Laparoscopic anterior versus endoscopic posterior approach for adrenalectomy: a shift to a new golden standard?

Case report: 65-year-old man with metachronous left sided adrenal metastasis of hepatocellular carcinoma

INTRODUCTION AND IMPORTANCE

Due to therapeutic advances and improvements in follow-up care, the diagnosis and treatment of extrahepatic metastases of hepatocellular carcinoma [HCC] have gained clinical significance. However, adrenal gland metastases of HCC remain a rare clinical encounter. Several systemic and local treatment options are discussed in current literature. Adrenalectomy in cases of isolated adrenal metastases with well-controlled intrahepatic lesions has been shown to benefit patients in case series.

PRESENTATION OF THE CASE

This 65-year-old patient presented with suspected metachronous left sided adrenal metastasis seven years after bisegmentectomy for HCC and after undergoing trans-arterial chemoembolization [TACE] for multifocal intrahepatic recurrences while being listed for liver transplantation "beyond Milan criteria". Adrenalectomy was suggested for histopathological confirmation of the suspected metastasis and re-consideration for liver transplant. The resection was performed laparoscopically and metastasis of HCC was confirmed in histopathological analysis. Postoperatively, the patient recovered quickly. However, the patient decided against re-listing for liver transplantation.

CLINICAL DISCUSSION

Current literature suggests, that minimally-invasive adrenalectomy should be considered in patients with no more than two extrahepatic lesions, a Child-Pugh-Score of less than A5, low alpha-fetoprotein [AFP] levels <100 ng/ml and size <3 cm. The oncological goal should be to achieve a tumor free extrahepatic situation with a potential oncological benefit.

CONCLUSION

Our patient presented as an ideal candidate for resection of the adrenal gland metastasis and could have been re-assessed postoperatively for liver transplantation. Still, more research is needed to improve patient-selection for metastasectomy in HCC.

Minimally invasive adrenalectomy: a cohort study of surgical approach and outcomes

BACKGROUND

In the context of minimally invasive adrenal surgery, there remains debate about whether the transperitoneal adrenalectomy (TPA) and posterior retroperitoneoscopic adrenalectomy (PRA) approach have equivalent indications. This study aims to examine complication and conversion rates associated with three surgical approaches for adrenal tumours over the last 17 years in a specialized endocrine surgical unit.

METHODS

All adrenalectomy cases performed in the period 2005-2021 were identified within a prospectively maintained surgical database. A retrospective cohort study was undertaken with patients divided into two cohorts (2005-2013 and 2014-2021). Surgical approach (open adrenalectomy (OA), TPA, PRA), tumour size, histopathology, complication and conversion rates were compared.

RESULTS

During the study period, 596 patients underwent adrenalectomy with 31 and 40 cases each year per cohort. The dominant surgical approach per cohort significantly changed from TPA (79% versus 17%) to PRA (8% versus 69%, P < 0.001), whilst the frequency of OA remained stable (13% versus 15%). TPA removed larger tumours (3.0 ± 2.9 cm) than PRA (2.8 ± 2.2 cm, P = 0.02), with the median size increasing from 3.0 ± 2.5 to 4.5 ± 3.5 cm per cohort (P < 0.001). The maximum tumour sizes treated by TPA and PRA were 15 and 12 cm, respectively. Adrenocortical adenoma was the commonest pathology treated by either laparoscopic technique. Complication rates were greatest for OA (30.1%) with no significant difference between minimally invasive approaches (TPA 7.3%, PRA 8.3%, P = 0.7). Both laparoscopic techniques had equivalent conversion rates (3.6%). PRA was preferably converted to TPA (2.8%) over OA (0.8%).

CONCLUSION

This study demonstrates the transition from TPA to PRA, offering similarly low complication and conversion rates.

Retroperitoneal approach in a child with ganglioneuroma: points of technique and literature review

Background data

Ganglioneuroma is rare in children and often incidentally discovered. The transperitoneal laparoscopic approach is the surgical choice for most of the surgeons because of the familiar anatomy and the wider working spaces. However, a posterior retroperitoneal approach started to be used in pediatric population demonstrating to be safe and effective.

Case presentation

We present a case of a child with radiological finding of a right adrenal mass. Due to the increased risk of having a malignant transformation, a surgical resection was decided using a retroperitoneal approach. The adrenal mass was recognized and completely enucleated. The histopathological examination revealed a GN. Clinical course was uneventful with hospital discharge after 3 days. The outcome was evaluated by ultrasound examination performed 3–6 to 12–24 months and then annually. After 24 months, the patient is completely asymptomatic, and no adrenal masses in both sides have been detected.

Conclusions

The posterior retroperitoneoscopy permits a more direct exposure of the adrenal gland, without violating the peritoneum, and a close vision to the main vessels. We believe that this technique is a valid option for pediatric patients with small adrenal lesions.

Perioperative factors influencing the difficulty of retroperitoneal laparoscopic adrenalectomy: a single-center retrospective study

Purpose

Identifying patients in whom adrenalectomy may be more difficult can help with surgical decision-making. This study investigated the perioperative factors affecting the difficulty of retroperitoneal laparoscopic adrenalectomy (RLA).

Methods

Sixty-eight patients who underwent RLA at our hospital between December 1, 2020 and May 1, 2021 were included. The difficulty of RLA was assessed by operating time and intraoperative blood loss. We analyzed the relationship between surgical difficulty and patient sex, age, and body mass index, pathological type, tumor side, tumor size, distance from the lower pole of the adrenal tumor to the upper pole of the kidney (DAK), and distance from the lower pole of the adrenal tumor to the renal pedicle (DARP).

Results

Mean operating time was 105.38 ± 33.31 min and mean intraoperative blood loss was 32.28 ± 22.88 ml. Univariate linear regression analysis showed that age (P = 0.047), tumor size (P = 0.002), DAK (P = 0.002), and DARP (P < 0.001) were significantly correlated with a longer operating time. Univariate logistic regression analysis showed that DARP (P = 0.001), DAK (P = 0.001), tumor size (P = 0.002), and age (P = 0.033) were significantly correlated with a longer operating time. Multivariate logistic regression indicated that DARP (OR 5.341; 95% CI 1.704–16.739; P = 0.004), and tumor size (OR 4.433; 95% CI 1.434–13.709; P = 0.010) were independent predictors of operating time.

Conclusion

Age, tumor size, DAK, and DARP were predictors of the difficulty of RLA. Older age, lower DARP and DAK, and a larger tumor size were associated with a longer operating time. DARP and tumor size were independent predictors of surgical difficulty.

Outcomes after Surgical Treatment of Metastatic Disease in the Adrenal Gland; Valuable for the Patient?

Simple Summary

Adrenal glands are common dissemination sites for metastases of various solid tumors. The rapid development of new treatment strategies, such as targeted therapy and immunotherapy for different cancer types, has led to increased metastatic adrenalectomies. Therefore, clear communication between oncologists and adrenal gland specialists has become increasingly important to outweigh surgical risks versus oncological advantages of adrenalectomies in these patients. This study assesses trends in diagnosis, type of surgery, and short-term and long-term surgical outcomes of patients who underwent metastatic adrenalectomy. We included a total of 95 patients with an adrenal metastasis of non-adrenal primary tumors, most often colorectal or lung cancer, who underwent (minimal invasive) adrenalectomy. 37.9% of the patients experienced one or more complications after adrenalectomy. Within our patient cohort, an increased demand for metastatic adrenalectomy was observed over the past years, which might be associated with the rise of targeted- and immunotherapy. Our data aims to assist multidisciplinary teams with weighing the pros and cons of resection of the metastasized adrenal gland of cancer patients.

Abstract

The adrenal glands are common dissemination sites for metastasis of various solid tumors. Surgical treatment is often recommended because targeted therapies and immunotherapy are frequently ineffective for adrenal metastasis. We report the experience with short-term and long-term surgical outcomes of patients undergoing surgery for adrenal metastasis in two hospitals. A retrospective, multicenter study was performed to analyze patient characteristics, tumor-related data, perioperative outcomes, and oncological outcomes. Postoperative complications that occurred within 30 days were scored according to the Clavien Dindo classification. Metastatic adrenalectomy was performed in 95 patients. We observed an increase from an average of 3 metastatic adrenalectomies per year between 2001–2005 to 10 between 2015–2019. The most frequent underlying malignancies were colorectal and lung cancer. In 55.8%, minimal invasive adrenalectomy was performed, including six conversions to open surgery. A total of 37.9% of patients had postoperative complications, of which ileus or gastroparesis, wound problems, pneumonia, and heart arrhythmias were the most occurring complications. Improved cancer care has led to an increased demand for metastatic adrenalectomy over the past years. Complication rates of 37.9% are significant and cannot be neglected. Therefore, multidisciplinary teams should weigh the decision to perform metastatic adrenalectomy for each patient individually, taking into account the drawbacks of the described morbidity versus the potential benefits.

Initial experience with laparoscopic posterior retroperitoneal adrenalectomy in single tertiary center

Purpose

Laparoscopic posterior retroperitoneal adrenalectomy (LPRA) is a surgical method that accesses the adrenal gland through the back. The aim of this study was to report initial experience of LPRA and evaluate possibilities for surgical application.

Methods

From March 2018 to December 2019, a total of 30 consecutive patients diagnosed with adrenal tumor underwent surgical treatment at Pusan National University Hospital were enrolled. Clinicopathologic features and various peri- and postoperative parameters were analyzed by retrospective medical record review. The mean age of the patients was 48.20±13.66 years.

Results

The mean body mass index (BMI) was 25.50±4.30 kg/m². Primary hyperaldosteronism was the most frequently preoperative diagnosed disease (n=13, 43.4%), followed by adrenal incidentaloma (n=8, 26.6%), Cushing syndrome (n=5, 16.6%) and pheochromocytoma (n=4, 13.3%). The mean size of postoperative adrenal tumor was 2.72±1.76 cm. The mean operating time was 162±58.14 minutes. Among the 30 patients, 28 patients underwent total adrenalectomy (93.3%) and two patients underwent cortical sparing adrenalectomy (6.7%). When LPRA was performed for patients with BMI >23.16 kg/m², the operating time was longer than the average (P=0.016).

Conclusion

LPRA was suitable and safe for patients with benign adrenal tumors. BMI, retroperitoneal fat density and postoperative adrenal weight may be related to the operating time, so they should be considered when deciding on a surgical method for adrenalectomy.

Single-port retroperitoneoscopic adrenalectomy: Initial experience and standardization of the technique

INTRODUCTION AND OBJECTIVE

The minimally invasive surgical approach to adrenal gland pathology is the most widely used nowadays, and retroperitoneoscopy occupies a relevant place. However, the evolution of these techniques towards even less invasive surgery through single-port access is anecdotal. The aim of this work is to describe our initial experience in single-port retroperitoneoscopic surgery (SPORS) of the adrenal gland focusing on perioperative data and postoperative pain.

MATERIAL AND METHODS

We collected and analyzed the demographic and operative data of a series of patients undergoing adrenalectomy through SPORS. All procedures were performed through a single 3-4 cm subcostal incision with a multichannel port. Surgical data such as operative time, bleeding, length of stay and presence of complications were collected. We used the visual analog scale (VAS) for postoperative pain assessment.

RESULTS

From December 2018 to August 2020, 6 patients with different types of adrenal pathology underwent consecutive surgeries in our Department by the same surgeon using SPORS. All surgeries were performed without requiring accessory trocar placement or reconversion to open surgery. The mean operative time was 91.6 ± 16.3 min, with <150 mL bleeding, mean length of stay of 35.8 ± 13.3 h and postoperative pain of VAS ≤3 (median 0.5). The mean size of specimens was 57.8 ± 18 mm. No complications were reported according to the Clavien-Dindo scale.

CONCLUSIONS

Even in initially adverse cases, SPORS adrenalectomy is a feasible and safe technique with good cosmetic and perioperative results.

Risk factors for haemodynamic instability and its prolongation during laparoscopic adrenalectomy for pheochromocytoma

OBJECTIVE

Pheochromocytoma is a rare neuroendocrine tumour that secretes catecholamines and originates in the adrenal gland. Although surgical resection is the only curative therapy for pheochromocytoma, it is associated with a risk of haemodynamic instability (HDI), such as extremely high blood pressure and/or post tumour removal hypotension and shock. We investigated the risk factors for HDI during pheochromocytoma surgery.

DESIGN AND PATIENTS

Eighty-two patients who underwent laparoscopic adrenalectomy for pheochromocytoma between July 2002 and February 2020 were examined. We excluded 3 patients with bilateral disease and 11 without detailed 24 h urinary data. We defined HDI as systolic blood pressure ≥ 200 or <80 mmHg. We investigated the risk factors for HDI during laparoscopic adrenalectomy for pheochromocytoma.

RESULTS

There were 29 males and 39 females with a median age of 50.5 years. Tumours were localised on the right adrenal gland in 28 patients and on the left in 40. The median tumour diameter was 37.5 mm and the median pneumoperitoneum time was 93.5 min. Twenty-five out of sixty-eight patients (37%) developed HDI. A multivariate analysis identified diabetes mellitus (DM; odds ratio: 3.834; 95% confidence interval: 1.062-13.83; p = .04) as an independent predictor of HDI. In terms of hormonal data, median 24 h urinary epinephrine levels (p = .04) and metanephrine levels (p = .01) were significantly higher in the HDI group. DM was also considered as a risk factor for prolonged HDI (p = .02).

CONCLUSION

Surgeons and anaesthesiologists need to be aware of the risk of HDI and its prolongation during laparoscopic adrenalectomy for pheochromocytoma for DM patients.

Single-port retroperitoneoscopic adrenalectomy: Initial experience and standardization of the technique

INTRODUCTION AND OBJECTIVE

The minimally invasive surgical approach to adrenal gland pathology is the most widely used nowadays, and retroperitoneoscopy occupies a relevant place. However, the evolution of these techniques towards even less invasive surgery through single-port access is anecdotal. The aim of this work is to describe our initial experience in single-port retroperitoneoscopic surgery (SPORS) of the adrenal gland focusing on perioperative data and postoperative pain.

MATERIAL AND METHODS

We collected and analyzed the demographic and operative data of a series of patients undergoing adrenalectomy through SPORS. All procedures were performed through a single 3-4cm subcostal incision with a multichannel port. Surgical data such as operative time, bleeding, length of stay and presence of complications were collected. We used the visual analog scale (VAS) for postoperative pain assessment.

RESULTS

From December 2018 to August 2020, 6 patients with different types of adrenal pathology underwent consecutive surgeries in our Department by the same surgeon using SPORS. All surgeries were performed without requiring accessory trocar placement or reconversion to open surgery. The mean operative time was 91.6±16.3minutes, with <150mL bleeding, mean length of stay of 35.8±13.3hours and postoperative pain of VAS ≤3 (median 0.5). The mean size of specimens was 57.8±18mm. No complications were reported according to the Clavien-Dindo scale.

CONCLUSIONS

Even in initially adverse cases, SPORS adrenalectomy is a feasible and safe technique with good cosmetic and perioperative results.

Adrenal cavernous hemangioma misdiagnosed as pheochromocytoma: a case report

BACKGROUND

Adrenal hemangioma is a rare benign adrenal tumor that is usually misdiagnosed preoperatively. We here present a case of adrenal cavernous hemangioma that was successfully treated with retroperitoneal laparoscopic adrenalectomy.

CASE PRESENTATION

A 67-year-old man with dull right back pain attended our clinic for examination of a mass on the right adrenal gland for 1 week. Pheochromocytoma was considered according to the preoperative computed tomography angiography + computed tomography urography findings and was subsequently corrected to adrenal gland hemangioma according to postoperative pathological findings. The patient showed no recurrence of adrenal hemangioma during the 1-year follow-up period after surgery.

CONCLUSION

Adrenal gland hemangioma is rare with a high rate of misdiagnosis, and it should be considered in imaging findings of adrenal tumors with typical hemangioma. Surgery is an effective treatment method.

Posterior retroperitoneoscopic adrenalectomy: recommendations to implement this approach

INTRODUCTION

The posterior retroperitoneoscopic approach (PRA) is seldom used in our country to perform adrenalectomies, although it offers possible advantages over laparoscopic anterior or lateral access, according to some authors. The aim of this study was to identify those features that determine the most suitable cases to start the implementation of this technique.

METHODS

A prospective observational study was performed with a 50 patients cohort. All the cases were operated using the PRA. Sex, age, body mass index (BMI), operative time, left or right side, size and anatomopathological characteristics of the lesion, conversion rates, complications and hospital stay were analyzed.

RESULTS

25 (50%) women and 25 (50%) men underwent surgery, with a median operative time of 80 minutes (45-180). A significantly shorter operative time (p = 0.002) was observed in women and in adenomas (p = 0.002). However, no correlation was observed between surgical time and BMI, lesion side or lesion size. There were no conversions. The complication rate was 14%, and most of the complications were grade i in Clavien Dindo's Scale. Median hospital stay was two days.

CONCLUSIONS

Retroperitoneoscopic adrenalectomy by posterior approach is a safe and reproducible procedure, with very good outcomes. The most suitable cases to implement this technique would be female patients with adrenal adenomas.

Surgical approach to patients with primary aldosteronism

Primary hyperaldosteronism (PA) is one of the most common causes of hypertension that is amenable to surgical cure. Once a patient has a biochemical diagnosis of PA, workup should proceed with tumor lateralization to determine whether the patient has unilateral or bilateral disease. Tumor lateralization can be done with noninvasive imaging such as a CT or MRI. However, in older patients or in patients with non-lateralizing imaging, arteriovenous sampling (AVS) should be considered. If the patient has confirmed unilateral disease, options for surgical intervention include laparoscopic or, less commonly, open. Laparoscopic adrenalectomy for PA has been shown to be a safe and effective procedure that is associated with less morbidity compared to open adrenalectomy. Patients can either undergo a laparoscopic transabdominal adrenalectomy via a lateral (most common) or anterior approach or a retroperitoneoscopic adrenalectomy via a posterior approach. The majority of patients have complete biochemical success, defined as normalization of plasma aldosterone, renin and potassium levels and appropriate suppression with stimulation tests. Less than half of patients have complete clinical success, defined as normotensive with no antihypertensive medications. However, the majority of patients who do not have complete clinical success will have some improvement in their blood pressure and/or are able to decrease the number of antihypertensive medications that they require.

Laparoscopic Treatment of Large Adrenal Tumor is Safe and Effective? A Single Center Experiences

BACKGROUND

The comparisons between open surgery and minimally invasive surgery for treatment of large adrenal tumor (LAT) are still lacking. In this study, we attempted to explore the safety and effectiveness of laparoscopic treatment of LAT by comparing the outcomes between open adrenalectomy (OA) and laparoscopic adrenalectomy (LA).

METHODS

From 2003 to 2018, 78 LAT patients underwent tumor resection by OA or LA method at a single academic institution. Data were retrospectively collected and analyzed.

RESULTS

The median largest diameter of LAT was 10.0 (IQR 9.0-13.4) cm. The median operation time in OA group was 215 (IQR 180-240) min versus 180 (IQR 135-245) min in LA group (P = 0.042). The median blood loss in OA group was 1000 (IQR 625-1500) ml versus 200 (IQR 100-700) ml in LA group (P < 0.001). The median Clavien-Dindo score in OA group was 2 (IQR 2-4) versus 0 (IQR 0-4) in LA group (P = 0.035). On univariate and multivariate analysis, the largest diameter of tumor was significantly associated with operation time, blood loss, and recovery time (P < 0.05).

CONCLUSIONS

Laparoscopic treatment of LAT was found to be safe and feasible in experienced hands and can replace open surgeries in most cases.

Fluorescence-enabled assessment of adrenal gland localization and perfusion in posterior retroperitoneoscopic adrenal surgery in a preclinical model

BACKGROUND

The posterior retroperitoneoscopic adrenal access represents a challenge in orientation and working space creation. The aim of this experimental acute study was to evaluate the impact of computer-assisted quantitative fluorescence imaging on adrenal gland identification and assessment of intraoperative remnant perfusion for adrenal resection in the posterior retroperitoneoscopic approach.

METHODS

Six pigs underwent simultaneous (n = 5) or sequential (n = 1) bilateral posterior retroperitoneoscopic adrenalectomy (n = 12). Fluorescence imaging was obtained via intravenous administration of 3 mL of Indocyanine Green (ICG) and by switching the camera systems to near-infrared mode (D-LIGHT P, KARL STORZ; Germany). Fluorescence-based visualization of adrenal glands before vascular division (n = 4), after the main vascular pedicle ligation (negative control, n = 1) or after adrenal resection (n = 7), was followed by completion adrenalectomy. The fluorescence signal intensity dynamics were recorded and analyzed using proprietary software. For each pixel, the slope of fluorescence signal intensity evolution over time was translated into a color-coded perfusion cartography, which was superimposed onto real-time images obtained with the corresponding left and right camera systems. Quantitative fluorescence signal analysis in the regions of interest (ROIs) served to assess adrenal remnant perfusion in divided adrenal glands.

RESULTS

In the retroperitoneum, the vascular anatomy was illuminated in fluorescence imaging first. The adrenal glands were promptly highlighted after primary intravenous ICG administration (n = 9) or showed a fluorescence signal intensity increase upon reinjection (n = 3). Quantitative fluorescence analysis showed a statistically significant difference between perfused and ischemic segments in divided glands (p = 0.0156).

CONCLUSIONS

Fluorescence imaging provides real-time guidance during minimally invasive adrenal surgery. Prior to dissection, it allows to easily discriminate the adrenal gland from surrounding retroperitoneal structures. After adrenal gland division, ICG injection associated with a computer-assisted quantitative analysis helps to distinguish between well-perfused and ischemic segments. Further studies are underway to establish the correlation between remnant perfusion and viability.

Comparison of Robotic Posterior Retroperitoneal Adrenalectomy over Laparoscopic Posterior Retroperitoneal Adrenalectomy: A Single Tertiary Center Experience

BACKGROUND

The aim of this study is to compare the clinical outcomes of laparoscopic posterior retroperitoneal adrenalectomy (LPRA) and robotic posterior retroperitoneal adrenalectomy (RPRA) and determine the differences that could affect the outcomes.

METHODS

We retrospectively analyzed 230 adrenalectomy cases from 2014 to 2017. There were 169 LPRA and 61 RPRA cases, and their clinicopathological features and surgical outcomes were compared.

RESULTS

In LPRA, there was a positive relationship between operation time and male gender, early period of experience, adrenal tumor size, and pheochromocytoma. In RPRA, adrenal tumor size and pheochromocytoma were the factors affecting the operation time. When the adrenal tumor size was ≤5.5 cm, the operation time of LPRA was shorter than that of RPRA (p=0.001). When the tumor size was >5.5 cm, there was no significant difference in the operation times of LPRA and RPRA (p=0.102).

CONCLUSIONS

RPRA is a feasible and technically safe approach for benign adrenal diseases. The use of RPRA could benefit patients and provide comfort by overcoming the factors contributing to a longer operation time in the laparoscopic technique, such as male gender and high BMI.

Adrenal Ganglioneuroma: Features and Outcomes of 42 Cases in a Chinese Population

BACKGROUND

Adrenal ganglioneuromas (AGNs) are extremely rare benign neoplasms. This study is to share our experience regarding diagnostic and operative management of these tumors.

METHODS

Clinical details as well as follow-up data were retrospectively analyzed in 42 primary AGN patients who received operative resection at a tertiary referral hospital in China between May 2005 and July 2016.

RESULTS

The mean age of the patients at diagnosis was 35.3 years (range 13-59 years). Among the patients, 28 were asymptomatic. The mean preoperative size was 5.3 ± 2.2 cm (range 2.1-14.0 cm), and 17 cases were larger than 5 cm. All patients underwent operative resection as open adrenalectomy in 20 patients and laparoscopy in 22 patients. The mean tumor size on pathologic examination was 6.0 ± 2.6 cm (range 2.2-17.0 cm). Laparoscopic operation showed its advantages over open surgery on the postoperative duration (5.0 vs. 7.3 days, p < 0.001) and estimated blood loss (69.5 vs. 157.5 ml, p = 0.047). No patient had recurrence or metastasis during a median follow-up of 70.5 months (range 3.7-164.3 months).

CONCLUSIONS

We describe the largest AGN series reported to date. The preoperative diagnosis of AGN remains difficult despite of the progression of imaging examination. After complete resection, the prognosis of AGN patients is excellent. Laparoscopic approach has its advantages in the resection of AGNs.

Adrenal Metastasis of Hepatocellular Carcinoma in Patients following Liver Resection or Liver Transplantation: Experience from a Tertiary Referral Center

Introduction

Adrenal metastasis of hepatocellular carcinoma (HCC) is a rare entity and can be treated by resection, local ablative therapy, or systemic therapy. Unfortunately, data about treatment outcome, especially in liver transplant recipients, are rare.

Patients and Methods

From 2005 to 2015, 990 liver resections and 303 liver transplantations because of HCC were performed at our clinic. We retrospectively analyzed treatment outcome of the patients with metachronous adrenal metastasis of HCC, who received either resection, local ablation, or surveillance only.

Results

10 patients were identified (0.8%). 7 patients received liver transplantation for primary HCC therapy, 3 liver resection, and 1 a local ablative therapy. 8 patients underwent adrenalectomy (one via retroperitoneoscopy), one was treated with local ablation, and one had surveillance only. Seven out of eight patients had no surgical complications and one experienced a pancreatic fistula, treated conservatively. 37.5% of the resected patients had recurrence 1 year after adrenalectomy and 75% after 2 years. The mean survival time after primary diagnosis of HCC was 96.6±22.4 months. After adrenalectomy, the mean survival time was 112.4±25.2 months. The mean time until tumor recurrence was 13.2±3.8 in the total cohort and 15.8±3.8 months in patients after adrenalectomy. The estimated overall survival after adrenalectomy was 77.2±17.4 months.

Conclusion

Metachronous adrenal metastasis occured in less than 1% of HCC patients. Adrenalectomy is a safe procedure and leads to acceptable survival rates even after liver transplantion. Therefore, it should be performed whenever the primary tumor is well controlled and the patient is in adequate physical condition.

Multicentre study evaluating the surgical learning curve for posterior retroperitoneoscopic adrenalectomy

BACKGROUND

Posterior retroperitoneoscopic adrenalectomy has gained international popularity in the past decade. Despite major advantages, including shorter duration of operation, minimal blood loss and decreased postoperative pain, many surgeons still prefer laparoscopic transperitoneal adrenalectomy. It is likely that the unfamiliar anatomical environment, smaller working space and long learning curve impede implementation. The present study assessed the number of procedures required to fulfil the surgical learning curve for posterior retroperitoneoscopic adrenalectomy.

METHODS

The first consecutive posterior retroperitoneoscopic adrenalectomies performed by four surgical teams from university centres in three different countries were analysed. The primary outcome measure was duration of operation. Secondary outcomes were conversion to an open or laparoscopic transperitoneal approach, complications and recovery time. The learning curve cumulative sum (LC-CUSUM) was used to assess the learning curves for each surgical team.

RESULTS

A total of 181 surgical procedures performed by four surgical teams were analysed. The median age of the patients was 57 (range 15-84) years and 61·3 per cent were female. Median tumour size was 25 (range 4-85) mm. There were no significant differences in patient characteristics and tumour size between the teams. The median duration of operation was 89 (range 29-265) min. There were 35 perioperative and postoperative complications among the 181 patients (18·8 per cent); 17 of 27 postoperative complications were grade 1. A total of nine conversions to open procedures (5·0 per cent) were observed. The LC-CUSUM analysis showed that competency was achieved after a range of 24-42 procedures.

CONCLUSION

In specialized endocrine surgical centres between 24 and 42 procedures are required to fulfil the entire surgical learning curve for the posterior retroperitoneoscopic adrenalectomy.