KIMURA, CHUJI

SUGITANI, AKIRA

TSUNEKAWA, KENGO

WATANABE, MIKIO

YAMAMOTO, TOSHIO

Kyoto University Research Information Repository

TitleA SUCCESSFUL CASE OF ADRENALECTOMY FORPRIMARY ALDOSTERONISMAuthor(s)KIMURA, CHUJI; TSUNEKAWA, KENGO; SUGITANI,AKIRA; YAMAMOTO, TOSHIO; WATANABE, MIKIOCitation日本外科宝函 (1959), 28(5): 1911-1916Issue Date1959-06-01URL http://hdl.handle.net/2433/206878RightType Departmental Bulletin PaperTextversionpublisherKyoto UniversityA SUCCESSFUL CASE OF ADRENALECTOMY FOR PRIMARY ALDOSTERONISM by CHU JI KIMURA, KEN GO TsuNEKA w A, AKIRA Su GIT ANI From the 2nd Surgical Division, Kyoto University Medical School (Director : Prof. Dr. YAsUMASA AovAur) Tosmo y AMAMOTO and MIKIO w ATANABE From the 1st Internal Clinic, Faculty of Medicine, K~oto University (Director : Prof. Dr. Gvoccm W AKidAKA) Received for publication May 2, 1959 1911 Since the first description of primary aldosteronism in 1954 by J. W. CoNN, ab~mt 30 cases have been reported up句 date.Recently we have observed a patient with this disease, who showed the typical syndrome of primary aldosteronism and who had a cortical adenoma of the left adr-enal gland. In this paper, the characteristic symptoms from the patient are presented with the surgical treatment for the adrenal gland tumor. CASE REPORT H. Y., a 27債year-oldman, was admitted to our Surgical Clinic on September 2, 1958, with the chief complaint of periodic paralysis of the upper and lower extrem-ities. in February, 1956, lie first noticed muscular weakness of the right hand and additionally noted p:ilγdipsia, pol;-・uria, and nycturia. Until March, 1958, these symptoms developed periodicallyア： theduration of the attack varied from one to ten days, the interval from two to five months. The degree and character of muscular weakness were also not uniform in each attack ; for example, intense generalized muscular Mアeaknessin major attacks, whereas only the fingers were invoh℃d in minor ones. In the intervals between these attacks he SU古eredfrom headaches and general fatigue. On March 18, 1958, he was admitted to the Internal Clinic of our Hospital. From the clinical findings and laboratory examinations, hi日 casewas diagnosed as primar:iア aldosteronismby Professor G. W AKISAKA, and referred to the Surgical Clinic for surgical treatment. CLINICAL FINDINGS The patient was a well developed and moderately nourished man. On admission to the Surgical Clinic, his blood pressure in an arm was 170/110 mmHg, temperature 37.0°C, pulse 80 per minute and respiratoryア rate20. The heart in size and position was normal. There were no murmur日 orabnormal sounds. The lungs were clear. There was no abnormality in the abdomen, genitalia and skeletal s；－’stem. No edema 1912 日本外科宝函第28'{§1第5号was present. Urinalvsis in preoperati＼℃l〕er匂〔1＼＼＇℃re as follows ：叩ecificgravity 1.013句 1.005:urine volume 4000 to 3000 cc per cla~’： protein 0 to trace : abnormal sedimtmt neg-ative: Sodium, 51 mEq./L.* Potassium, 42.0 mEq./L.": Aldosterone, 40.6 gamma/24 hours.* Serum electrolyte concentrations ＼＼℃re: Sodium, 165 mEq./L.*: Potassium, 1.93 mEq./L.*: C冶lcium,4.4 mEq./L.* The electrocardiogram showed the depressed and rounded T waves associated with prominent l' wa,・cs. Renal clearance test: RPF, 268 cc/m.: RBF, 421 cc/m.: GFR, 50 cc/m. : FF, 18.8 /c. Retroperitoneal air insu市ationwith tomography revea・led a contour of left suprarcnal mass (Figs. 1 and 2). Fig-. 1. Perirenal pneumoroentgenogram showing contour of left suprarenal mass at arrow. Fig. 2. Tomogram, left suprarenal mass at arrow. OPERATION i (Fig.~＿ 3): For prcmedication, 50 mg of cortisone acetate wa日administered6 hours .before the op巴ration.The operative procedure was carried out on September 12, 1958, under balanced anesthesia with nitrous oxide, ether and cyclopropane. λL-form incision ＼＼＇山 madein the upper abdomen, a transperitoneal approach was used. The splenic flexure wa日 displaceddownwards after cutting o百thespleno-colic and phrenicocolic ligament片. Subsequent！γ，I>:; cutting o百apart of the gastro・splenic and phrcnicosplenic ligaments, the stomach, spleen, and pancreas were medially llisplaced. Thereby the rctroperitoneal space was entirely developed, exposing the upper pole of the left kiclne~· situated in the bottom of operative field. The left adrenal gland was exactl；.’ recognized by tracing of the suprarenal vein arising from renal one. In the gland, a golden 3℃llow tumor, large as a cherry, was detected, which wお sphericalin shape. Therefore, a total left adrenalectomy, inclu-cling the tumor, ＇γas performed, after cutting the adrenal arteries and ＼℃in, with *Each of these 、aluesare the extreme ones between March 18, 1958 and September 12, 1958. A SUCCESSFUL CASE OF ADHENALECTOMY FOR PRIMARY ALDOSTERONISM 1913 Pl.NCREAS INFZRIOR PHRl'lHC 1 VEIN DIA:!'宜RAGMl ’l INTERl¥AL SPERJ!ATIC VEIN Fig・. 3. Schematic ilustration o士i;neoperative白eld.the separation of the surrouncling tissues such as of the pancreas, diaphragm, and left kidney. In exploring the right adrenal, the stomach and spleen were returned to the normal position, and then the transverse colon was retracted downwards, and the duodenum was mobilized from the rctroperitoneum. As no abnormalities were dete-cted by palpating the region of the right adrenal gland, it was left alone. During the operation the patient’s blood pressure was almost constant at 130/ 100, though there was a temporary swing from 120/90加 150/120.POSTOPERATIVE COURSE During the白rst日evenpostoperative da）・sthe patient n’as given 100旬 25mg of cortisone acetate per da.¥・ The patient’s postoperati＼℃ course was entirelJ-ア uneve-ntful. All symptoms were gradually improved, and he was discharged on October 24, 1958, completely cured. PATHOLOGICAL EXAMINATION (Figs. 4 and 5) The specimen consisted of an adenoma and the surrounding adrenal gland. The adenoma weighed 2.1 g, measured 1.5 !Jy 1.7 by 1.8 cm, well-encapsulated. The cut surface showed a golden 3・cllowcolour, with neither necrosis nor hemorrhage. Microscopically there were many kinds of cell-arrangements which resembled 1914 日本外科宝函第28巻第5号Fig. 4. Cortical adenoma in the left adrenal gland. Fig" 5. Microscopic appearance of the adenoma. each adrenal cortex zone respecth・el：－. λn acknomatous cell-2rra1;gcment 'ms also observed. There ＂’as nonuniformit~・ of the size of the cells and nuclei. The histologic diagnosis was“adrenocortical adenoma". DISCUSSION Primary alclosteronism, as established H’CoNN, is a s:--mptom complex resulting from the hypersecrction of aldosterone. In our case, the typical symptcms were present, i. e., periodic muscular weakness, occasional tetan＞」likeattack with the TROUSSEAU’s sign, hypertension, pol~·dipsia and polyuria. Likewise, the characteristic findings "・ere exhibited in clinical examination, i. e., marked increase of aldosterone in urine, hypokaliemia, h~·pernat1℃mia, hyposthenm泊 orisosthenuria, pota~sium deple-tion wave of electrocardiogram, and impaired renal function. In most cases of primary aldosteronism reported in the literatures, adrenal cortical adenoma has been disclosed b>・ surgical exploration, although there have been a few cases of carcinoma or h ~・perplasia. In our case, the adenoma of the left adrenal cortex, which was detected 1η・ prior roentgen examination, was successfully removed by surgical operation. Generall~· ， concerning the surgical management of adrenal gland tumor many opinions ha,・e been given. In the resection of the tumor, it is important to choose the most convenient approach. In this respect, it is our opinion that the anterior transperitoneal approach is the most satisfactory procedure in comparison to the posterolateral, transthoracic or various other ones. Because, the following factors are indicated : 1) it is unnecessary to change the ~.atient ’s position to exploration of the contralateral adrenal, 2) operative manipula-t10n is easier than the other approaches since a wider operative field is obtained, 3) as a considerable factor, the courses of the blood vessels entering the gland are exposed. The arterial Yessels are abundant in number and Yer:・: slender. on the other ha叫 thesuprarenal vein is the only one larger and almost invariable in cou胤A SUCCESSFUL CASE OF ADRENALECTOMY FOR PRIMARY ALDOSTERONISM 1915 Therefore even when the gland is buried in the retroperitoneal adipose tissue, one can accurate!~’日nd the gland by tracing of the suprarenal vein from the bifurcation. To detect these vessels, the anterior approach is also very useful. As for the surgical management of primary aldosteronism itself, it has been generally accepted that, 1) one should undergo operation for its removal in an early stage, before secondary irreversible renal and heart lesions develop and that, 2) as CoNN describes, in the event that no adenoma is found at operation a total or exten-sive subtotal adrenalectomy should be performed. For preoperative preparation and postoperative care, the adequate administration of cortical hormone is of vital importance in order to avoid an acute adrenocortical insu白ciency, although there is the opinion that such cortical hormone is not neces-sarily required because it is almost normally secreted in this lesion. In our case, a total of 400mg of cortisone acetate was administered ・¥'ithout a川ア acutecomplications. Anesthetic management for this disease must also be carefully conducted. Rec-ently, GARLINGTON and BAILEY reported two cases of primary hyperaldosteronism, in which the management was complicated by unusual fluctuations of blood pressure and resistance to depressing drugs. Fortunately, in our case, the blood peressure was almost constant (130/100) throughout the entire course of the left adrenalectomy and the exploration of right adrenal without any relief of depressing drug. For the regulation of aldosterone secretion, many investigations have. been reported. In the research of the field, the question discussed by F. C. BARTTER et al., as to whether a lesion in the central nervous system can lead to aldosterone produ-ction is of considerable interest. Furthermore, the experiments carried out in G. FARRELL’s labJratory, concerning the aldosterone regulating center and its inhibitory area in the diencephalon and the midbrain, suggest many important problems. / SUMMARY A case of primary aldosteronism associated with the left adrenocortical adenoma is described, and the surgical management of the adrenal gland is mainly discussed. This case has b巴enreported by Ch. KrnuRA at the Surgical Conference in KrnTo (the Kyoto-Geka-SRUDANKH) on Nov. 20, 1958 and also by T. Yamamoto at the Nth Annual Meeting of West Japan of Japan Endocrinological Society on Oct. l, 1958. We wish to express our sincere thanks to Prof. G. W AKrnAKA, M. D. and G. MARUD" M. D. for their valuable advice in endocrinological respects, and also to T. ANDO, M. D. for his interpretation of the pathological material. The roentgenograms used in this report w巴r巴 generouslyloaned by the Department of Urology (Director : Prof. D. T. !NADA). REFERENCES 1) Abe, H. et al. : Primary Aldosteronism. Saishin-igaku, 13, 1572, 1958. 2) Bartter, F. C. and Bi邑clieri,E. G.: Primary Aldosteronism. Ann. Int. Med., 48, 647, 1958. 3) Belvile, J.羽r.et al.: Anesthesia for Bilateral Adrenalectomy, A Statistical and Clinical Analysis. Anesthesiology, 19, 217, 1958. 1916 日本外科宝函第28巻第5号4) Conn, J. W. : Primary Aldosteronism, a New Clinical Syndrome. J. Lab. & Clin. Med., 45, 6, 1955. 5〕 Conn,J. W.: Primay Aldosteronism. J. Lab. & Clin. Med., 45, 661, 1955. 6) Conn, J. W. and Louis, L. H. : Primary Aldosteronism, New Clir】icalEntity. Ann. Int. Med., 44, 1, 1956. 7) Fine, D. et al.: Primary Aldosteronism. New Eng_. J. Med., 256, 147, 1957. 8) Far・rel,G.: Regulation of Aldosterone Secretion. Physiol. Rev., 38, 709, 1958. 9) Grimson, K. S. et al.: Diagnosis and Management of Tumors of the Adrenal Gland. Ann. Surg., 134, 451, 1951. 10) Garrpd, 0. et al.・: The Signi自canceof the Assay of Aldosterone in Human Urine and Blood. Proc. Roy. Soc. :Vied., 49, 885, 1956. 11) Garlington, L. N. and Bailey, P. J. : Primary Hyperaldosteronism : Anesthetic Experience with Two Cases. Anesthesiology, 19, 661, 1958. 12) Garrod, 0. et al.: Some Factors Affecting Aldo.;;terone Secretion. Proc. Roy. Soc. Med., 49, 888, 1956. 13) Holton, C. et al.: l¥Ialignant Hypertension and Hyperaldosteronism.Proc. Roy. Soc. Med., 49, 890, 1956. 14〕 Ibayashi,H.: ACTH & Cortical Hormon. Nihonrinsyo, 15, 726, 1957. 15) Milne, M. D. et al.: Primay Aldosteronism. Proc. Hoy. Soc. Med., 49, 883, 1956. 16) Priestley, J. T. et al. : Subtotal Adrenalectomy for Cushing’s Syndrome. Ann. Surg., 134, 464, 1951. 17) Scott, W. W. & Hudson, P. B .The Surgery of the Adrenal. C. C. Thomas, 19,5~. (in Japa-nese, translated by Shibusawa, 1955). 18) Shibusawa, K. : Adrenalectomy for Cushing’s Syndrome. Shujutsu, 6, 3, 1952. 19) Shibusawa, K.: Surgery of the Adrenals. Recent adYances in Surgical Research (Surgical Endocrinology). Igaku-shoin, 1957. 20) Saito, S.: Aldosterone. Nihonrinsyo, 14, 188, 1956. 21〕 Saito,T. et al.: Dignosis of Adrenal Gland Tumor. Saishin-igaku, 13, 1308, 1958. 22) Torikai, T. et al.: Primary Aldosteronism and Potassium-losing Nephritis. Japanese Medical Journal (Nipponiji shinpo), 1720, 1, 1957. 辛口文抄録Primary Aldosteronismの手術治験例京都大学医学部外科学教室第2講座（主任：青柳安誠教授）木村忠司・恒川謙吾・杉谷京都大学医学部内科学教室第l講座（主任：脇坂行一教授）山 本俊男 ・渡辺幹雄""--"fl. 27才の男，周期性四IJ－＼：！初年を主訴として入院した 出した結果，術前の診断の正しかったことを知った・；；；，其の特異的な症状及び臨床検査所見からPrimary ついで此の疾患に勺し、ての文献的考察を行うと共にpaldosteronismと診断して手術を行い左副腎腺腫を摘 一般副腎腫湯の外科的処置に言及した．

Primary Aldosteronismの手術治験例

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Primary Aldosteronismの手術治験例

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