in many occasions as seen in literature.
I am going to report in detail about far advanced breast cancer and severe ascites which I experienced considerably in many chances. The breast cancers which can be the indication of surgery of the adrenals are difficult to receive radical operation because of local reccurence after radical operation and metastasis to remote organs. To these cases, we did bilateral adrenalectomy as well as adrenalsplenic venous shunt.The latter operation is based on the principle that sex hormone is inactivated selectively in the liver.
Although this inactivation is found out in literature, we have confirmed it by the repeated experimentation in vivo and in vitro. The anastomosis has a big advantage which we need not to give adrenal cortical hormone after operation, but its indication is limited, that is to say, anatomical impossibility of anastomosis and metastasis of the liver or adrenal gland itself are considered to be out of indication of anastomosis. The postoperative results of the extirpation and anastomosis were almost same, and the betterment of objective symptoms were observed in the half of the cases. The other half of the cases of breast cancer considered to be so-called "hormone independent". Therefore, it will be convenient if we can determine which, before the operation. From our studies, we have convinced that the total observation of endocrine system which can be deduced from the conditions of excretions of steroids, gonadotrophin and prolactin etc. into urine, especially the reaction after the administration of pituitary gonadotrophin would be the important indicator.
In doing above mentioned operation, "hormone replacement" during and immediately after operation is the very important problem. In anastomosis, the administration of adrenal cortical hormone after operation is unnecessary, but essentially indispensable in extirpation. We studied the effects of Cortisone, Prednisolone, 6-Methyl-Prednisolone, Triamcinolone, Dexamethasone and Desoxycorticosterone re garding about the hormon maintenance therapy on the patients who had total adrenalectomy by using the following points as criteria, the normal metabolism of sugar and electrolytes, subduability of pituitary function and maintenance of normal liver function.
Next, we would like to discuss the principle why we do adrenal extirpation to the patient with ascites. From the remarkable disturbance of Na excretion into urine in ascitic dog and patient with ascites, we infered that the treatment of ascites exists in raising Na excretion in to urine.
As we found out the fact that Na accumulation in ascitic dog and patient with ascites was caused by the excessive excretion of aldosterone which was excreted from the zona glomerulosa (secondary aldosteronism), adrenalectomy was considered in order to remove it. We studied the conditions and maintenance by steroid after adrenalectomy experimentally. Clinically, we selected the adrcnalectomy indicated cases which had no esophageal varix and resisted to all other treatments. Most of them were poor-risk cases with severe liver disfunction, and died soon after operation. But some of them who could tolerate operative invasion were escaped from ascites. Therefore, about the adrenalectomy on the patient with excessive ascites, we need further investigations.
Finally I will mention about the technique of the operations. How to anastomose or extirpate safely and securely was one of the objects of our studies. So-called posterolateral approach or abdominal one should be selected by each case.
While one doubts the rate of success of anastomosis, we confirmed the high rate of success of our method by the analysis of postoperative hormone matabolism and autopsy.
(Author's abstract)
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