Unlocking Weight Loss After Adrenalectomy: Key Factors and Surprising Outcomes Revealed!

Adrenalectomy, particularly laparoscopic adrenalectomy, is often the recommended procedure for addressing adrenal masses. This article delves into the effects of adrenalectomy, especially concerning weight changes and related health outcomes.

What is Adrenalectomy?

Laparoscopic adrenalectomy is the gold standard procedure for most adrenal masses. It is a minimally invasive surgical technique. During the procedure, small incisions are made in the abdomen through which a laparoscope (a thin tube with a camera) and surgical instruments are inserted. The surgeon uses the camera to visualize the adrenal gland and surrounding tissues on a monitor, allowing for precise removal of the adrenal gland. This approach offers several advantages over traditional open surgery, including smaller incisions, reduced pain, less blood loss, shorter hospital stays, and faster recovery times.

Indications for Adrenalectomy

Adrenalectomy is performed to treat various conditions related to the adrenal glands. These include:

Nonfunctioning Tumors: Tumors that do not produce excess hormones. When adrenalectomy was performed for nonfunctioning tumors, neoplasia was identified in 22.9% of patients.
Pheochromocytoma: Tumors of the adrenal medulla that produce excess catecholamines (e.g., adrenaline).
Aldosteronoma: Tumors that produce excess aldosterone, leading to primary aldosteronism.
Subclinical Cushing's Syndrome: Mild excess cortisol production without overt Cushing's syndrome symptoms.
Cushing's Syndrome: A condition caused by prolonged exposure to high levels of cortisol.
Sex Hormone-Secreting Tumors: Tumors that produce excess sex hormones.

Surgical Technique and Outcomes

Laparoscopic and robotic adrenalectomy requires that patients undergo a general anesthesia. The laparoscope allows for 10X magnification of the operative field, allowing the surgeon to accomplish the surgical procedure with improved visualization and without placing his hands into the abdominal cavity. The abdomen is filled with carbon dioxide gas to create a larger working space for the surgeon to accomplish the operation. In addition, the surgeon controls a stereoscopic lens which provides a three dimensional, high definition image of the anatomy. The affected adrenal gland is then dissected and exposed. The tumor, adrenal gland and surrounding fat are excised along with any visible surrounding lymph nodes, preserving the adjacent organs including the liver, spleen, bowels and kidney. Once the adrenal tumor is excised, it is immediately placed within a plastic sack and the mass is removed from the abdomen intact through one of the pre-existing abdominal incisions.

Laparoscopic adrenalectomy is a safe procedure with a low complication rate and short hospital stay. A study retrospectively reviewed laparoscopic adrenalectomies performed for adrenal masses between May 2000 and September 2010 by nine surgeons at a single institution. They removed 96 adrenal glands in 95 patients. The average length of stay was 1.8 days. We experienced no conversions to open procedure and no perioperative mortality. Minor complications occurred at a rate of 1.2%.

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Impact on Hypertension

Hypertension improves in the majority of patients with Cushing's syndrome and aldosteronoma and just under the majority of those with pheochromocytoma. Hypertension improved or resolved in 63% of patients with Cushing's syndrome, 56% with aldosteronoma, and 47% with pheochromocytoma. For patients with highs of aldosterone from a small tumor, minimally invasive (laparoscopic) adrenalectomy can help return blood pressure and electrolytes to a healthy level after the body adjusts. Your blood pressure will drop immediately after surgery, and some (not all) patients need to stay in the hospital for a few days to manage the blood pressure changes.

Weight Changes After Adrenalectomy

One of the most common universal features of the excess cortisol is weight gain, typically involving the face, neck, or belly. Often, the legs tend to lose fat, and become very slender. Less well known is the fact that Conn’s syndrome (Primary hyperaldosteronism) also can cause weight gain.

Weight gain, overweight, obesity and morbid obesity are very common. The degree of obesity is based on the body mass index (BMI). Weight gain, and obesity factor in with all surgery and especially surgery that involves the abdomen. Especially for inexperienced surgeons, the higher the BMI of the patient the more challenging the operation is.

Factors Influencing Weight After Surgery

Hormonal Imbalance: Adrenal tumors that secrete hormones like cortisol or aldosterone can cause weight gain. Removal of the tumor can lead to hormonal rebalancing and potential weight loss.
Cushing’s Syndrome: Cushing’s syndrome causes high levels of cortisol, a hormone produced by the adrenal cortex. If this problem is caused by a tumor on your adrenal gland, adrenalectomy may treat these symptoms.
Primary Hyperaldosteronism (Conn's Syndrome): Less well known is the fact that Conn’s syndrome (Primary hyperaldosteronism) also can cause weight gain.
BMI Considerations: For patient with a BMI greater than 50, special considerations sometimes need to be taken. These patients (if they have Cushing’s syndrome) sometimes benefit from medical treatment such as Korlym before their operation. Occasionally, having bariatric surgery such a sleeve gastrectomy may be beneficial prior to adrenal surgery.
Surgical Factors: Weight gain, and obesity factor in with all surgery and especially surgery that involves the abdomen. Especially for inexperienced surgeons, the higher the BMI of the patient the more challenging the operation is. For the Mini Back Scope Adrenalectomy (MBSA) the key information is the distance from the skin to where the adrenal gland is. If your BMI is greater than 40 it is a good idea to plan to lose about 10 to 20 pounds before your adrenal operation. You are still a great candidate for the Mini Back Scope Adrenalectomy (MBSA). However, losing some weight before the operation will enable you to get mobile much quicker, and recover in a much better fashion. It will help ensure that your operation I a great success.

Study Results on BMI

Average BMI was 32.9 kg/m(2) preoperatively and 31.9 kg/m(2) postoperatively (P=.46).

The Role of Adipose Tissue

We have previously shown that following adrenalectomy, gold thioglucose (GTG)-treated hyperphagic obese mice exhibit anorexia, weight loss and a pronounced hypoglycemia which leads ultimately to their death. In the present study, we sought to determine whether the increased adipose tissue mass which is characteristic of GTG-treated obese mice exerted a role in the onset and development of anorexia after adrenalectomy. Accordingly, the effects of adrenalectomy on food intake, weight gain, plasma glucose and corticosterone levels were investigated in normal untreated controls, GTG-treated hyperphagic obese mice and GTG-treated non obese mice. The GTG-treated non obese mice were prepared by restricting their daily intake of chow (pair-feeding) to that consumed by normal untreated mice. After adrenalectomy, all mice were allowed free access to food. As expected, all GTG-treated hyperphagic obese mice exhibited anorexia and weight loss following adrenalectomy. In contrast, about half (52%) of the GTG-treated non obese mice exhibited anorexia and weight loss after adrenalectomy. The response of the GTG-treated non obese adrenalectomized mice was not due to differences in adrenal insufficiency since all adrenalectomized mice had blood levels of corticosterone of less than 0.5 microgram%.

Post-Operative Care and Considerations

Steroid Replacement

Patients with Cushing’s syndrome (excess cortisol) from an adrenal tumor will most likely need to take steroids for some time after surgery. The adrenal gland producing too much steroid hormone causes brain signals that tell the adrenal gland to produce steroids to shut off. This process should begin to work again within a few weeks to months, but sometimes this takes longer. In the meantime, you will need to take prescribed steroids (usually hydrocortisone) twice each day.

Glucocorticoid Withdrawal Syndrome

Some patients who have adrenalectomy for Cushing’s syndrome feel like they don’t have enough cortisol hormone, even though the doses of steroids they are receiving are what their body needs. Your body may be used to much higher doses of steroids than it needs, and receiving normal amounts can cause multiple symptoms including exhaustion, joint or muscle pain, depression, anxiety and overall feeling poorly.

Adrenal Insufficiency

Patients whose adrenal glands don’t work correctly or who have had an adrenal gland(s) removed are at risk for acute adrenal insufficiency.

Nelson’s Syndrome

In approximately 20% of patients who need to have both adrenal glands removed, the pituitary gland in the brain can react to not being able to produce cortisol from the adrenal glands. Nelson’s syndrome occurs when the pituitary gland grows in response to trying to stimulate the absent adrenal glands. The levels of adrenocorticotropic hormone, which is made by the pituitary gland and stimulates the adrenal glands to produce cortisol, become high (>300 mg/dL) and the skin becomes darker in color (hyperpigmentation).

Gastrointestinal Issues

In addition to other symptoms, people with pheochromocytoma may have gastrointestinal dysmotility - the stomach and intestines don’t work correctly. There may be unexplained nausea and vomiting, weight loss or problems having bowel movements, or the belly may be uncomfortable and feel like it is swollen with air.

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General Post-Operative Instructions

Diet: Your diet will be advanced slowly following surgery from liquids to solids as tolerated. It is often the case that your appetite will be poor for up to a week following surgery. In addition, your intestinal function is often sluggish due to the effects of surgery and general anesthesia. It is for these two reasons that we recommend taking only small amounts of liquids by mouth at any one time until you begin to pass flatus and your appetite returns. Patients may resume a regular diet as tolerated.
Activity: Walking 4-6 times a day for the first two weeks after surgery on a level surface is strongly encouraged as prolong sitting or lying can increase your risk of pneumonia and deep vein thrombosis. It is permissible to climb stairs. No heavy lifting or exertion for up to 4 weeks following surgery. Patients may begin driving once they are off of narcotic pain medication and have full range of motion at their waist.

Benefits and Risks of Laparoscopic Adrenalectomy

Benefits

These minimally invasive laparoscopic techniques have translated into a significant benefit to patients including reduced blood loss and transfusions, reduced pain, shorter hospital stays, improved cosmesis, and a faster recovery as compared to open surgery. While open surgery requires either a large abdominal or flank incision, minimally invasive approaches involve 3-4 keyhole incisions in the abdomen. Most patients with adrenal tumors who are candidates for open surgery are also excellent candidates for a laparoscopic or robotic approach. These minimally invasive approaches have become the standard of care for most adrenal tumors.

Risks

As with any major surgery, complications, although rare, may occur with laparoscopic and robotic adrenalectomy.

Bleeding: Blood loss during this procedure is typically less than 100 cc with the rare need for a blood transfusion (<2% of patients).
Infection: Although patients are given broad spectrum intravenous antibiotics immediately prior to surgery, infections of the urinary tract and skin incisions may still occur but are rare.
Adjacent Tissue / Organ Injury: Although uncommon, adjacent organs and tissues may be injured as a result of your surgery. This includes the colon, bowel, vascular structures, kidney, nerves, muscles, spleen, liver, pancreas and gallbladder. If injury to your lung cavity occurs, a small chest tube may be required to evacuate air, blood, and fluid from around your lung, thus allowing your lung to expand and work properly.
Incisional Hernia: Because of the small laparoscopic incisions, hernias at these sites can rarely develop.
Conversion to Open Surgery: In the rare event of complications or due to difficulty in dissecting by means of laparoscopic or robotic surgery, conversion to open surgery is sometimes required.
Postoperative Pain: Although most patients in the first few days after surgery experience mild pain at their incision sites, this is generally well controlled by use of intravenous pain medication, patient-controlled anesthesia pump, or oral pain medication provided by your nurse.
Nausea: Nausea is common following any surgery especially related to general anesthesia.

Long-Term Outlook

Prognosis is generally excellent as most adrenal tumors are benign. In cases of adrenal cancer, further therapies may be required as these are generally aggressive cancers. As mentioned previously, most adrenal tumors are benign and therefore prognosis remains excellent as most are cured with surgery alone.

Patient Story

Charlotte Strecker has overcome adrenal carcinoma five times. Charlotte was 27 years old and in her last year of pharmacy school when she began experiencing high blood pressure, nausea and pain that radiated to the right side of her back. After an ultrasound, she was diagnosed with stage III adrenal carcinoma. Charlotte has been treated by Jeffrey E. Under Dr. Lee’s care, Charlotte underwent a second surgery to remove the adrenal gland tumor. Three months later, a CT scan revealed the cancer was back for the third time. About two years later, she had her fourth recurrence. Nearly two years after that, she had her fifth recurrence. Charlotte experienced something else that she wishes she hadn’t. She gained nearly 100 pounds. “Dr. Lee asked that I try to lose weight. He said I was going to die from the weight gain before I would die from cancer,” Charlotte says. “I was emotionally drained and exhausted from the recurrences,” she says. After her third surgery, Charlotte stopped taking the oral chemotherapy and cut back on the steroids. After getting bad news five times in six years, Charlotte has received good news for the past 11 years.

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