The early postoperative assessment is probably the most difficult area of management in the spectrum of this fascinating and complex disease. Cured patients, unlike those with acromegaly and patients with visual loss, seldom feel well. In fact, it is almost a truism to say that a patient with Cushing's who has been cured feels "rotten" for a while. The patient may lose his or her red color and may regain his or her normal blood pressure, but many feel "washed out" and their skin becomes dry, itchy, and flaky.
Biochemically, profound suppression of normal adrenal secretion has occurred because of long-term steroid-induced inhibition of the hypothalamic-pituitary axis. The early morning postoperative cortisol should be low, below 50 nmol/L (1.8 M-g/dL) being considered a cure (5).
In our practice, we withhold replacement until this level has been achieved. Alternatively, the patient can be replaced until an early formal check, off hydrocortisone for >24 h, has been carried out. If the level fails to fall within 72 h, re-exploration is advised. If the result is equivocal, 24 h urine free cortisols (UFCs) may be carried out to further clarify the issue.
When cortisols fail to suppress and the surgical findings, particularly with histologic confirmation, strongly suggest the presence of tumor, re-exploration is strongly indicated.
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