Current achievements and challenges in adrenal surgery.

Adrenal surgery is now done in almost ideal circumstances. Mortality and complications are rare except in Cushing's syndrome. All major adrenal hormones and their stimulators are measurable and discriminating tests abound. Imaging techniques detect small masses. Inhibitors of hormone synthesis and cell receptors allow amelioration of metabolic hazards preoperatively. Primary aldosteronism is first medically controlled, and patients are selected for operation if difficult to control and if the type of disease is responsive to adrenalectomy. Cushing's disease usually requires pituitary adenomectomy, but some of the 15-30 per cent failures, those with ectopic adrenocorticotrophic hormone (ACTH) producing tumours, or adrenal adenomas warrant adrenalectomy. Metabolic hazards are controlled pre-operatively by aminoglutethimide. Benefits of adrenalectomy are uncertain and many challenges remain. Hazards of phaeochromocytomectomy are avoided by pre-operative adrenergic blockade. Myocardial disease warrants delay. Small unilateral lesions of all types are best removed through unilateral approaches. Small masses found on imaging and without apparent effect can be observed.