Introduction: Unilateral aldosterone-producing adenoma (APA) represents a potentially curable cause of hypertension through laparoscopic adrenalectomy. However, surgical intervention may not be suitable for all patients, particularly those with significant comorbidities or a preference for less invasive management. Endoscopic ultrasound (US)-guided trans-gastric (TG) radiofrequency ablation (RFA) offers a minimally invasive alternative to treat left-sided APAs which are in closed proximity with the stomach. This new approach was successfully performed in our centre.
Case report: A 35-year-old woman with a history of familial adenomatous polyposis syndrome and previous total colectomy was referred for assessment of hypertension associated with severe hypokalaemia at 2.14 mmol/L. Biochemical evaluation confirmed primary aldosteronism with high plasma aldosterone (47.1ng/dL; nl<14), suppressed renin concentration (0.8mU/L; nl>4.0) and a high aldosterone-to-renin ratio of 58.9 (nl<2.4). Abdominal CT-scan imaging showed bilateral adrenal nodules (left: 23 x 16 mm and right: 17 x 12 mm), both evoking benign adenomas. Adrenal vein sampling showed a clear lateralization ratio (10.0) of aldosterone secretion from the left side. As the patient expressed a clear desire for a minimally invasive curative treatment with preservation of left adrenal tissue, endoscopic US-TG-RFA was considered after informed consent. After a medical preparation with spironolactone 50 mg/day and an alpha-blocker (terazosin 2.5 mg twice daily for 2 weeks), the left adrenal nodule could be successfully ablated under light general anaesthesia, using a 10 mm STARMed needle (Taewoong Medical, Seoul, South Korea) and generator set at 30 W.
Follow-up: No immediate complication was noted after the procedure and blood pressure and heart rate remained normal. Complete clinical remission of hypertension was achieved within one week, allowing discontinuation of spironolactone. After five month, the patient’s blood pressure remained consistently below 104/84 mmHg without medication, and CT scan imaging showed a reduction size of the left adrenal lesion with focal areas of necrosis but no evidence of delayed complication. Biochemical cure of APA was confirmed by normalization of potassium (3.82mmol/L), aldosterone (8.2ng/dL) and renin serum concentrations (1.1mU/L), consistent with residual primary hyperaldosteronism.
Conclusion: Endoscopic ultrasound-guided trans-gastric RFA is an effective and safe, minimally invasive, adrenal-sparing alternative to surgery for patients with unilateral left-sided APA.