only a small percentage of patients have a medical problem such as cushing 's syndrome , which could in fact be its cause . the association of both procedures at a single stage may be debatable due to the increased risk of performing both complex procedures and to the surgical risk of a morbidly obese patient with such a endocrinological comorbidity . here we present the case of a 52 year - old man diagnosed with cushing 's syndrome during the preoperative screening for bariatric surgery . a sleeve gastrectomy and left adrenalectomy were performed using a laparoscopic approach at the same time . a 52 year - old man was referred to our department for the assessment of morbid obesity . he had a 10 year history of hypertension which had worsened in the last few months and was being treated with 3 antihypertensive agents . he had a recent history of type 2 diabetes that was controlled with diet , hyperlipidemia under pharmacological treatment and sleep apnea treated with continuous positive airway pressure support . in our center patients with obesity are studied to exclude endocrine causes of obesity and laboratory tests to screen for hypothyroidism and cushing syndrome are routinely performed . he referred a 20  kg weight increase in 2 years with no history of alcohol drinking or intake of exogenous glucocorticoid drugs . his physical examination showed a weight of 153  kg with body mass index of 53.8  kg / m at the first visit in the outpatients clinic . a central distribution of fat with a waist circumference of 150  cm and cervical and dorsocervical fat pad ( buffalo hump ) were observed . suspected hypercortisolism was confirmed by a failure to suppress the level of cortisol after 1  mg dexamethasone ( dst ) . the measurement of acth levels showed suppressed acth indicating an acth independent disease . an overnight low dose followed by a high dose dst suppression test serum and urinary cortisol were not suppressed in response to either the low dose or the high - dose confirming an acth independent disease . adrenal computed tomography was performed and a well - defined left adrenal mass measuring 3  cm and suggestive of adenoma was observed ( fig . the patient was positioned in the lithotomy position and tilted - up 40 under general anesthesia . ports were placed in the same way we use for the sleeve gastrectomy ( fig . 2 ) . once the pneumoperitoneum was achieved , the lesser sac was opened and the sleeve gastrectomy was performed , guided by a 36f tube . for the adrenalectomy , an anterior supragastric approach was used . the key point consists in identifying the diaphragmatic  adrenal channel which runs on the left crus and crosses the middle adrenal artery and joins the adrenal vein . the left diaphragmatic vein was dissected and followed caudally until the left adrenal gland vein was found ( fig . 4 ) . once the vein was clipped and cut , the rest of the gland was carefully dissected in an anti - clockwise direction with blunt dissection . the patient spent 24  h in the post - surgical icu , and was then discharged to the surgical ward . the pathologist reported a corticoadrenal pigmented adenoma . since the hypothalamic  pituitary axis and the contralateral adrenal gland was suppressed by the prolonged autonomous cortisol secretion , our patient required glucocorticoid therapy after surgery which was maintained awaiting the recovery of the remaining adrenal . after surgery , the patient was followed - up in the outpatient clinic with the surgeon , endocrinologist and dieticians . one month after surgery , plasma cortisol was 47  nmol / l ( 155678 ) , acth 3.6  pmol / l and the hypothalamic adrenal axis had still not recovered , as shown by a blunted response of the short synacthen - stimulated cortisol level ( peak level of 140 four months after surgery , the patient had lost weight as expected for a sleeve gastrectomy ( 23  kg ) and reported normal glycemic controls , his blood pressure was < 130/80  mmhg while still using 3 antihypertensive agents . plasma and urinary cortisol were still under normal range and a blunted response to the short synacten - stimulated cortisol persisted . one year later , the patient continued doing well with a weight loss of 35  kg ; he just needed one antihypertensive agent . the last control was done 2 years after surgery , the patient maintained a bmi of 29  kg / m . although there is little epidemiological data on the incidence of cushing 's syndrome , this is an uncommon disease with an estimated annual incidence of 2.3 cases per million population per year . as it is a rare cause of obesity many authors do not recommend including its screening in the routine preoperative evaluation of morbidly obese patients . have described two cases of unidentified cushing syndrome in morbidly obese patients that underwent bariatric surgery before their cushing syndrome was diagnosed . in these patients bariatric surgery was unsuccessful and had significant postoperative specific complications because of the underlying disease . in agreement with our opinion , the authors highlighted the benefits of performing screening tests and a correct diagnosis before surgery . it is a rare case of obesity , but if it is misdiagnosed its consequences may be severe . to avoid this scenario , our group always recommends a 24-h urinary free cortisol test , a simple and low cost tool for screening . in this patient , the bariatric procedure to be chosen may be widely discussed . due to the patient 's bmi , the presence of cushing 's syndrome makes it a high - risk procedure , so we prefer to do a sleeve gastrectomy . sleeve gastrectomy in itself also has favorable results in terms of weight loss and comorbidity resolution , with low morbidity and mortality rates in those high - risk patients . moreover , in this case , the sleeve gastrectomy may facilitate a good surgical field for the left adrenalectomy . one of the key points of this approach is a good dissection of the left diaphragmatic vein . after a sleeve gastrectomy is done , with a complete dissection of the left crus and the short gastric vessels we get an excellent visualization of the diaphragmatic  adrenal  renal channel . the authors also remarked on the outstanding exposure of the surgical field for the adrenalectomy after the sleeve gastrectomy . bardaro and gagner described another case similar to ours , using a gastric by - pass combined with a left adrenalectomy . in that case , the most difficult aspect was the exposure of the gland by keeping the stomach and the new reservoir retracted , which invalidated two ports during the adrenalectomy . both papers show the possibility of combining two major procedures adding neither morbidity nor mortality . we do agree with these authors that the combination of these procedures may be an indication in experienced teams , for better recovery of the patients and avoiding cumulative surgical risk for these high - risk patients . both procedures can be safely associated if there is a multidisciplinary and expert team in laparoscopic surgery with experience in morbidly obese patients . dr . g. ruiz de gordejuela and the other co - authors have no conflict of interest . written informed consent was obtained from the patient for publication of this case report and accompanying images . a copy of the written consent is available for review by the editor - in - chief of this journal on request . amador g. ruiz de gordejuela was one of the assistants of the surgery , he wrote and reviewed the paper . she initiated the diagnosis of the patient and contributed to the endocrinoly part with dr .
introductionthe advances in laparoscopic surgical technique and the greater experience of surgical teams have enabled the combination of different surgical techniques in a single procedure . 
 this paper presents a case of a sleeve gastrectomy and a left adrenalectomy by laparoscopy for a morbidly obese patient with cushing 's syndrome.presentation of casea 52 year - old male patient with a bmi of 53  kg / m2 was diagnosed as having cushing 's syndrome caused by a left adrenal tumor . 
 sleeve gastrectomy was performed according to the usual technique . 
 the adrenalectomy was performed at the same time by a left supragastric approach . 
 the evolution was favorable , with 52% of excess weight loss observed after six months . 
 plasma and urinary cortisol at the 3- and 6-month follow - ups were under normal range and the patient required glucocorticoid therapy , confirming the cure of cushing 's syndrome.discussionteams with experience of advanced laparoscopic surgery can successfully combine complex procedures in one surgical period . 
 the approach we used for the adrenalectomy proved itself to be feasible after the sleeve gastrectomy.conclusionboth procedures can be safely done in experience teams . 
 sleeve gastrectomy facilitates the direct supragastric approach .