1
|
Gao TP, Green RL, Kuo LE. Adrenalectomy Outcome Variations Across Different Functional Adrenal Tumors. J Surg Res 2024; 298:201-208. [PMID: 38626717 DOI: 10.1016/j.jss.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/20/2024] [Accepted: 03/21/2024] [Indexed: 04/18/2024]
Abstract
INTRODUCTION Adrenalectomy generally has favorable outcomes. It is unknown if patients with functional adrenal tumors experience different clinical outcomes than those with benign adrenal tumors, due to the presence of comorbid conditions secondary to the functional tumor. We investigated outcomes following open and laparoscopic adrenalectomy for benign nonfunctional (BNF) versus functional adrenal masses. METHODS Patients undergoing adrenalectomy were identified in the 2015-2020 National Surgical Quality Improvement Program database, then categorized as BNF, hyperaldosteronism, hypercortisolism, and pheochromocytoma. The primary outcome of interest was 30-d morbidity and secondary outcomes included 30-d mortality, 30-d readmission, and postoperative length of stay (LOS). Subgroup analysis was performed based upon surgical approach. Univariate analysis was performed, followed by multivariable logistic regression for individual outcomes that differed significantly between patients with BNF and functional neoplasm, factoring in patient demographics and operative approach with statistical significance on univariate analysis. Descriptive statistics and outcomes were analyzed using Pearson's χ2 test and Mann-Whitney U-test as appropriate. RESULTS There were 3291 patients with BNF while 484 had hyperaldosteronism, 263 hypercortisolism, and 46 pheochromocytomas. Within the laparoscopic group of 3615 (88.5%) of adrenalectomy patients, compared to BNF patients, patients with hyperaldosteronism had lower rates of postoperative morbidity (1.9% versus 5.2%, P < 0.001) and shorter LOS (1 d, interquartile range (IQR) [1-1] versus 1d IQR [1-2], P = 0.003); these persisted on multivariate analysis (OR 0.32, 95% confidence interval [CI] 0.14-0.74 and odds ratio 0.47, 95% CI 0.36-0.60, P < 0.001). Patients with hypercortisolism had higher morbidity (7.3% versus 5.2%, P < 0.001), 30-d readmission rates (5.3% versus 2.9%, P = 0.042) and longer LOS (2d, IQR [1-3] versus 1d, IQR [1-2, P < 0.001). On multivariate analysis, presence of hypercortisolism was independently associated with increased likelihood of readmission within 30 d (OR 2.20, 95% CI 1.11-2.99, P = 0.012) and longer LOS (>1 d) (OR 1.79, 95% CI 1.33-2.40, P < 0.001). Compared to BNF patients, patients with pheochromocytoma had higher rates of postoperative morbidity (6.2% versus 5.2%, P < 0.001). Within the open group of 469 (11.5% of adrenalectomy patients), there were no statistically significant differences in outcomes between patients with BNF and functional adrenal masses. CONCLUSIONS Outcomes after adrenalectomy performed for functional neoplasms differ based on surgical indication.
Collapse
Affiliation(s)
- Terry P Gao
- Department of General Surgery, Temple University Lewis Katz School of Medicine, Philadelphia Pennsylvania.
| | - Rebecca L Green
- Department of General Surgery, Temple University Lewis Katz School of Medicine, Philadelphia Pennsylvania
| | - Lindsay E Kuo
- Department of General Surgery, Temple University Lewis Katz School of Medicine, Philadelphia Pennsylvania
| |
Collapse
|
2
|
Saadi A, Mokadem S, Bedoui MA, Zaghbib S, Hermi A, Bellali M, Boussaffa H, Ayed H, Bouzouita A, Allouche M, Chakroun M, Slama RB. A cadaveric anatomical study of the adrenals: vascular relationship. Endocrine 2024; 83:483-487. [PMID: 37932646 DOI: 10.1007/s12020-023-03585-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/23/2023] [Indexed: 11/08/2023]
Abstract
The adrenal gland is a retroperitoneal organ with intimate relationships with neighboring organs but also with the large retroperitoneal vessels. Our aim was to study the vascular relationships of the adrenal gland with the large abdominal vessels. Our work is an anatomical dissection of 80 fresh cadaveric adrenals. The subjects didn't have a history of retroperitoneal surgery. Dissection conditions were similar to those in the living. All measurements were made in situ. On the right side, the average distance between the adrenal gland and the renal vein (DR) was 13 mm (0-20). In one case, the adrenal gland laid directly on the right renal vein (DR = 0). The average length L, over which the right adrenal gland entered behind the inferior vena cava (IVC), was 8 mm (0-12). In 4 cases, the right adrenal was lateral to the IVC and in 6 cases the length L exceeded 10 mm. On the left side, the mean distance DL, separating the adrenal gland from the left renal vein was 8 mm with extremes ranging from 0 mm to 18 mm. In eleven cases, the adrenal gland laid directly on the left renal vein. The right adrenal gland has a close relationship with the IVC and is often located behind it. This close relationship helps to explain the increased incidence of IVC lesions during surgery. The left adrenal gland has an intimate relationship with the left renal vein and often lies on top of it. This explains the risk of injury to the left renal pedicle during left adrenal surgery.
Collapse
Affiliation(s)
- Ahmed Saadi
- University of Tunis El Manar Faculty of Medicine of Tunis, Charles Nicolle Hospital, Urology Department, Tunis, Tunisia
| | - Seif Mokadem
- University of Tunis El Manar Faculty of Medicine of Tunis, Charles Nicolle Hospital, Urology Department, Tunis, Tunisia
| | - Mohamed Ali Bedoui
- University of Tunis El Manar Faculty of Medicine of Tunis, Charles Nicolle Hospital, Urology Department, Tunis, Tunisia.
| | - Selim Zaghbib
- University of Tunis El Manar Faculty of Medicine of Tunis, Charles Nicolle Hospital, Urology Department, Tunis, Tunisia
| | - Amine Hermi
- University of Tunis El Manar Faculty of Medicine of Tunis, Anatomy department, Tunis, Tunisia
| | - Mohammed Bellali
- University of Tunis El Manar Faculty of Medicine of Tunis, Charles Nicolle Hospital, Department of legal and forensic medicine, Tunis, Tunisia
| | - Hamza Boussaffa
- University of Tunis El Manar Faculty of Medicine of Tunis, Charles Nicolle Hospital, Urology Department, Tunis, Tunisia
| | - Haroun Ayed
- University of Tunis El Manar Faculty of Medicine of Tunis, Charles Nicolle Hospital, Urology Department, Tunis, Tunisia
| | - Abderrazek Bouzouita
- University of Tunis El Manar Faculty of Medicine of Tunis, Charles Nicolle Hospital, Urology Department, Tunis, Tunisia
| | - Mohamed Allouche
- University of Tunis El Manar Faculty of Medicine of Tunis, Charles Nicolle Hospital, Department of legal and forensic medicine, Tunis, Tunisia
| | - Marouene Chakroun
- University of Tunis El Manar Faculty of Medicine of Tunis, Charles Nicolle Hospital, Urology Department, Tunis, Tunisia
| | - Riadh Ben Slama
- University of Tunis El Manar Faculty of Medicine of Tunis, Charles Nicolle Hospital, Urology Department, Tunis, Tunisia
| |
Collapse
|
3
|
Gao RR, Chilukuri N, Rokhlin P, Shebrain S. Thirty day postoperative outcomes following laparoscopic adrenalectomy for functional adrenal tumors. Surg Endosc 2023; 37:7893-7900. [PMID: 37415017 DOI: 10.1007/s00464-023-10255-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/23/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Functional adrenal tumors (FATs) are rare and if left untreated, there is a substantial risk of morbidity and mortality due to uncontrolled excess hormone secretion. The three most common FATs are cortisone-producing tumors (hypercortisolism), aldosterone-producing tumors (hyperaldosteronism), and catecholamines-producing tumors (pheochromocytomas). The study aims to evaluate demographic characteristics and 30-day outcomes after laparoscopic adrenalectomy of FATs. METHODS Patients who underwent laparoscopic adrenalectomy for FATs were selected from the ACS-NSQIP database (2015-2017), and divided into three groups (hyperaldosteronism, hypercortisolism, and pheochromocytoma). Preoperative demographics, medical comorbidities, and 30-day postoperative outcomes among the three groups were analyzed using the chi-squared test, analysis of variance (ANOVA) and Kruskal-Wallis one-way analysis of variance. Multivariable logistic regression was performed to assess the effects independent variables on the likelihood of increased overall morbidity. RESULTS Of a total of 2410 patients who underwent laparoscopic adrenalectomy, 345 (14.3%) patients with FATs were included. Patients in the hypercortisolism group were younger, had higher proportion of females, had higher BMI, had a higher proportion of White ethnicity and had a higher proportion of diabetes. The hyperaldosteronism group had a higher proportion of Black ethnicity and a higher proportion of hypertension (HTN) requiring medication. Thirty day postoperative outcomes showed that the pheochromocytoma group had a higher rate of serious morbidity, overall morbidity, and highest readmission rates. There were three deaths, 1 in the pheochromocytoma and 2 in the hypercortisolism groups. Operative time (in minutes) was longer in the hypercortisolism group. Median length of stay was higher in hypercortisolism (2 days) and pheochromocytoma (1.5 day) groups. CONCLUSION Functional adrenal tumors show distinct variations in patient demographics and postoperative outcomes. It is essential to use this information during the preoperative period to optimize patients prior to intervention and counsel patients about potential postoperative outcomes.
Collapse
Affiliation(s)
- Raisa R Gao
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Dr., Kalamazoo, MI, 49007, USA.
| | - Nitin Chilukuri
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Dr., Kalamazoo, MI, 49007, USA
| | - Pnina Rokhlin
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Dr., Kalamazoo, MI, 49007, USA
| | - Saad Shebrain
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Dr., Kalamazoo, MI, 49007, USA
| |
Collapse
|
4
|
Hue JJ, Alvarado C, Bachman K, Wilhelm SM, Ammori JB, Towe CW, Rothermel LD. Outcomes of malignant pheochromocytoma based on operative approach: A National Cancer Database analysis. Surgery 2021; 170:1093-1098. [PMID: 33958205 DOI: 10.1016/j.surg.2021.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/30/2021] [Accepted: 04/01/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Malignant pheochromocytoma is often managed with adrenalectomy. Most literature focusing on postoperative outcomes are from single institutions. This study aimed to describe outcomes of adrenalectomy for malignant pheochromocytoma using a national database. We hypothesized that minimally invasive approaches might be associated with improved short-term outcomes but potentially inferior oncologic efficacy. METHODS Patients who underwent adrenalectomy for malignant pheochromocytoma were identified in the National Cancer Database (2010-2016). Patients were categorized as minimally invasive adrenalectomy or open adrenalectomy. Short- and long-term outcomes were compared. RESULTS A total of 276 patients underwent adrenalectomy for malignant pheochromocytoma: 50.7% open adrenalectomy and 49.3% minimally invasive adrenalectomy. Demographics were similar, except those who underwent open adrenalectomy had larger tumors compared to minimally invasive adrenalectomy (8.2 cm vs 4.7 cm; P < .001). Tumor size ≥6 cm was associated with a reduced likelihood of minimally invasive adrenalectomy (relative to open adrenalectomy) on multivariable regression (odds ratio = 0.23; P < .001). Open adrenalectomy was associated with longer duration of stay relative to minimally invasive adrenalectomy (6 vs 3 days; P < .001). Rates of positive margins, unplanned readmissions, or 30-/90-day mortalities were similar based on operative approach. Five-year survival rates were similar (open adrenalectomy 74.3%, minimally invasive adrenalectomy 79.1%). There was no association between overall survival and operative approach on multivariable Cox analysis when controlling for tumor size, laterality, and clinicodemographic variables. CONCLUSION Patients with larger malignant pheochromocytomas were more likely to undergo an open adrenalectomy. With the exception of an increased duration of stay, there was no difference in short- or long-term postoperative outcomes. These data suggest that minimally invasive adrenalectomy appears safe among tumors <6 cm.
Collapse
Affiliation(s)
- Jonathan J Hue
- Department of Surgery, University Hospitals Cleveland Medical Center, OH. https://twitter.com/jj_hue
| | - Christine Alvarado
- Department of Surgery, University Hospitals Cleveland Medical Center, OH. https://twitter.com/calvaradomd
| | - Katelynn Bachman
- Department of Surgery, University Hospitals Cleveland Medical Center, OH
| | - Scott M Wilhelm
- Department of Surgery, University Hospitals Cleveland Medical Center, OH
| | - John B Ammori
- Department of Surgery, University Hospitals Cleveland Medical Center, OH. https://twitter.com/ammorijohn
| | - Christopher W Towe
- Department of Surgery, University Hospitals Cleveland Medical Center, OH
| | - Luke D Rothermel
- Department of Surgery, University Hospitals Cleveland Medical Center, OH.
| |
Collapse
|
5
|
Limberg J, Stefanova D, Ullmann TM, Thiesmeyer JW, Buicko JL, Finnerty BM, Zarnegar R, Fahey TJ, Beninato T. Not all laparoscopic adrenalectomies are equal: analysis of postoperative outcomes based on tumor functionality. Surg Endosc 2020; 35:2601-2606. [PMID: 32495185 DOI: 10.1007/s00464-020-07678-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/27/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Laparoscopic adrenalectomy is known to have a low complication rate; however, the influence of functional tumor subtype on postoperative outcomes is not well defined. METHODS Patients undergoing laparoscopic adrenalectomy for benign adrenal tumors between 2009 and 2017 were selected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Patient demographics, postoperative outcomes, and length of stay were compared between tumor subtypes. RESULTS A total of 3946 patients underwent a laparoscopic adrenalectomy during the study period; 3214 (81.5%) were performed for non-functional adenomas, and 732 (18.6%) for functional tumors-467 (64%) aldosteronomas, 184 (25%) cortisol-producing adenomas, and 81 (11%) pheochromocytomas. The risk of any complication was highest for patients with Cushing's (6.5%) and lowest with Conn's syndrome (1.1%) compared to other lesions (3.7% pheochromocytoma, 5.3% adenoma, p < 0.001). Among the patients with functional tumors, those with cortisol-producing adenomas had the highest rates of both deep surgical site infection (1.6%, p = 0.026) and urinary tract infection (2.2%, p = 0.029), whereas myocardial infarction was most prevalent in patients with pheochromocytoma (2.5%, p = 0.012). When adjusted for demographic differences, BMI, and comorbidity scores, no tumor type was associated with increased complication rate; instead aldosteronoma (vs. benign adenoma) was independently predictive of fewer adverse events [0.3 (95% CI 0.1-0.7), p = 0.004] and a shorter length of hospital stay [0.6 (95% CI 0.4-0.8), p = 0.001]. The overall mortality rate was low at 0.4%, although significantly higher in Cushing's patients (2.2%, p = 0.015). CONCLUSIONS Laparoscopic adrenalectomy is a safe operation with low mortality and complication rates. However, postoperative risks differ between tumor subtype, so patients should be counseled accordingly.
Collapse
Affiliation(s)
- Jessica Limberg
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA.
| | - Dessislava Stefanova
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA
| | - Timothy M Ullmann
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA
| | - Jessica W Thiesmeyer
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA
| | - Jessica L Buicko
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA
| | - Brendan M Finnerty
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA
| | - Toni Beninato
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA
| |
Collapse
|
6
|
Lateral Transperitoneal Adrenalectomy Versus Posterior Retroperitoneoscopic Adrenalectomy for Benign Adrenal Gland Disease: Randomized Controlled Trial at a Single Tertiary Medical Center. Ann Surg 2020; 269:842-848. [PMID: 29189215 DOI: 10.1097/sla.0000000000002603] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to compare the surgical outcomes of lateral transperitoneal adrenalectomy (LTA) and posterior retroperitoneoscopic adrenalectomy (PRA) for benign adrenal tumor. BACKGROUND Although LTA is the standard treatment for benign adrenal gland tumor, PRA has recently gained popularity. Studies comparing the surgical outcomes of the 2 approaches have reported conflicting findings and thus it remains unclear which approach is superior. METHODS This trial was conducted between September 2012 and February 2016. Patients were randomized to either LTA or PRA groups in a 1:1 ratio using web-based randomization. The primary outcome was operative time, and the secondary outcomes were blood loss, intraoperative hemodynamic stability, postoperative pain, recovery of bowel movement, and complication rates. This trial was registered with ClincalTrials.gov, number NCT01676025. RESULTS A total of 83 patients were randomly assigned to the LTA group (n = 42) or the PRA group (n = 41). Median follow-up was 31.3 months. The mean operative times of LTA and PRA were comparable (59.7 ± 18.6 vs 67.6 ± 28.7 minutes, P = 0.139). Logistic regression analysis showed that male sex [odds ratio (OR) = 4.20] and pheochromocytoma (OR = 5.06) were associated with an operative time ≥60 minutes. There were no differences in the secondary outcomes between the groups. One patient in the PRA group required open conversion. CONCLUSION Both LTA and PRA were performed safely with similar operative outcomes, and thus are comparable options for the treatment of benign adrenal gland tumor.
Collapse
|
7
|
Preoperative risk factors of hemodynamic instability during laparoscopic adrenalectomy for pheochromocytoma. Surg Endosc 2015; 30:2984-93. [DOI: 10.1007/s00464-015-4587-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 09/19/2015] [Indexed: 12/11/2022]
|
8
|
Radiofrequency Ablation of Functioning Adrenal Adenomas: Preliminary Clinical and Laboratory Findings. J Vasc Interv Radiol 2015; 26:1459-64. [PMID: 26231110 DOI: 10.1016/j.jvir.2015.06.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 06/08/2015] [Accepted: 06/12/2015] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To evaluate clinical and laboratory findings in patients undergoing radiofrequency (RF) ablation for functioning adrenal adenomas. MATERIALS AND METHODS Eleven adult patients, nine with Conn syndrome and two with Cushing syndrome, underwent percutaneous computed tomography-guided RF ablation for benign adrenal neoplasms. Systolic, diastolic, and mean blood pressure and the number of classes of antihypertensive drugs used by each patient were analyzed before and 1, 4, and 12 weeks after the procedure. Serum hormone levels were analyzed within 30 days before and 12 weeks after the procedure. RESULTS Of the nine patients with Conn syndrome, eight showed normal serum aldosterone levels after the procedure and one patient had a nodule located very close to the inferior vena cava, resulting in incomplete ablation. The two patients with Cushing syndrome had normal serum and salivary cortisol levels after the procedure. Mean aldosterone concentration at baseline was 63.3 ng/dL ± 28.0 and decreased to 13.3 ng/dL ± 13.5 at 12 weeks postoperatively (P = .008). Systolic, diastolic, and mean blood pressures decreased significantly in the first week after the procedure (P < .001) and remained stable during further follow-up. CONCLUSIONS In patients with Conn syndrome or Cushing syndrome, percutaneous RF ablation of functioning adrenal adenomas may result in normalization of hormone secretion, improvement in blood pressure, and reduced need for antihypertensive drugs.
Collapse
|
9
|
Kiriakopoulos A, Petralias A, Linos D. Posterior retroperitoneoscopic versus laparoscopic adrenalectomy in sporadic and MENIIA pheochromocytomas. Surg Endosc 2014; 29:2164-70. [PMID: 25303922 DOI: 10.1007/s00464-014-3912-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 05/16/2014] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Retroperitoneal adrenalectomy (PRA) comprises an alternative approach in the management of adrenal tumors that has been set as the treatment of choice in our Institution. We assess the impact of PRA the management of hereditary and sporadic pheochromocytomas comparing its outcomes to the laparoscopic technique, in a case-controlled setting. PATIENTS AND METHODS From May 2008 to January 2013, 17 patients [5 males and 12 females, mean age: 51 yrs (range 26-73)] with pheochromocytomas underwent PRA. Demographics, tumor characteristics, operative time, complications, hospital stay, and postoperative pain (based on VAS score at days 1 and 3) were compared to 17 selected laparoscopic patient controls [7 males and 10 females, mean age 49 yrs (range 25-64)]. RESULTS 17 patients, 11 with the sporadic form and 6 with MENIIA associated pheochromocytomas, comprised the retroperitoneoscopic group. 19 pheochromocytomas with a mean size 3.7 cm (range 1.7-7.0) at a mean operative time: 105.6 min (range 60-180) were accordingly excised. In the laparoscopic group, 13 patients had sporadic pheochromocytomas, whereas 4 patients had MENIIA syndrome. Mean tumor size of the laparoscopic series was 5.1 cm (range 1.7-8.5) at a mean operative time of 137 min (range 75-195). No mortality or conversions were encountered in both groups. No blood transfusions were needed. Mean visual analog scale pain scores were significantly lower for the retroperitoneoscopic group both on days 1 and 3 [0.94 (0-3) vs 4.15 (3-6), p < 0.001 and 0.06 (0-1) vs 3.5 (2-6) p < 0.001] respectively. Mean hospital stay for the patients of the retroperitoneoscopic group was significantly better than the laparoscopic group [(2.1 ± 0.24 days vs 40 ± 0.70 days) p < 0.001]. CONCLUSIONS Retroperitoneoscopic adrenalectomy is associated with excellent clinical results in the management of sporadic and hereditary pheochromocytomas. Moreover, it appears to be superior to the laparoscopic approach, because it is faster and affords the patient with less pain and shorter hospital stay.
Collapse
|
10
|
Porpiglia F, Fiori C, Bertolo R, Cattaneo G, Amparore D, Morra I, Didio M, De Luca S, Scarpa RM. Mini-retroperitoneoscopic Adrenalectomy: Our Experience After 50 Procedures. Urology 2014; 84:596-601. [DOI: 10.1016/j.urology.2014.04.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 04/23/2014] [Accepted: 04/26/2014] [Indexed: 10/25/2022]
|
11
|
Kiernan CM, Shinall MC, Mendez W, Peters MF, Broome JT, Solorzano CC. Influence of adrenal pathology on perioperative outcomes: a multi-institutional analysis. Am J Surg 2014; 208:619-25. [PMID: 25129428 DOI: 10.1016/j.amjsurg.2014.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 05/17/2014] [Accepted: 06/03/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Endoscopic or open adrenalectomies are performed for variable pathologies. We investigated if adrenal pathology affects perioperative outcomes independent of operative approach. METHODS A multi-institutional retrospective review of 345 adrenalectomies was performed. A multivariate analysis was utilized. RESULTS Pathology groups included benign non-pheochromocytoma tumors (50.4%), pheochromocytomas (41%), adrenocortical carcinomas (5.2%), and metastatic tumors (3.4%). Controlling for age, body mass index, tumor size, procedure type, and pathology, pheochromocytomas exhibited greater blood loss (92 mL more, P = .007) and operative times (33 min more, P < .001) than benign non-pheochromocytoma tumors. Metastatic tumors demonstrated longer operative times (53 min more, P = .013). Open adrenalectomy was associated with greater blood loss (396 mL more, P = .001), transfusion requirement (P = .021), operative times (79 min more, P < .001), hospital stay (6.6 days more, P < .001) and complications (P < .001) when compared with endoscopic adrenalectomy. CONCLUSIONS The type of adrenal pathology appears to influence blood loss and operative time but not complications in patients undergoing adrenalectomy. Open adrenalectomy remains a major driver of adverse perioperative outcomes.
Collapse
Affiliation(s)
- Colleen M Kiernan
- Division of General Surgery, Vanderbilt University, Nashville, TN, USA.
| | - Myrick C Shinall
- Division of General Surgery, Vanderbilt University, Nashville, TN, USA
| | - William Mendez
- Division of Endocrine Surgery, University of Puerto Rico, San Juan, PR, USA
| | - Mary F Peters
- Department of Anesthesiology, Vanderbilt University, Nashville, TN, USA
| | - James T Broome
- Division of Surgical Oncology/Endocrine Surgery, Vanderbilt University, Nashville, TN, USA
| | - Carmen C Solorzano
- Division of Surgical Oncology/Endocrine Surgery, Vanderbilt University, Nashville, TN, USA
| |
Collapse
|
12
|
Vilallonga R, Zafon C, Fort JM, Mesa J, Armengol M. Past and present in abdominal surgery management for Cushing's syndrome. SAGE Open Med 2014; 2:2050312114528905. [PMID: 26770719 PMCID: PMC4607216 DOI: 10.1177/2050312114528905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 02/24/2014] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Data on specific abdominal surgery and Cushing's syndrome are infrequent and are usually included in the adrenalectomy reports. Current literature suggests the feasibility and reproducibility of the surgical adrenalectomies for patients diagnosed with non-functioning tumours and functioning adrenal tumours including pheochromocytoma, Conn's syndrome and Cushing's syndrome. DISCUSSION Medical treatment for Cushing's syndrome is feasible but follow-up or clinical situations force the patient to undergo a surgical procedure. Laparoscopic surgery has become a gold standard nowadays in a broad spectrum of pathologies. Laparoscopic adrenalectomies are also standard procedures nowadays. However, despite the different characteristics and clinical disorders related to the laparoscopically removed adrenal tumours, the intraoperative and postoperative outcomes do not significantly differ in most cases between the different groups of patients, techniques and types of tumours. Tumour size, hormonal type and surgeon's experience could be different factors that predict intraoperative and postoperative complications. Transabdominal and retroperitoneal approaches can be considered. Outcomes for Cushing's syndrome do not differ depending on the surgical approach. Novel technologies and approaches such as single-port surgery or robotic surgery have proven to be safe and feasible. CONCLUSION Laparoscopic adrenalectomy is a safe and feasible approach to adrenal pathology, providing the patients with all the benefits of minimally invasive surgery. Single-port access and robotic surgery can be performed but more data are required to identify their correct role between the different surgical approaches. Factors such as surgeon's experience, tumour size and optimal technique can affect the outcomes of this surgery.
Collapse
Affiliation(s)
- Ramon Vilallonga
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Universitary Hospital Vall d’Hebron, Center of Excellence for the EAC-BC, Barcelona, Spain
| | - Carles Zafon
- Department of Endocrinology, Universitary Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Diabetes and Metabolism Research Unit (VHIR), Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), ISCIII, Barcelona, Spain
| | - José Manuel Fort
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Universitary Hospital Vall d’Hebron, Center of Excellence for the EAC-BC, Barcelona, Spain
| | - Jordi Mesa
- Department of Endocrinology, Universitary Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Diabetes and Metabolism Research Unit (VHIR), Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), ISCIII, Barcelona, Spain
| | - Manel Armengol
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Universitary Hospital Vall d’Hebron, Center of Excellence for the EAC-BC, Barcelona, Spain
| |
Collapse
|
13
|
Yuan X, Wang D, Zhang X, Cao X, Bai T. Retroperitoneal Laparoendoscopic Single-Site Adrenalectomy for Pheochromocytoma: Our Single Center Experiences. J Endourol 2014; 28:178-83. [PMID: 24004249 DOI: 10.1089/end.2013.0488] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Xiaobin Yuan
- First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Dongwen Wang
- First Clinical Medical College, Shanxi Medical University, Taiyuan, China
- Department of Urology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Xuhui Zhang
- Department of Urology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Xiaoming Cao
- Department of Urology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Tao Bai
- Department of Pathology, First Hospital of Shanxi Medical University, Taiyuan, China
| |
Collapse
|
14
|
Stefanidis D, Goldfarb M, Kercher KW, Hope WW, Richardson W, Fanelli RD. SAGES guidelines for minimally invasive treatment of adrenal pathology. Surg Endosc 2013; 27:3960-80. [PMID: 24018761 DOI: 10.1007/s00464-013-3169-z] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 08/02/2013] [Indexed: 02/07/2023]
Affiliation(s)
- Dimitrios Stefanidis
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, CMC Surgical Specialty Center, Suite 300, 1025 Morehead Medical Plaza, Charlotte, NC, 28204, USA,
| | | | | | | | | | | | | |
Collapse
|
15
|
Carter YM, Mazeh H, Sippel RS, Chen H. Safety and feasibility of laparoscopic resection for large (≥ 6 CM) pheochromocytomas without suspected malignancy. Endocr Pract 2013; 18:720-6. [PMID: 22982788 DOI: 10.4158/ep12014.or] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine whether laparoscopic adrenalectomy in patients without radiologic evidence of cancer compromises the perioperative and long-term outcomes in patients with large (≥ 6 cm) pheochromocytomas. METHODS We analyzed a prospective adrenal database of consecutive patients who underwent adrenalectomy at our institution between September 2000 and September 2010. Patients with diagnosed pheochromocytoma who underwent laparoscopic adrenalectomy were included. Patients with tumors smaller than 6 cm were compared with those presenting with tumors 6 cm or larger. RESULTS One hundred fifty-seven patients underwent adrenalectomy, and there were 32 catecholamine-secreting tumors. Of the 33, 7 were excluded from the study because of open surgery. Thus, 25 patients presented with 26 pheochromocytomas and underwent laparoscopic adrenalectomy. Thirteen of the 25 patients (52%) were women. Mean age (± standard error of the mean) was 53 ± 3 years. Mean tumor size was 5.2 ± 0.5 cm, and 11 pheochromocytomas (42%) were 6 cm or larger. Tumor size was significantly different between the large pheochromocytoma and the small pheochromocytoma groups (7.6 ± 0.4 vs 3.6 ± 0.4 cm, P<.001), but there was no significant difference in intraoperative complications, estimated blood loss, cancer diagnosis, or recurrence. The length of stay was comparable between the 2 cohorts, and there were no incidents of capsular invasion or adverse cardiovascular events. CONCLUSION Laparoscopic adrenalectomy of pheochromocytomas larger than 6 cm is feasible and safe with comparable results to those achieved with laparoscopic adrenalectomy in patients with smaller pheochromocytomas.
Collapse
Affiliation(s)
- Yvette M Carter
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin 53792, USA
| | | | | | | |
Collapse
|
16
|
Ip JCY, Lee JC, Sidhu SB. Laparoscopic Adrenalectomy: The Transperitoneal Approach. CURRENT SURGERY REPORTS 2012. [DOI: 10.1007/s40137-012-0002-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
17
|
Lin YC, Lee HY, Juang GD, Yeh CH, Cheng YH, Chuo KY, Chen HE, Tsai TF, Hwang TIS. Technical modification of retroperitoneal laparoscopic adrenalectomy for primary hyperaldosteronism and clinical outcomes. Asian J Surg 2012; 36:20-5. [PMID: 23270821 DOI: 10.1016/j.asjsur.2012.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Revised: 05/09/2012] [Accepted: 08/09/2012] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND/OBJECTIVE Standard laparoscopic adrenalectomy requires early control of the main adrenal vein; however, the small retroperitoneal working space is challenging for beginners to perform this maneuver. We report a technical modification of retroperitoneal laparoscopic adrenalectomy (RLA) for primary hyperaldosteronism (PHA) and the clinical outcomes. METHODS A total of 38 RLAs were performed for the patients with PHA. The patients were placed in true lateral position with mild bending to expand the surgical field. Instead of attempting to control the main adrenal vein initially, we adopted a technical modification that manipulating and freeing the gland first before controlling the main adrenal vein. RESULTS The RLAs were successfully performed in all but one case, which was converted to open surgery due to pancreatic injury. Mean operative time was 124 minutes and estimated blood loss was 74 ml. Mean maximal fluctuation of systolic blood pressure was 29 mmHg. For the right-side RLA, less operative time (113.5 vs. 137.9 minutes) and estimated blood loss (59.5 vs. 91.2 ml) were noted compared with the left-side procedure. Postoperative complications included cerebrovascular accident in one patient, one surgical site hematoma, and two patients had postoperative fever. Potassium level returned to normal in all patients and 70% of the patients reduced their antihypertensives. CONCLUSION Technical modification RLA for PHA without initial control of the main adrenal vein is a safe and feasible procedure. No vigorous blood pressure fluctuation was intraoperatively noted. No vascular injury occurred. Moreover, the right-side procedure became easier.
Collapse
Affiliation(s)
- Yi-Chia Lin
- Division of Urology, Department of Surgery, Shin Kong WHS Memorial Hospital, Taipei, Taiwan, ROC
| | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Shimabuku M, Sasaki A, Higa M, Kakazu M, Asato M, Shiroma H. Single-incision laparoscopic adrenalectomy for primary aldosteronism: report of a case. Surg Today 2011; 41:1306-9. [PMID: 21874437 DOI: 10.1007/s00595-010-4430-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Accepted: 08/20/2010] [Indexed: 01/09/2023]
Abstract
We herein report the first case of a single-incision laparoscopic access (SILA) adrenalectomy in Japan. A 74-year-old woman who was a hepatitis B virus carrier was referred to our hospital because of an abnormal screening result during a routine health checkup. Abdominal computed tomography and an endocrinologic workup revealed a 2-cm left adrenal tumor with primary aldosteronism. We prioritized the safety of the SILA adrenalectomy by choosing a left lower abdominal approach. A SILS port was inserted through a 2.5-cm incision. An ultrasonic coagulator was the main tool used during the surgical procedure. The duration of the surgery was 105 min and the blood loss was 1 ml. This result was comparable to that of a conventional laparoscopic adrenalectomy. Based on our experience, an SILA adrenalectomy is thus considered to be feasible and safe, with better cosmetic results and a greater overall patient satisfaction than that of a conventional laparoscopic adrenalectomy. However, further studies will be necessary before the universal adoption of this new technique can be considered.
Collapse
Affiliation(s)
- Masamori Shimabuku
- Department of Surgery, Tomishiro Central Hospital, 25 Ueta, Tomishiro, Okinawa, 901-0243, Japan
| | | | | | | | | | | |
Collapse
|
19
|
Bergamini C, Martellucci J, Tozzi F, Valeri A. Complications in laparoscopic adrenalectomy: the value of experience. Surg Endosc 2011; 25:3845-51. [DOI: 10.1007/s00464-011-1804-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Accepted: 05/19/2011] [Indexed: 12/13/2022]
|
20
|
Nau P, Demyttenaere S, Muscarella P, Narula V, Hazey JW, Ellison EC, Melvin WS. Pheochromocytoma does not increase risk in laparoscopic adrenalectomy. Surg Endosc 2010; 24:2760-4. [DOI: 10.1007/s00464-010-1042-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Accepted: 03/13/2010] [Indexed: 10/19/2022]
|
21
|
Perioperative haemodynamic changes in patients undergoing laparoscopic adrenalectomy for phaeochromocytomas and other adrenal tumours. Surgeon 2010; 8:9-14. [DOI: 10.1016/j.surge.2009.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
22
|
Perry KA, El Youssef R, Pham TH, Sheppard BC. Laparoscopic adrenalectomy for large unilateral pheochromocytoma: experience in a large academic medical center. Surg Endosc 2009; 24:1462-7. [PMID: 20033709 DOI: 10.1007/s00464-009-0801-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Accepted: 11/11/2009] [Indexed: 01/28/2023]
Abstract
BACKGROUND Laparoscopic adrenalectomy is the treatment of choice for most adrenal lesions. Concerns have persisted about its application to large pheochromocytomas due to reports of hemodynamic instability, difficult dissection, and tumor spillage. METHODS Thirty patients underwent laparoscopic adrenalectomy for unilateral pheochromocytoma between 1998 and 2006. Outcome measures including operative time, blood loss, intraoperative hemodynamic instability, conversion rate, complications, and disease recurrence were analyzed based on tumor size. RESULTS Twenty-two patients had small tumors and eight had large lesions. These groups did not differ in terms of operative time, blood loss, conversion rate, length of stay or complication rate. Intraoperative hemodynamic instability occurred in 56.7% of cases, but was not different between groups. There were no recurrences in either group. CONCLUSIONS Laparoscopic adrenalectomy is a safe and effective treatment for large pheochromocytomas. Intraoperative hemodynamic instability remains a frequent occurrence regardless of tumor size. There were no cases of disease recurrence or iatrogenic pheochromocytosis.
Collapse
Affiliation(s)
- Kyle A Perry
- Department of Surgery, Oregon Health and Science University, OHSU M/C L223A, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | | | | | | |
Collapse
|
23
|
Kazaryan AM, Marangos IP, Rosseland AR, Røsok BI, Villanger O, Pinjo E, Pfeffer PF, Edwin B. Laparoscopic adrenalectomy: Norwegian single-center experience of 242 procedures. J Laparoendosc Adv Surg Tech A 2009; 19:181-9. [PMID: 19216698 DOI: 10.1089/lap.2008.0286] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The last 15 years have been characterized by a rapid expansion of minimally invasive surgery as treatment for adrenal diseases. During these years, both indications and surgical techniques have shown improvements. This study analyzed an 11-year single-center experience with laparoscopic adrenalectomy. MATERIALS AND METHODS Between January 1997 and April 2008, 242 laparoscopic adrenalectomies were performed in 220 patients at Rikshospitalet University Hospital. Of these, 192 patients were operated on for benign lesions, 23 for malignant lesions, and in 5 cases "en bloc" adrenalectomies were performed. Benign lesions included 136 hormonally active lesions (41 pheochromocytomas, 48 Conn adenomas, 25 Cushing adenomas, and 18 patients with Cushing's disease) and 56 with hormonally inactive lesions (among them, 47 nonfunctional adenomas). Malignant lesions included 16 adrenal metastases and 7 adrenocortical carcinomas. RESULTS All adrenalectomies were completed laparoscopically. The median time of unilatateral adrenalectomy was 85 (range, 35-325) minutes. The median blood loss was 0 (range, 0-1100) mL. There were 6 intraoperative and 7 postoperative minor complications. The number of complications did not differ between the types of adrenal pathology. Only 19% of the patients required opioids postoperatively. Per- and postoperative parameters were homogeneous among patients with different adrenal lesions. The patients with adrenocortical carcinoma had a distinctive intraoperative course with an evidently longer operative time and higher blood loss. The median postoperative hospital stay was 2 (range, 1-15) days. Hospital stay was the only postoperative parameter where a difference was found between patients with different adrenal lesions. The patients with carcinoma, pheochromocytoma, and Cushing's disease had the longest median postoperative stay, respectively, 5 (range, 2-6), 3 (range, 1-15), and 3 (range, 2-6) days. CONCLUSIONS Laparoscopic adrenalectomy is a safe, effective procedure providing improved fast and uncomplicated patient recovery independent of the type of adrenal lesion. Laparoscopic adrenalectomy can be easily introduced and may soon replace traditional open surgery in specialized centers.
Collapse
|
24
|
Morris L, Ituarte P, Zarnegar R, Duh QY, Ahmed L, Lee J, Inabnet W, Meyer-Rochow G, Sidhu S, Sywak M, Yeh M. Laparoscopic adrenalectomy after prior abdominal surgery. World J Surg 2008; 32:897-903. [PMID: 18228091 DOI: 10.1007/s00268-007-9438-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Compared with the open procedure, laparoscopic adrenalectomy (LA) is associated with decreased operative time, perioperative complications, and hospital stay. Some regard prior abdominal surgery as a contraindication to LA or suggest a retroperitoneoscopic approach. We studied the effect of prior abdominal surgery on the feasibility and safety of transabdominal LA. METHODS We retrospectively analyzed 246 consecutive LAs performed at four academic centers from 2002 to 2006. Cases were grouped according to prior abdominal surgery (PAS) (n=92, 37%) or no prior surgery (NPS) (n=154, 63%). Statistical power was greater than 0.90 to detect the following differences in endpoints: conversion 2%, operating time 22%, and complications 2%. RESULTS Mean tumor size was 3.3 cm, 8.1% of tumors were larger than 7 cm, and 20% were pheochromocytomas. Prior operations were upper abdominal (37%), lower abdominal (48%), or laparoscopic (15%). There were nine conversions (3.7%), one in the PAS group and eight in the NPS group (p=0.14), with conversions related to large tumor size and pheochromocytoma (both p<0.01). Operating time was 158+/-59 min across groups. The subgroup with prior upper abdominal surgery had nonsignificantly longer operating times compared with the NPS group (183 vs. 165 min, p=0.16). Operative blood loss was 67+/-84 ml and the perioperative complication rate was 12.2%, with no differences between groups. CONCLUSION Prior abdominal surgery does not impede transabdominal LA. More than one-third of patients requiring adrenalectomy will have had prior abdominal surgery, and these patients should not be denied the benefits of a laparoscopic procedure.
Collapse
Affiliation(s)
- Lilah Morris
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Liao CH, Chueh SC. Laparoscopic Adrenalectomy for a 6-cm Left Adrenal Pheochromocytoma with Needlescopic Instruments. J Endourol 2008; 22:1949-51; discussion 1953. [DOI: 10.1089/end.2008.9770] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Chun-Hou Liao
- Division of Urology, Department of Surgery, Cardinal Tien Hospital, Taipei, Taiwan
| | - Shih-Chieh Chueh
- Department of Urology, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| |
Collapse
|
26
|
Strebel RT, Müntener M, Sulser T. Intraoperative complications of laparoscopic adrenalectomy. World J Urol 2008; 26:555-60. [PMID: 18481069 DOI: 10.1007/s00345-008-0272-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Accepted: 04/19/2008] [Indexed: 12/12/2022] Open
Abstract
A laparoscopic or retroperitoneoscopic access to the adrenal gland is the standard of care for adrenalectomy in most cases. Although in laparoscopic adrenalectomy the approach is minimally invasive, the procedure is challenging. This is reflected in the scope of possible complications. The surgeon must consider complications related to the anatomical topography of the adrenal gland, which typically encompasses the complications known from open surgery and complications related to the minimal invasive access. In this topic paper we will address the most frequently encountered complications of adrenalectomy: vascular injuries, injuries of the bowel, pleural tears, and injuries to the liver, spleen and pancreas. Fortunately, these complications occur rarely. However, many of these complications can have devastating consequences. Therefore, it's the surgeon's obligation to be aware of the possible complications he might encounter during laparoscopic adrenalectomy. This awareness is essential for their prevention and it helps the laparoscopic surgeon to identify complications intraoperatively.
Collapse
Affiliation(s)
- Raeto T Strebel
- Department of Urology, Kantonsspital Graubünden, Loëstr. 170, 7000, Chur, Switzerland.
| | | | | |
Collapse
|
27
|
Tiyadath BN, Sukumar S, Saheed CSM, Hattangadi SB. Laparoscopic adrenalectomy --- is it any different in phaeochromocytoma and non-phaeochromocytoma? Asian J Surg 2008; 30:244-9. [PMID: 17962126 DOI: 10.1016/s1015-9584(08)60033-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Laparoscopic adrenalectomy (LA) for phaeochromocytoma is a feasible, safe and effective treatment. The effects of associated catecholamine release render LA more challenging, although with comparable morbidity to LA for other diseases of the adrenal gland. METHODS Data from case records of 44 patients who underwent LAs between May 2002 and May 2006 were analysed retrospectively. The patients were divided into a phaeochromocytoma group (Group I) and a non-phaeochromocytoma group (Group II). The aim of this study was to assess the operative course and outcome of LA in the two groups. RESULTS The mean operating time and blood loss were slightly higher in LA for phaeochromocytomas compared to LA for other pathologies, but these differences were not statistically significant. The mean hospital stay was 3.84 days in both groups. The phaeochromocytoma group had a slightly higher complication rate of 21% compared to 12%. None of the procedures needed open conversion. A terminal hand assist was employed in two patients in Group I and one patient in Group II. Two patients with bilateral phaeochromocytoma had single stage bilateral LA. CONCLUSION LA is feasible and effective in phaeochromocytoma. It is associated with a slightly longer operating time, more blood loss and complications when compared with non-phaeochromocytoma masses. LA can be done in a single operation for bilateral masses. Terminal hand assist is a viable and effective option for very large masses.
Collapse
Affiliation(s)
- Balagopal Nair Tiyadath
- Department of Urology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India.
| | | | | | | |
Collapse
|
28
|
Liao CH, Lai MK, Li HY, Chen SC, Chueh SC. Laparoscopic adrenalectomy using needlescopic instruments for adrenal tumors less than 5cm in 112 cases. Eur Urol 2007; 54:640-6. [PMID: 18164803 DOI: 10.1016/j.eururo.2007.12.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Accepted: 12/14/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To examine the safety and efficacy of laparoscopic adrenalectomy with needlescopic instruments for most adrenal tumors less than 5cm. METHODS Transperitoneal laparoscopic adrenalectomy with needlescopic instruments for 112 patients with presumptively benign adrenal tumors < 5cm were enrolled from July 2000 to February 2005. Operative time, blood loss, conversion and complication rates, and postoperative data were analyzed by appropriate statistical methods. RESULTS All 112 operations were completed without any mortality or reoperation. Mean operative time was 151min and mean blood loss was 30ml. Only one patient required a blood transfusion and application of a hand-assisted device. Conversion to conventional laparoscopic instruments was necessary in another five patients (4.5%). The operative time of the latter 100 cases (147+/-5.1min, mean+/-standard error of mean) was significantly shorter than that of the initial 12 cases (183+/-8.8min, p=0.001). Larger tumors, previous abdominal surgery, and pheochromocytoma group were independent risk factors of a longer operative time. Except for one leiomyosarcoma, all other tumors were benign adrenal pathologies (57 aldosterone-producing adenomas, 23 Cushing's adenomas, 12 pheochromocytomas, and 20 incidentalomas). CONCLUSION The safety and effectiveness of laparoscopic adrenalectomy employing needlescopic instruments for most adrenal tumors less than 5cm was feasible with acceptable operative time. Pheochromocytomas can also be managed with a longer operative time. Patients with previous upper midline or ipsilateral upper quadrant open surgery might not be suitable candidates for such a technique.
Collapse
Affiliation(s)
- Chun-Hou Liao
- Division of Urology, Department of Surgery, Cardinal Tien Hospital, Taipei, Taiwan
| | | | | | | | | |
Collapse
|
29
|
Pang TC, Bambach C, Monaghan JC, Sidhu SB, Bune A, Delbridge LW, Sywak MS. Outcomes of laparoscopic adrenalectomy for hyperaldosteronism. ANZ J Surg 2007; 77:768-73. [PMID: 17685956 DOI: 10.1111/j.1445-2197.2007.04225.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Primary hyperaldosteronism is a frequent cause of resistant hypertension and is amenable to surgical intervention when caused by a unilateral aldosterone-producing adenoma. The aim of this study was to investigate the long-term results of laparoscopic adrenalectomy in the control of hypertension caused by primary hyperaldosteronism. METHODS A prospective case series of patients undergoing laparoscopic adrenalectomy for hyperaldosteronism was studied. Blood pressure (BP), serum aldosterone levels, plasma renin activity, serum potassium and antihypertensive requirement were measured before and after adrenalectomy. RESULTS Sixty-two patients with hyperaldosteronism underwent laparoscopic adrenalectomy in the period from December 1995 to August 2005. The median follow up was 59 months. There was a significant decrease in both systolic blood pressure and diastolic blood pressure at final follow up compared with that before operation. Systolic blood pressure decreased from 149 mmHg to 129 mmHg at final follow up (P < 0.0001). Diastolic blood pressure decreased from 89 mmHg to 80 mmHg (P < 0.0001). Antihypertensive requirement was decreased from an average of 2.6 separate medications preoperatively to 1.4 medications at final follow up (P < 0.0001). Serum aldosterone levels were significantly lower (698 (confidence interval 534-862) pg/mL vs 181 (confidence interval 139-225) pg/mL, P < 0.0001). Overall, 34% of patients had cure of hypertension and did not require any antihypertensive agent. A further 51% had improvement in BP control, whereas 5% had no change or had worsening hypertension. Multivariate regression analysis showed that age and gland size were independent factors predicting sustained hypertension after surgery. CONCLUSION In appropriately selected patients with primary hyperaldosteronism, laparoscopic adrenalectomy is effective in improving long-term BP control. Larger adrenal gland size and older age at time of surgery are predictors of persisting hypertension.
Collapse
Affiliation(s)
- Tony C Pang
- Department of Surgery, University of Sydney Endocrine Surgical Unit, Sydney, Australia
| | | | | | | | | | | | | |
Collapse
|
30
|
Wu JCH, Wu HS, Lin MS, Chou DA, Huang MH. Comparison of robot-assisted laparoscopic adrenalectomy with traditional laparoscopic adrenalectomy - 1 year follow-up. Surg Endosc 2007; 22:463-6. [PMID: 17704877 DOI: 10.1007/s00464-007-9488-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Revised: 05/26/2007] [Accepted: 06/12/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND Laparoscopic adrenalectomy offers distinct benefits to patients and has now become the gold standard for the removal of adrenal lesions. Nonetheless, the procedure poses a challenge for surgeons in regards to the maneuverability of instruments, the two-dimensional operating field and the counterintuitive movements. This study reports our experience using the Zeus robotic surgical system in laparoscopic adrenalectomy compared with traditional laparoscopic adrenalectomy. PATIENTS AND METHODS From January 2003 to February 2005, a total of 12 patients were prospectively enrolled to receive robot-assisted laparoscopic adrenalectomy (RALA) or traditional laparoscopic adrenalectomy (TLA). The time necessary for robotic setup and operation was recorded, as well as complications, technical problems, postoperative hospital stay, morbidity, and mortality. RESULTS Five RALA procedures and seven TLA were successfully completed. There was no significant difference between the groups in terms of age, body mass index, and tumor size. Resection times were longer in the RALA group (168.0 +/- 30.7 min vs. 131.4 +/- 29.0 min, p = 0.05). There were no perioperative complications. There was neither postoperative mortality nor morbidity at the time of discharge and during one year follow-up. CONCLUSIONS RALA is as safe and technically feasible as TLA, It provides a real benefit for the surgeon with the three dimensional view, a comfortable sitting position, the elimination of the surgeon's tremor, and increased degrees of freedom of the operative instruments compared with TLA. However, patient outcomes and operative costs should be evaluated further.
Collapse
Affiliation(s)
- Jungle Chi-Hsiang Wu
- Department of Urology, Show Chwan Memorial Hospital, No. 542, Sec. 1, Chung-Shan Rd., Changhua, Taiwan, ROC
| | | | | | | | | |
Collapse
|
31
|
Solorzano CC, Lew JI, Wilhelm SM, Sumner W, Huang W, Wu W, Montano R, Sleeman D, Prinz RA. Outcomes of Pheochromocytoma Management in the Laparoscopic Era. Ann Surg Oncol 2007; 14:3004-10. [PMID: 17690941 DOI: 10.1245/s10434-007-9489-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2007] [Accepted: 05/22/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND Laparoscopic adrenalectomy (LA) is the preferred surgical approach for pheochromocytomas. We have investigated the changes in diagnosis, management and outcome of pheochromocytomas treated since the widespread advent of LA. METHODS Data were collected retrospectively from 96 patients with pheochromocytomas that had been surgically treated at three tertiary referral centers. RESULTS There were 53 females. Mean age was 47 years (10-81). Tumors were found incidentally in 40% of patients. Of the 96 patients, 12 (13%) had familial syndromes. CT or MRI localized the adrenal lesion in all patients. MIBG scans obtained from 32 patients were concordant with the CT/MRI in 19, were false negative in 9 and misleading in 1, and altered management in only 3 patients. Mean tumor size was 5.6 cm (1.8-17). There were 92 adrenal pheochromocytomas and 9 paragangliomas. Laparoscopy was successful in 67 of 74 (91%) patients, with 20 of 67 (30%) having tumors of 6 cm or greater in size. Conversions to open procedures were performed in patients with 4 left, 2 right pheochromocytomas and 1 paraganglioma. Of the patients, 22 had an open procedure due to suspicion of malignancy or large tumors. Malignancy was observed in 4 of 92 (4.3%) pheochromocytomas and 4 of 9 (44%) paragangliomas. Average follow-up was 22 months (1-122). There were seven recurrences. Postoperative biochemical tests available in 64 patients were normal in 90%. CONCLUSIONS The diagnosis of pheochromocytoma was made incidentally in 40% of patients. MIBG is not necessary for unilateral non-hereditary pheochromocytomas localized by CT/MRI. LA is possible with excellent results in most patients, including for treatment of lesions 6 cm or greater in size with no signs of invasion. Laparoscopy should be used cautiously for paragangliomas because of a high rate of malignancy.
Collapse
Affiliation(s)
- Carmen C Solorzano
- Department of Surgery, Sylvester Cancer Center, University of Miami/Jackson Memorial Medical Center, 1475 NW 12th Ave, Room 3550, Miami, FL 33136, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Is the laparoscopic adrenalectomy for pheochromocytoma the best treatment? Surgery 2007; 141:723-7. [PMID: 17560248 DOI: 10.1016/j.surg.2006.10.012] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2006] [Revised: 09/13/2006] [Accepted: 10/15/2006] [Indexed: 11/25/2022]
Abstract
BACKGROUND Laparoscopic adrenalectomy has become the gold standard for removing adrenal masses, but several authors still debate the role of laparoscopic adrenalectomy in pheochromocytoma. The purpose of this study was to evaluate the short- and long-term outcomes of laparoscopic versus open adrenalectomy for pheochromocytomas and to compare the feasibility and safety of laparoscopic adrenalectomy for neoplasms that are smaller than 6 cm versus those that are larger than 6 cm. METHODS From January 1990 to December 2005, the same team in our department carried out 221 adrenalectomies in 211 patients. A total of 64 of these patients underwent 71 adrenalectomies for pheochromocytoma, 24 patients (37%) had open adrenalectomy, and 40 patients (63%) had laparoscopic adrenalectomy. Sex, age, side and size of lesion, operating time, duration of hospital stay, need for intensive care, intraoperative blood pressure variations, blood loss, postoperative analgesia, return to oral nutrition, and complications were compared among groups. RESULTS An advantage of laparoscopic adrenalectomy over open adrenalectomy was observed in mean operating time, hospital stay, need for intensive care, intraoperative hypertension, intraoperative blood loss, postoperative analgesia, and return to oral nutrition (P <or= .035 in all). The analysis of tumor size (<or=6 vs >6 cm) in laparoscopic adrenalectomy showed that none of the variables differed significantly, except for intraoperative blood loss, which was greater for the larger neoplasms (P = .007). CONCLUSIONS Laparoscopic adrenalectomy, when performed by experienced laparoscopic surgeons, is preferable to open adrenalectomy for the majority of pheochromocytomas, and as long as there is no evidence of invasion of surrounding structures, tumor size does not appear to have a profound effect on surgical outcome.
Collapse
|
33
|
Toniato A, Boschin I, Bernante P, Opocher G, Guolo AM, Pelizzo MR, Mantero F. Laparoscopic adrenalectomy for pheochromocytoma: is it really more difficult? Surg Endosc 2007; 21:1323-6. [PMID: 17294305 DOI: 10.1007/s00464-006-9190-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2006] [Revised: 09/12/2006] [Accepted: 09/18/2006] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Laparoscopic adrenalectomy (LA) has become the gold standard technique for almost all the adrenal masses, but several Authors still debate about LA in pheochromocytoma. BACKGROUND The purpose of this study was to compare feasibility and safety of LA for pheo and analyze the results relative to LA for incidentaloma, Conn's disease and Cushing's disease. METHODS Between January 1994 and March 2006, 167 LAs were carried out in 160 consecutive patients at our Department and 46 of them were affected by pheo, 60 by Conn's disease, 34 by adrenal incidentaloma and 20 by Cushing's disease. The following parameters were statistically analysed: Side and size of lesion, conversion to open adrenalectomy (OA), operating time, length of hospital stay, intraoperative blood pressure variations, blood loss, blood transfusion, need for postoperative analgesia, resumption of oral nutrition and postoperative complications. RESULTS Successful LA was performed in 159 out of 167 cases (95.2%). Significant statistical advantages were observed for pheo, even if its average size was larger (p > 0.001), in terms of average operating time (p < 0.001), average length of hospital stay (p < 0.001), average intraoperative blood loss (p > 0.001), postoperative analgesia (p < 0.001), oral nutrition (p < 0.001). LA for patients with Cushing's disease (average length of hospital stay and intraoperative blood loss, p < 0.023 and p > 0.002 respectively) and with adrenal incidentaloma (intraoperative blood loss p < 0.009) seems to be a more challenging procedure. CONCLUSION The evaluation of this relatively large monoinstitutional experience suggests that LA could be considered the most suitable method for removing pheochromocytoma. This tumour tends to be larger than most functional cortical adenomas, nevertheless it allows even a significant reduction in operating time with a faster recovery.
Collapse
Affiliation(s)
- Antonio Toniato
- Institute of Surgical Pathology, Department of Medical and Surgical Sciences, University of Padua, Via Giustiniani 2, Padua, 35128, Italy.
| | | | | | | | | | | | | |
Collapse
|
34
|
Abstract
In this article the authors have attempted to summarize and evaluate the current literature regarding the feasibility and indications of the laparoscopic approach to the resection of adrenal lesions. The overall results suggest that laparoscopic adrenalectomy is safe, effective, and has major advantages for patients in terms of decreased pain, hospital stay, and short- and long-term morbidity. For large and malignant lesions, good judgment and careful consideration must be given to the entire clinical picture so that the laparoscopic approach is used for patients who will derive benefits from the minimally invasive approach without compromising an oncologically sound resection or safety of operation. Additional studies will help clarify these remaining controversies further. The laparoscopic approach for adrenalectomy has demonstrated that significant and beneficial advances in surgery are improving the care offered patients.
Collapse
Affiliation(s)
- Charlotte Ariyan
- Department of Surgery, Memorial Sloan-Kettering Hospital, 1275 York Avenue, New York, NY 10021, USA
| | | |
Collapse
|
35
|
Wilhelm SM, Prinz RA, Barbu AM, Onders RP, Solorzano CC. Analysis of large versus small pheochromocytomas: Operative approaches and patient outcomes. Surgery 2006; 140:553-9; discussion 559-60. [PMID: 17011902 DOI: 10.1016/j.surg.2006.07.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2006] [Accepted: 07/12/2006] [Indexed: 11/25/2022]
Abstract
BACKGROUND Laparoscopic adrenalectomy for small pheochromocytomas, although challenging, is widely accepted. However, its application to pheochromocytomas larger than 6 cm is questioned due to concerns of malignancy and case complexity. Our aim was to examine the impact of pheochromocytoma tumor size (>/=6 cm vs <6 cm) on operative approach and postoperative patient outcomes. METHODS A retrospective review of adrenalectomies performed at 3 university hospitals over 1 decade was analyzed. All pheochromocytomas were identified and then divided based on size into large (>/=6 cm) and small (<6 cm) groups. We examined patient and tumor demographics, pathologic diagnosis, operative approach (laparoscopic vs open), postoperative complications, and biochemical cure rates. Data were analyzed using the Student t test and Fisher exact test with a P value <.05 considered significant. RESULTS From 1995 to 2005, 65 pheochromocytomas were resected. Of the total, 38% (n = 25) tumors were >/=6 cm and 62% (n = 40) were <6 cm. For the large tumors, 1 out of 25 (4%) was malignant, whereas no small tumors were malignant. There was no statistically significant increased risk of malignancy in tumors >/=6 cm in size (P = .31). Initial operative approach was based on surgeon preference. Of the adrenalectomies performed, 88% were laparoscopic, with 3 of 25 (12%) large tumors requiring conversion from laparoscopic to open for intraoperative bleeding. None of the small tumors required conversion. No major postoperative complications (eg, stroke or myocardial infarction) occurred in either group. Minor complications (eg, wound infections and hematomas) were noted in 16% of large tumors and 12.5% of small tumors (P = .45). A total of 96% (24 of 25) patients with large tumors and 100% with small tumors showed postoperative biochemical cure. Tumor recurrence was noted in 1 patient with a tumor <6 cm. CONCLUSIONS Pheochromocytomas >/=6 cm pose a challenge for laparoscopic resection, and concerns have been raised about the validity of this operative approach. This study demonstrates that there is no significant difference in the rate of malignancy for pheochromocytomas >/=6 cm versus <6 cm. There also were no significant differences identified in complication rates, postoperative biochemical cures, or tumor recurrence rates between these groups. Laparoscopic resection of pheochromocytomas can be safely accomplished regardless of size in centers with surgeons experienced in these procedures.
Collapse
Affiliation(s)
- S M Wilhelm
- University Hospitals of Cleveland/Case Western Reserve University, Cleveland, Ohio, USA
| | | | | | | | | |
Collapse
|
36
|
Abstract
Laparoscopic adrenalectomy (LA) was first described in the literature in 1992, and has become the preferred method for the removal of benign functioning and non-functioning tumors of the adrenal gland <12 cm. The objectives of the present study are to review the experience of LA gained since it was first done in 1992 and to critically evaluate its effectiveness for the surgical management of endocrine hypertension; specifically pheochromocytoma, aldosteronoma and Cushing's syndrome and disease, as opposed to open adrenalectomy. The benefits of minimally invasive techniques for the removal of the adrenal gland include decreased requirements for analgesics, improved patient satisfaction, shorter hospital stay and recovery time when compared to open surgery. LA can be performed safely for bilateral disease and may become the standard of care for malignant tumors. Current limitations are operator-dependent and not a factor of limitations of minimally invasive techniques. A thorough pre-operative work-up is key for differentiating the various cases of hypertension and adequate pre-operative treatment is paramount when indicated.
Collapse
Affiliation(s)
- Andrew A Gumbs
- New York-Presbyterian Hospital, Division of Laparoscopic and Bariatric Surgery and Department of Surgery, Joan and Sanford I. Weill Medical College of Cornell University, PO Box 294, New York, NY 10021, USA
| | | |
Collapse
|
37
|
Gockel I, Heintz A, Roth W, Junginger T. [Minimally invasive adrenalectomy for pheochromocytoma: routine or risk?]. Chirurg 2006; 77:70-5. [PMID: 16362351 DOI: 10.1007/s00104-005-1105-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND As a result of intraoperative catecholamine secretion with hemodynamic changes, larger tumor size, and marked neovascularization, adrenalectomy is more challenging and prone to complications for pheochromocytoma than for other adrenal diseases. The aim of this study was to examine the relative intraoperative risk of cardiovascular complications with the minimally invasive approach. PATIENTS AND METHODS Between February 1992 and May 2005, 82 operations were performed on 71 pheochromocytoma patients at our clinic. Of them, nine adrenalectomies were bilateral, one was trilateral, and two patients had recurrent procedures. Another five patients were included whose first operations took place before 1992. Thirty-six procedures were carried out conventionally (35 transperitoneally, one retroperitoneally) and 46 were endoscopic (28 transperitoneally, 18 retroperitoneally). There was no conversion to open procedure. RESULTS The median age at the time of surgery was 45 (24-75) years, and the median history of symptoms was 12 months (0-180). The openly resected pheochromocytomas were significantly larger than those in endoscopic operations: 5.5 cm (1-19 cm) vs 3.5 cm (0.5-8 cm) (P=0.0011). Compared with patients undergoing conventional procedures, those operated on endoscopically showed higher intraoperative systolic and diastolic blood pressures and peaks of more than 200 mmHg, although these differences were statistically insignificant. Multivariate analysis identified gender (P=0.0107), operative approach (P=0.0153), age (P=0.0364), and tumor size (P=0.0484) as factors with a possible influence on intraoperative hemodynamic alterations. Postoperative hospital stay was significantly shorter following endoscopic adrenalectomy (P=0.0001). CONCLUSION Endoscopic adrenalectomy for pheochromocytoma is suitable as a routine operation and harbors no increased risk of cardiovascular complications, making it the method of choice. The open procedure should be reserved for extraadrenal tumors or large tumors with the suspicion of malignancy.
Collapse
Affiliation(s)
- I Gockel
- Klinik für Allgemein- und Abdominalchirurgie, Johannes-Gutenberg-Universität Mainz.
| | | | | | | |
Collapse
|
38
|
|
39
|
Gockel I, Heintz A, Roth W, Junginger T. Adrenalectomy for Bilateral and Recurrent Pheochromocytoma: Increased Intraoperative Risk? Am Surg 2006. [DOI: 10.1177/000313480607200308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Adrenalectomy for pheochromocytoma is per se associated with a specific intraoperative cardiovascular risk caused by catecholamine secretion during manipulation of the tumor. Bilateral or multiple, and recurrent chromaffine tumors are special subentities with a potentially more intensified and longer surgical preparation. The aim of our study was to examine these effects on hemodynamic changes compared with those observed for primary, solitary tumors. Of the 82 studied interventions between February 1992 and May 2005, 58 were seen to involve primary, unilateral tumors, 17 involved bilateral (1 trilateral) findings, and there were 7 cases of recurrency. The hemodynamic changes related to primary, solitary pheochromocytomas revealed a higher frequency of intraoperative blood pressure crises (37%) compared with the comparative groups (11.8% in bilateral and 0% in recurrent tumors), as well as higher maximum pCO2 values noted. The intraoperative blood loss was more pronounced in interventions involving recurrencies. Aside from an appropriate preliminary therapy using an α-blocker and the careful surgical preparation of the adrenal gland, the different hemodynamic changes possibly may be related to the presence of smaller tumors in bilateral pheochromocytoma, as well as being based upon the already existent ligature of the draining vein in the event of recurrent procedures. The extent to which the adrenergic effect of the increased maximum pCO2 value plays a role on the development of higher maximum blood pressure values and more frequent intraoperative blood pressure crises continues to remain unclear.
Collapse
Affiliation(s)
- Ines Gockel
- From the Department of General and Abdominal Surgery, Johannes Gutenberg-University, Mainz, Germany
| | - Achim Heintz
- From the Department of General and Abdominal Surgery, Johannes Gutenberg-University, Mainz, Germany
| | - Walter Roth
- From the Department of General and Abdominal Surgery, Johannes Gutenberg-University, Mainz, Germany
| | - Theodor Junginger
- From the Department of General and Abdominal Surgery, Johannes Gutenberg-University, Mainz, Germany
| |
Collapse
|
40
|
Mann GN, Link JM, Pham P, Pickett CA, Byrd DR, Kinahan PE, Krohn KA, Mankoff DA. [11C]Metahydroxyephedrine and [18F]Fluorodeoxyglucose Positron Emission Tomography Improve Clinical Decision Making in Suspected Pheochromocytoma. Ann Surg Oncol 2006; 13:187-97. [PMID: 16418883 DOI: 10.1245/aso.2006.04.022] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2005] [Accepted: 08/11/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pheochromocytomas are rare tumors of chromaffin cells for which the optimal management is surgical resection. Precise diagnosis and localization may be elusive. We evaluated whether positron emission tomography (PET) scanning with the combination of [18F]fluorodeoxyglucose (FDG) and the norepinephrine analogue [11C]metahydroxyephedrine (mHED) would allow more exact diagnosis and localization. METHODS Fourteen patients with suspected pheochromocytoma were evaluated by anatomical imaging (computed tomography or magnetic resonance imaging) and [131I]metaiodobenzylguanidine (MIBG) planar imaging. PET imaging was performed by using mHED with dynamic adrenal imaging, followed by a torso survey and FDG with a torso survey. Images were evaluated qualitatively by an experienced observer. RESULTS Eight patients had pathology-confirmed pheochromocytoma. Of the other six, two patients had normal adrenal tissue at adrenalectomy, and the other four had subsequent clinical courses inconsistent with a diagnosis of pheochromocytoma. In four of eight patients with pheochromocytoma, MIBG failed to detect one or more sites of pathology-confirmed disease. The mHED-PET detected all sites of confirmed disease, whereas FDG-PET detected all sites of adrenal and abdominal disease, but not bone metastases, in one patient. MIBG and FDG-PET results were all negative in the six patients without pheochromocytoma. One patient with adrenal medullary hyperplasia had a positive mHED-PET scan. PET scanning aided the decision not to operate in three of six patients. The resolution of PET functional imaging was superior to that of MIBG. CONCLUSIONS PET scanning for pheochromocytoma offers improved quality and resolution over current diagnostic approaches. PET may significantly influence the clinical management of patients with a suspicion of these tumors and warrants further investigation.
Collapse
Affiliation(s)
- Gary N Mann
- Department of Surgery, University of Washington, Box 356410, 1959 N.E. Pacific Street, Seattle, Washington 98195, USA.
| | | | | | | | | | | | | | | |
Collapse
|
41
|
Cho DH, Yoo ES, Kwon TK. A Comparison of Laparoscopic and Open Adrenalectomy in Patients with Pheochromocytoma. Korean J Urol 2006. [DOI: 10.4111/kju.2006.47.6.614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Deok Hyun Cho
- Department of Urology, College of Medicine, Kyungpook National University, Daegu, Korea
| | - Eun Sang Yoo
- Department of Urology, College of Medicine, Kyungpook National University, Daegu, Korea
| | - Tae Kyun Kwon
- Department of Urology, College of Medicine, Kyungpook National University, Daegu, Korea
| |
Collapse
|
42
|
Kercher KW, Novitsky YW, Park A, Matthews BD, Litwin DEM, Heniford BT. Laparoscopic curative resection of pheochromocytomas. Ann Surg 2005; 241:919-26; discussion 926-8. [PMID: 15912041 PMCID: PMC1357171 DOI: 10.1097/01.sla.0000164175.26785.06] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Pheochromocytomas are relatively uncommon tumors whose operative resection has clear medical and technical challenges. While the safety and efficacy of laparoscopic adrenalectomy are relatively well documented, few studies with extended follow-up have been conducted to measure the success of the procedure for the most challenging of the adrenal tumors. In addition, several reports question the applicability of a minimally invasive approach for sizeable pheochromocytomas. The purpose of our investigation was to assess the outcomes of laparoscopic adrenalectomy for pheochromocytomas in the largest study to date when performed by experienced laparoscopic surgeons. METHODS All pheochromocytomas removed by the authors from January 1995 to October 2004 were reviewed under an Institutional Review Board approved protocol. Eighty-five percent were documented in a prospective fashion. RESULTS Eighty consecutive patients underwent laparoscopic resection of 81 pheochromocytomas. Seventy-nine were found in the adrenal (42 left, 35 right, 1 bilateral); 2 were extra-adrenal paragangliomas. Eight patients had multiple endocrine neoplasia syndrome. Two lesions were malignant. There were 48 females and 32 males with a mean age of 45 years (range, 15-79 years). Mean tumor size was 5.0 cm (range, 2-12.1 cm); 41 of these lesions were 5 cm in size or larger. Average operative time and blood loss were 169 minutes (range, 69-375 minutes) and 97 mL (range, 20-500 mL), respectively. Intraoperative hypertension (systolic blood pressure, >170 mm Hg) was reported in 53% of patients and hypotension (systolic blood pressure, <90 mm Hg) in 28% of patients. There were no conversions to open surgery. Mean length of stay was 2.3 days (range, 1-10 days). There were 6 perioperative morbidities (7.5%) and no mortalities. No patient required a blood transfusion. No recurrence of endocrinopathy has been documented at a mean follow-up of 21.4 months. CONCLUSION Laparoscopic resection of pheochromocytomas, including large lesions, can be accomplished safely by experienced surgeons. A short hospital stay with minimal operative morbidity and eradication of endocrinopathy support the minimally invasive approach for adrenalectomy in the setting of pheochromocytoma.
Collapse
Affiliation(s)
- Kent W Kercher
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina 28232, USA
| | | | | | | | | | | |
Collapse
|
43
|
Gockel I, Vetter G, Heintz A, Junginger T. Endoscopic adrenalectomy for pheochromocytoma: difference between the transperitoneal and retroperitoneal approaches in terms of the operative course. Surg Endosc 2005; 19:1086-92. [PMID: 16021380 DOI: 10.1007/s00464-004-2141-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2004] [Accepted: 02/11/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Due to the intraoperative catecholamine secretion with hemodynamic changes, a larger tumor size and marked neovascularization, as compared with other adrenal pathologies, endoscopic adrenalectomy for pheochromocytoma represents a particular challenge involving a more difficult and morbid procedure. The aim of this study was to identify the optimal surgical approach for endoscopic adrenalectomy in patients with pheochromocytoma. METHODS Over a period of 10 years (February 1994 to June 2004), 38 consecutive patients underwent endoscopic adrenalectomy for pheochromocytoma. As three patients underwent a bilateral procedure, a total of 41 adrenalectomies were performed. The transperitoneal approach was carried out in 23 patients, whereas 18 patients underwent a retroperitoneal adrenalectomy by a single operative team. Perioperative parameters were prospectively followed. RESULTS There was no conversion to the open procedure. Intraoperative hypertensive episodes occurred in 21 patients (55.3%) and were controlled by antihypertensive agents. In 11 patients (28.9%), blood pressure values rose to above 200 mmHg (> 1 min). A comparison between the retroperitoneal and transperitoneal procedures did not show a significant difference between the maximum intraoperative systolic (p = 0.730) and diastolic (p = 0.663) blood pressure values although intraoperative blood pressure peaks were seen more frequently during retroperitoneal adrenalectomy. The operative time was shorter for the patients who had transperitoneal adrenalectomy than compared to for those who had retroperitoneal adrenalectomy, although the difference was not significant. The intraoperative blood loss, perioperative morbidity, and length of postoperative hospital stay did not differ significantly between the surgical techniques (p > 0.05). CONCLUSION After adequate preparation, endoscopic adrenalectomy may be performed in patients with pheochromocytoma via both the retroperitoneal and the transperitoneal approaches. The shorter operating time, less frequent intraoperative blood pressure peaks, and the better overview of the operating field recommend the transperitoneal approach with the patient placed in a lateral position as the preferred operative procedure.
Collapse
Affiliation(s)
- I Gockel
- Department of General and Abdominal Surgery, Johannes Gutenberg University, Langenbeckstrasse 1, D-55101 Mainz, Germany.
| | | | | | | |
Collapse
|