Adrenalectomy for Cushing syndrome and primary aldosteronism
Stem
A 44-year-old woman, 92 kg, BMI 36, with a cortisol-secreting left adrenal adenoma is scheduled for laparoscopic adrenalectomy. She has hypertension on three drugs, insulin-treated diabetes with a glucose of 240 mg/dL, easy bruising, proximal weakness and snoring. Blood pressure is 158/96 mmHg and potassium 3.2 mmol/L. She is not taking exogenous steroids.
Question
What concerns you, and how do you prepare her and plan the anesthetic?
Ideal answer
HeadlineCortisol excess touches every system; I optimize glucose, pressure and potassium, plan glucocorticoid coverage because her other adrenal is suppressed, and protect fragile skin and bones.
- Glucocorticoid coverage from induction, tapered after, because removing the adenoma leaves a suppressed contralateral gland and risks adrenal crisis.1
- Insulin infusion and potassium repletion, because hyperglycemia and hypokalemia worsen infection and arrhythmia risk.
- Treat her as a likely obstructive sleep apnea airway, with video laryngoscopy ready and minimal opioid.
- Careful positioning and padding, because osteoporosis, myopathy and thin skin make fractures and skin tears easy.1
- Thromboprophylaxis from the day before, because these patients are prothrombotic; one center starts LMWH preoperatively.1
Watch for: hypotension, hypoglycemia or lethargy as steroids taper, and glucose and potassium on day 1; endocrinology times formal axis testing.
Breaking down the answer
- The systemic picture — hypertension, insulin resistance and diabetes, dyslipidemia, osteoporosis, muscle atrophy, depression and immunosuppression.1 In this series 62.3% had hypertension and 43.0% diabetes.
- Steroid regimens differ — one Cushing protocol gives about 200 mg hydrocortisone-equivalent from induction, tapered over 2–3 days;1 a primary aldosteronism protocol with cortisol co-secretion gives a single 100 mg intraoperatively and reassesses on day 1.2
- Testing the axis afterward — with mild cortisol co-secretion, a day-1 morning cortisol below 5 µg/dL strongly suggests insufficiency and above 14.5 µg/dL adequate reserve; intraoperative dexamethasone confounds it.2 Changes if: overt Cushing, then I cover empirically and test later.
- Aldosterone excess, the other adrenal problem — hypertension with hypokalemia; the goal before surgery is a mineralocorticoid antagonist for at least 4 weeks, blood pressure under 140/90 and potassium 4–5 mmol/L.2
- Co-secretion — 10–30% of patients with primary aldosteronism also have mild autonomous cortisol secretion,2 so I ask about it before every adrenalectomy.
Follow-up question
The next patient has an aldosterone-producing adenoma. He started spironolactone a week ago; potassium is 2.7 mmol/L despite supplements, and blood pressure is 176/104 mmHg. The surgeon wants to proceed today. Do you?
Follow-up answer
HeadlineNo, I postpone this elective case: his potassium and pressure are not optimized, and a few more weeks of mineralocorticoid blockade will make him safer.
I tell the surgeon why and agree a plan with endocrinology. The antagonist should run at least 4 weeks, titrated to blood pressure under 140/90, potassium 4–5 mmol/L and a renin that rises; surgery is postponed above 180/110.2 On return, I stop the antagonist and potassium supplements on day 1, halve antihypertensives, and check potassium, because 5–10% develop hyperkalemia from contralateral suppression.2
Pitfalls that cost points
- Restarting an ACE inhibitor or ARB after aldosteronoma removal; with the other adrenal suppressed, hyperkalemia follows.2
- Calling the operation a failure because pressure is still high in the first weeks; the full effect takes 1–3 months.2
- Assuming every adrenal adenoma secretes one hormone; co-secretion changes steroid plans.
Rapid-fire
Q: Risk factors for postoperative hyperkalemia after aldosteronoma removal? A: Low preoperative GFR, rising creatinine, adenoma over 2 cm, older age and long-standing hypertension; about 5% need mineralocorticoid replacement.2
Q: Why does GFR fall after surgery? A: Removing aldosterone ends glomerular hyperfiltration and unmasks underlying kidney disease.2
Q: How long before spironolactone fixes potassium? A: Days; blood pressure takes 4–8 weeks, maximal effect up to 3 months.2
Q: Which surgical approach is used for Cushing adenomas? A: Minimally invasive transabdominal laparoscopic or posterior retroperitoneoscopic adrenalectomy.1
Numbers to know
| Item | Value |
|---|---|
| Primary aldosteronism: BP before surgery | < 140/90; postpone > 180/110 mmHg2 |
| Potassium target on antagonist | 4–5 mmol/L2 |
| Antagonist lead time | ≥ 4 weeks2 |
| Postoperative hyperkalemia | 5–10%2 |
| Day-1 cortisol | < 5 µg/dL insufficient; > 14.5 adequate2 |
Links
- Adrenal insufficiency and stress-dose steroids, pheochromocytoma, Hypokalemia and whether to delay surgery, Diabetes mellitus and perioperative glucose, hyperkalemia
- Endocrine Society guidelines on primary aldosteronism and Cushing syndrome
Sources
- 1.Minimally invasive adrenalectomy for Cushing's syndrome and mild autonomous cortisol secretion: a 20-year experience from a tertiary endocrine surgery center · BMC Surg (PMC13599287), 2026 · pmc.ncbi.nlm.nih.govInstitutional protocol: LMWH from the day before surgery; about 200 mg hydrocortisone-equivalent from induction, tapered over 2-3 days.
- 2.Perioperative management of patients with primary aldosteronism: a practical approach for the endocrinologist · Endocr Connect (PMC13280532), 2026 · pmc.ncbi.nlm.nih.gov
Facts on this page were checked against these sources on Nov 2, 2026. Guidelines change; confirm doses against current institutional protocols.