Complications of laparoscopic adrenalectomy: results of 169 consecutive procedures

Laparoscopic adrenalectomy (LA) has become the gold standard for adrenalectomy. Review of the literature indicates that the rate of intra- and postoperative complications is not negligible. The aim of this study was to evaluate the complications observed in a series of 169 consecutive LAs performed at a same center for a variety of endocrine disorders. Between June 1994 and December 1998 a series of 169 LAs were performed in 159 patients: 149 unilateral LAs and 10 bilateral LAs. There were 98 women and 61 men with a mean age of 49. 7 years (range 22-76 years). There were patients with 61 Conn syndrome, 41 with Cushing syndrome, 1 androgen-producing tumor, 29 pheochromocytomas, and 37 nonfunctioning tumors. Mean tumor size was 32 mm (range 7-110 mm). LA was performed by a transperitoneal flank approach in the lateral decubitus position. Mean operating time was 129 minutes (range 48-300 minutes) for unilateral LA and 228 minutes (range 175-275 minutes) for bilateral LA. There was no mortality. Twelve patients had a significant complication (7.5%): three peritoneal hematomas requiring (in two cases) laparotomy and (in one case) transfusion; one parietal hematoma; three intraoperative bleeding episodes without need for transfusion; one partial infarction of the spleen; one pneumothorax; one capsular effraction of the tumor; and two deep venous thromboses. Eight tumors were malignant at final histology (4.7%), of which four were completely removed laparoscopically. Conversion to open surgery was required in eight cases (5%): for malignancy in four cases, difficulty of dissection in three cases, and pneumothorax in one case. With a mean follow-up of 26.58 months (range 6-60 months) all patients are disease-free. We conclude that LA is a safe procedure. With increasing experience the morbidity becomes minor. To avoid complications LA should be converted to open surgery if local invasion is suspected or if there is difficulty with the dissection.

The pineal gland and cancer. I. Pinealectomy corrects congenital hormonal dysfunctions and prolongs life of cancer-prone C3H/He mice

Hormonal derangements almost invariably anticipate and signal the onset of tumors. Chronic, nocturnal melatonin administration delays aging in normal strains of mice. On the contrary it promotes and accelerates the onset of tumors in the cancer-prone strain of C3H/He mice. Grafting of a young pineal gland into aging mice prolongs their longevity and maintains juvenile circadian hormonal functions while pinealectomy (Px) does the opposite. We investigated if Px in C3H/He mice would modify their congenitally deranged pituitary function and affect their longevity. It was found that contrarily to Px in normal mice, Px in C3H/He mice remarkably maintains juvenile night levels of thyroid hormones and lipids, preserves a cell-mediated immune response and significantly prolongs their life. The pineal gland and its pathology may be the key for understanding, not only the causes of metabolic aging, but also the origin of those congenital or progressive aging-related hormonal alterations preceding onset of all tumors and thus allow preventive corrective interventions with pineal-derived agents.

The physiology of the endocrine system

Understanding the basic physiology of endocrinology and metabolism is important for the safe conduct of anesthesia of patients with endocrine disease. Full endocrine assessment and considered interpretation of the results is essential before anesthesia and surgery. In this chapter, we have covered the background physiology and the basic investigations that may be required to diagnose and direct treatment in order to optimize perioperative care.

Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures

One hundred consecutive laparoscopic adrenal procedures for a variety of endocrine disorders were reviewed. There was no mortality, morbidity was 12%, and conversions was 3%. During follow-up, none had recurrence of hormonal excess. Laparoscopic adrenalectomy is the procedure of choice for adrenal removal except in carcinoma or masses > 15 cm.

OBJECTIVE

The authors evaluate the effectiveness of laparoscopic adrenalectomy for a variety of endocrine disorders.

SUMMARY BACKGROUND DATA

Since the first laparoscopic adrenalectomy was performed in 1992, this approach quickly has been adopted, and increasing numbers are being reported. However, the follow-up period has been too short to evaluate the completeness of these operations.

METHODS

One hundred consecutive laparoscopic adrenal procedures from January 1992 until November 1996 were reviewed and followed for adequacy of resection.

RESULTS

Eighty-eight patients underwent 97 adrenalectomies and biopsies. The mean age was 46 years (range, 17-84 years). Indications were pheochromocytomas (n = 25), aldosterone-producing adenomas (n = 21), nonfunctional adenomas (n = 20), cortisol-producing adenomas (n = 13), Cushing's disease (n = 8), and others (n = 13). Fifty-five patients had previous abdominal surgery. Mean operative time was 123 minutes (range, 80-360 minutes), and estimated blood loss was 70 mL (range, 20-1300 mL). There was no mortality, and morbidity was encountered in 12% of patients, including three patients in whom venous thrombosis developed with two sustaining pulmonary emboli. During pheochromocytoma removal, hypertension occurred in 56% of patients and hypotension in 52%. There were three conversions to open surgery. The average length of stay has decreased from 3 days (range, 2-19 days) in the first 3 years to 2.4 days (range, 1-6 days) over the past 16 months. During follow-up (range, 1-44 months), two patients had renovascular hypertension and none had recurrence of hormonal excess.

CONCLUSION

Laparoscopic adrenalectomy is safe, effective, and decreases hospital stay and wound complications. Prior abdominal surgery is not a contraindication. Pheochromocytomas can be resected safely laparoscopically despite blood pressure variations. Venous thrombosis prophylaxis is mandatory. The laparoscopic approach is the procedure of choice for adrenalectomy except in the case of invasive carcinoma or masses > 15 cm.

[Pineal gland cysts: clinical and radiological course]

We describe the clinical and radiologic evolution of pineal gland cysts found in computed tomography or magnetic resonance images in 12 patients. The patients had complained of headache and/or lateralized sensory symptoms. None had signs of intracranial hypertension or tectal dysfunction. Only one patient, who had partial epilepsy and a large cyst, was treated by ventriculo-cystic shunt; the rest were treated conservatively. The follow-up period in 11 patients was from 2 to 5 years. No changes were observed in cyst size or radiological characteristics; nor did signs of tectal dysfunction develop. In patients with no signs or symptoms directly attributable to these cysts, surgery can be avoided if no radiological changes are found upon follow-up.

Operative experience of U.S. general surgery residents with diseases of the adrenal glands, endocrine pancreas, and other less common endocrine organs

The aim of this study was to determine if the experience of general surgery residents is adequate and effective. The Resident Statistic Summaries (Report C) of the Residence Review Committee (Surgery) for eight academic years from 1986 to 1994 were analyzed. The main outcome measurements were total number of residents and programs, average number of operations performed, maximum number of operations performed, standard deviation, and the most common number of operations performed. For adrenalectomy, the average per resident was 0.98. The maximum range was from 7 to 15. The standard deviations ranged from 1.12 to 2.00. For pancreatic endocrine operations the average per resident was 0.15 with maximums of 3 to 10. For other endocrine procedures (nonthyroid and nonparathyroid) the average per resident was 0.14, with the maximums ranging from 7 to 19. The most common number of any of these procedures performed by U.S. graduates was 0. The number of adrenal, endocrine pancreas, and other less common endocrine procedures available for graduates of U.S. residency training programs is limited. As a consequence, most U.S. resident graduates have little or no experience with any of these procedures. Our findings suggest a strong need for fellowship training for any surgeon hoping to develop expertise in the management of these unusual and infrequent endocrine surgical diseases.

Medicolegal analysis of errors in diagnosis and treatment of surgical endocrine disease

BACKGROUND

The medicolegal impact of adverse events in surgical endocrine disease has not been described previously. This study was undertaken to determine the causes, costs, and outcomes of endocrine malpractice litigation.

METHODS

Jury verdict reports from the U.S. civil court system from 1985 through 1991 were reviewed. Sixty-two malpractice cases were identified from 21 states.

RESULTS

The 62 cases were classified into three categories, totaling 63 adverse events: (1) complications (n = 34, 54%) from thyroid (n = 32, 51%) or parathyroid (n = 2, 3%) surgery; (2) delayed diagnosis (n = 22, 35%) of thyroid cancer (n = 11, 18%), adrenal tumors (n = 9, 14%), and hyperparathyroidism (n = 2, 3%); and (3) medical morbidity (n = 7, 11%) from radioactive iodine (n = 5, 8%) or from propylthiouracil (n = 2, 3%). Surgical injuries, mostly recurrent nerve injuries by general surgeons, accounted for the greatest number of cases and the highest cost of litigation.

CONCLUSIONS

Medical malpractice involving endocrine disease results in expensive litigation, a result of serious harm. Technical misadventures account for most cases, followed closely by delays in diagnosis. These data may aid design of risk prevention strategies in endocrine disease.

[Endocrine crises in patients with kidney diseases]

Among surgical patients renal diseases association with diabetes mellitus was found in 117, with thyroid affection in 82 patients. Twenty-six patients were treated for primary hyperparathyroidism, 46 were operated on for adrenal tumors: pheochromocytoma (23 cases), Conn's syndrome (3 cases). Hyperglycemic coma in patients with acute purulent renal diseases was primarily due to overlooked diabetes mellitus. Thyrotoxic crises emerged after urgent ureterolithotomy in a female patient suffering from toxic goiter, hypothyroid coma occurred in a male subject with undetected hypothyroidism following pyelolithotomy. Clinical variability of the symptoms, no attempts oriented on their detection led to diagnosis of pheochromocytoma, Conn's syndrome, primary hyperparathyroidism in emergency situations or at autopsy. Timely diagnosis and pathogenetic therapy of endocrine crises produced favourable outcomes.

[Recent progress in endocrine surgery: more refined and rational interventions for varied endocrine diseases]

Better understanding of pathogenesis and natural history of various endocrine diseases along with development of new and sensitive assays for accurate measurement of hormones and of modern image diagnostic procedures for clear demonstration of pathological tissues has enabled us to detect many kinds of endocrine diseases much more frequently than before and to perform a more refined and rational surgical intervention. Endocrine surgery is now a challenging and fascinating field of general surgery. This fact is best exemplified as follows: (1) different therapeutic approaches for intrathyroidal and extrathyroidal papillary carcinomas of the thyroid, (2) early detection and 131I treatment of clinically occult hematogenous metastasis of follicular carcinoma of the thyroid, (3) clinical usefulness of the serum calcitonin and CEA concentrations as sensitive tumor markers in the treatment of medullary thyroid carcinoma, (4) rational use of preoperative localization test and unilateral neck exploration for parathyroid adenoma, and specific surgical intervention for metastatic parathyroid carcinoma, (5) how to treat adrenal incidentalomas and a trial of subclassification of pheochromocytomas into epinephrine- and norepinephrine-secreting tumors, and (6) intraoperative localization of insulinoma by ultrasound and newly developed surgical approaches for gestrinoma.

Analysis of uncoupling protein and its mRNA in adipose tissue deposits of adult humans

Brown adipose tissue (BAT) is a specialized adipose tissue whose specific marker is the uncoupling protein (UCP). UCP and its mRNA were previously detected in the perirenal fat of several adult subjects undergoing surgery for pheochromocytoma. We have investigated the possible association of the presence of UCP and its mRNA with pathological conditions other than pheochromocytoma. We obtained adipose tissue from both the periadrenal and the perirenal regions of 36 subjects: group A: human infants (n = 6); group B: adult subjects (n = 11) undergoing surgery for pheochromocytoma; group C: adult subjects (n = 9) undergoing surgery for other endocrine pathologies; group D: adult patients (n = 10) operated for non-endocrine pathologies. In all subjects of group A UCP was detectable by Western analysis. Interestingly, in two newborns, we also found a positive signal for UCP in the peristernal and the retroperitoneal adipose tissues as well as in the perirenal fat. We also identified UCP in eight cases in group B, in five cases in group C and six cases in group D. The human H-UCP-0.5 genomic probe detected a typical BAT mRNA in the periadrenal adipose tissue of all subjects of groups B, C and D showing a positive Western blot. Our results confirm the presence of well-developed BAT in human infants, as well as in adults with pheochromocytoma. They also suggest that human BAT UCP and UCP mRNA are present in adult subjects in pathological conditions other than pheochromocytoma. It might be argued that certain hormones distinct from catecholamine could activate BAT development in human adults.(ABSTRACT TRUNCATED AT 250 WORDS)

The clinical and endocrine outcome to trans-sphenoidal microsurgery of nonsecreting pituitary adenomas

From 1962 to 1987, 126 patients underwent trans-sphenoidal surgery for primary treatment of pituitary adenomas unassociated with clinical or biochemical evidence of hormonal overproduction. There were 73 male and 53 female patients (mean age, 50 +/- 12 years). Before surgery, 56% of the patients (70 of 124) had headaches, 74% (94 of 126) had deterioration of vision, and 12% (15 of 126) had ophthalmoplegia. Endocrine evaluation revealed the presence of hypogonadism in 75% (87 of 115), adrenal insufficiency in 36% (46 of 126), and hypothyroidism in 18% (21 of 122). Plasma prolactin was increased in 65% (56 of 86) with a mean level of 39 +/- 14 micrograms/l (normal, 3 to 20 micrograms/l). Radiologic enlargement of the sella turcica was documented in all cases: 67% (84 of 126) had enclosed and 33% (42 of 126) had invasive adenomas. After surgery, vision was normalized or improved in 75% (71 of 94) of the patients. Thyroid, adrenal, and gonadal functions were improved in 14% (three of 22), 41% (19 of 46), 11% (ten of 87), were unchanged in 82% (100 of 122), 77% (97 of 126), 89% (102 of 115), and worsened in 15% (19 of 22), 8% (ten of 126), 3% (102 of 115), respectively. Permanent diabetes insipidus occurred in 5% (seven of 126). Two patients died during the immediate postoperative period. The recurrence rate in patients with a mean follow-up of 6.4 +/- 4.2 years was 21% (15 of 71). These data indicate that trans-sphenoidal microsurgery is an effective and safe initial treatment for patients with nonsecreting pituitary adenoma and may reverse hypopituitarism.

The role of adrenalectomy in Cushing's syndrome

Forty-four patients with Cushing's syndrome were treated by adrenalectomy between 1975 and 1989. Twenty patients had adrenal adenomas: 13 with obvious Cushing's syndrome and 7 whose disease was subclinical, detected after evaluation of an incidentally discovered adrenal mass (es). Twelve patients underwent bilateral adrenalectomies for Cushing's disease after failed transsphenoidal explorations and pituitary irradiation. Six patients had primary adrenal hyperplasia, five as manifestations of Carney's complex. Two others underwent bilateral adrenalectomies for ectopic adrenocorticotropic hormone from carcinoid tumors. Four patients had adrenocortical carcinoma treated with transabdominal adrenalectomy. Three are alive from 8 years to 5 months. There was one postoperative death (2.3%) caused by coagulopathy and multiple organ failure and three (7%) minor postoperative complications. Follow-up showed good to excellent results in 95% of patients. It is concluded that adrenalectomy provides prompt relief from the severe morbidity of Cushing's syndrome regardless of the cause. It is the treatment of choice for adrenal adenomas, carcinomas, primary hyperplasia, and selected patients with Cushing's disease.

Cytoreductive hepatic surgery for neuroendocrine tumors

We retrospectively reviewed 37 patients who underwent hepatic resection between 1970 and 1989 to evaluate the role of cytoreductive hepatic surgery in patients with metastatic neuroendocrine tumors (carcinoid, 24; islet cell, 13). Seventeen resections were curative (no gross residual tumor); nine patients had symptomatic endocrinopathies and seven patients had symptoms caused by the primary tumor. Eight of nine patients with symptomatic endorcrinopathies obtained complete relief of symptoms; five are alive with no evidence of disease at 2 to 82 months (mean, 26 months). Six of seven patients with symptoms caused by the primary tumor obtained complete relief; five are alive with no evidence of disease at 5 to 28 months (mean, 14 months). One symptom-free patient underwent curative hepatic resection 5 years after abdominoperineal resection for a rectal carcinoid. Twenty resections were palliative (gross residual tumor); 16 patients had symptomatic endocrinopathies and 4 patients had symptoms caused by the primary tumor. Eight of 16 patients with symptomatic endocrinopathies obtained complete relief; five are alive at 2 to 30 months (mean, 11 months), with a mean duration of complete relief of 6 months (3 to 12 months). All four patients who underwent resection for symptoms caused by the primary tumor obtained complete relief; two are alive and symptom free at 10 and 101 months. Our experience suggests that curative surgery should be considered in all patients with completely resectable metastatic disease and that palliative surgery, despite the short duration of complete relief, should be considered in selected patients because it delays and may reduce the subsequent need for medical therapy.

Reevaluation of pulmonary neoplasms resected as small cell carcinomas. Significance of distinguishing between well-differentiated and small cell neuroendocrine carcinomas

The clinicopathologic features of 50 cases of surgically resected small cell carcinoma were reevaluated (doubly blinded). Two pulmonary carcinomas were excluded because neuroendocrine features could not be demonstrated; two additional cases also were excluded because the tumors grossly invaded the chest wall and their pulmonary origin was not substantiated. Thirty-four tumors were confirmed to be small cell neuroendocrine carcinoma (SCNC). Only seven of 11 (64%) patients with T1N0,T2N0 tumors survived more than 1 year; one of 11 (9%) patients survived more than 2 years. In 12 cases, the diagnosis was changed to well-differentiated neuroendocrine carcinoma (WDNC). Of these, nine of nine (100%) patients with T1N0,T2N0 tumors survived more than 1 year; six of eight (75%) patients survived more than 2 years. These observations strongly indicate that a significant number of long-term survivors with the diagnosis of small cell carcinoma may, in fact, have a distinctly less aggressive type of pulmonary neuroendocrine carcinoma. It was concluded that the distinction between small cell and well-differentiated types of neuroendocrine carcinomas has significant prognostic and therapeutic implications.