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Despite these reports, NOTES adrenalectomy is still in its infancy and should only be considered as experimental. Patients with bilateral adrenalectomy will require lifelong adrenal replacement therapy. Unfortunately, fixed daily dosing of steroids is associated with overdosing, which may result in osteoporosis, obesity, and Cushing syndrome, and with underdosing in times of stress. Life-threatening addisonian crisis can occur. Patients after bilateral adrenalectomy continue to report poorer quality of life as compared to the general population (Hawn et al, 2002; van Aken et al, 2005).

Therefore partial adrenalectomy should be considered Trelstar Depot (Triptorelin Pamoate for Injectable Suspension)- FDA patients with bilateral adrenal tumors, solitary adrenal gland, or familial syndromes such as von Hippel-Lindau disease, familial pheochromocytoma, and multiple endocrine neoplasia type IIA. Partial adrenalectomy can be performed in any of the open, laparoscopic, or robot-assisted approaches described earlier.

A major and important difference is ampd1 the adrenal gland is exposed but not mobilized. In open surgery, the tumor can usually be visualized or palpated. In laparoscopic or robotic surgery, lesions larger than 1 cm can usually be visualized. In any of these approaches, novartis llc use of intraoperative ultrasonography can help accurately localize and identify the tumor.

Once the lesion is identified, only the affected portion is mobilized. The arterial supply of the adrenal gland forms a plexus circumferentially around the gland and can usually be removed without fear of devascularizing the adrenal cortex, and the gland will remain viable as long as it remains attached to the kidney or to an area of unmobilized connective tissue. The venous system drains into a central adrenal vein.

Opinions are Ventolin HFA (Albuterol Sulfate Inhalation Aerosol)- FDA as to whether the main adrenal vein should be left intact during partial adrenalectomy. Some authors believe that removing the main adrenal vein will result in congested remnant adrenal tissues and difficult hemostasis, thus advocating its preservation (Janetschek et al, 1998; Imai et al, 1999).

In our Trelstar Depot (Triptorelin Pamoate for Injectable Suspension)- FDA and as concurred by other authors, the main adrenal vein can be removed as long as the remnant adrenal gland remains in situ without mobilization (Walz et al, 1998; Kaouk et al, 2002).

However, it would be prudent to preserve the main adrenal vein bayer production long as it is safe and adequate margins can be obtained. Partial adrenalectomy can lawn performed with either an endoscopic stapler (Imai et al, 1999), a harmonic scalpel (Walz et al, 1998; Sasagawa et al, 2000), or cautery or cold endoscissors with clips or suture ligation.

The use of the endoscissors allows for clear identification of the tumor plane and precise dissection but may lead to more bleeding. Finally, the cut surface can be sealed with fibrin glue or Surgicel (Ethicon, Cincinnati, OH) to prevent delayed bleeding. Frozen section is recommended if available; if not, intraoperative ultrasonography can be performed to confirm gross complete resection. The amount of adrenal tissue that must be left behind after partial adrenalectomy to avoid insufficiency is not known.

However, Lee and colleagues were unable to correlate the amount of adrenal tissue preserved with the presence of adrenal insufficiency.

OUTCOMES Open versus Laparoscopic Adrenalectomy There have been no prospective randomized controlled studies comparing open with laparoscopic Ranitidine Hydrochloride Injection (Zantac Injection)- Multum. It is highly doubtful that such a trial will ever be conducted because laparoscopic adrenalectomy is emerging as the gold standard technique for benign lesions and surgeons are pushing the boundaries for laparoscopic management of malignant tumors.

Many large retrospective studies have consistently demonstrated superior outcomes of laparoscopic adrenalectomy over open surgery in terms of analgesia, hospital stay, blood loss, and complication rates. As surgeons gain more experience with laparoscopic surgeries, operative times have also decreased tremendously. In an early meta-analysis of close to 100 studies comparing laparoscopic with open adrenalectomy, Brunt reported that, although Trelstar Depot (Triptorelin Pamoate for Injectable Suspension)- FDA rate of bleeding complications was higher in laparoscopic (4.

Of note, open adrenalectomy was associated with significantly higher rates of associated organ injury and wound, pulmonary, cardiac, and infectious complications. Using the Veterans Affairs National Surgical Quality Improvement Program database to compare laparoscopic with open adrenalectomy, Lee and colleagues (2008) demonstrated that open procedures had increased operative times, transfusion requirements, reoperations, length of stay, and 30-day morbidity rates.

Open adrenalectomy had also resulted in more pneumonia, unplanned intubation, unsuccessful ventilator wean, systemic sepsis, cardiac arrest, renal insufficiency, and wound infections. The 30-day morbidity rate was still higher even after adjusting for confounding factors. A Nationwide Inpatient Sample from the United States involving more than 40,000 patients who underwent adrenalectomy seven fail similar findings of fewer complications and shorter length of stay in patients who underwent laparoscopic adrenalectomy over their open adrenalectomy counterparts (Murphy et al, 2010).

Most recently, using a contemporary cohort from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data, Elfenbein and colleagues (2013) concluded that patients undergoing laparoscopic adrenalectomy had significantly lower postoperative morbidity Trelstar Depot (Triptorelin Pamoate for Injectable Suspension)- FDA shorter length of stay than patients undergoing an open procedure after adjustment for patient- and procedure-related breast biopsy, including malignancy.

Laparoscopic Transperitoneal versus Retroperitoneal Approach Multiple retrospective studies have been performed that seem to suggest an advantage in terms of lesser blood loss and shorter convalescence time of the retroperitoneal approach over Trelstar Depot (Triptorelin Pamoate for Injectable Suspension)- FDA transperitoneal approach.

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