TAMPA — Findings from a large surgical series on adrenalectomy for adrenal hypercortisolism were presented at ENDO 2026, the annual meeting of the Endocrine Society. The series suggests that postoperative hormonal testing to help individualize surgical strategies can optimize outcomes for patients who underwent adrenalectomy for adrenal hypercortisolism.

Tobias Carling, MD, PhD, affiliated with the Carling Adrenal Center and the Hospital for Endocrine Surgery in Tampa, Florida, discussed these results in a video. "Surgical management for adrenal hypercortisolism -- whether it ranges from mild autonomous cortisol secretion (MACS) all the way to overt Cushing syndrome -- sort of has to balance between achieving biochemical remission but at the same time preserving adrenocortical function," Carling said.

"We performed 1,965 consecutive adrenalectomies over 4 years and 784 of those patients had biochemically unequivocal adrenal hypercortisolism," Carling said. "So what we studied is the tailored surgical approach of using unilateral adrenalectomy for unilateral disease, unilateral adrenalectomy for bilateral disease, and bilateral function-preserving adrenalectomy for bilateral disease."

"And we performed a postoperative day 1 high-dose dexamethasone suppression test and cosyntropin stimulation test," Carling said. "And the purpose of that is that we can diagnose both persistent hypercortisolism as well as diagnose postoperative hypocortisolism or adrenal insufficiency."

"So the results were that the postoperative cosyntropin stimulation test showed a significant difference between the three groups," Carling said. He noted that group one consisted of patients who had unilateral adrenalectomy for unilateral disease, group two was unilateral adrenalectomy for bilateral adrenal hypercortisolism, and group three was patients who had function-preserving surgery.

"And what we could see is that patients that had curative surgery for unilateral adrenalectomy in unilateral disease had stimulated cortisol levels that were expected, but patients that had only unilateral surgery for bilateral disease had stimulated levels that were consistent with persistent hypercortisolism," Carling said. "Whereas those that went on to have the second surgery on the other side came down with the cortisol levels similarly to those that only had unilateral disease."

"I think our studies have a lot of implications and we need more studies to understand this disease entity with bilateral disease that can be tricky for clinicians to deal with, but number one, the surgical strategies have to be individualized based on the laterality on cross-sectional imaging and the patient's phenotype," Carling said. "And number two, using this combined high-dose dexamethasone suppression test together with cosyntropin stimulation test and those profiles help improve the decisions for which patients where unilateral surgery is sufficient but also identifying those that need a second operation on the contralateral gland."

"So this then translates to optimized long-term endocrine outcomes and a more individualized strategy for these patients," Carling said.