Comparison of transperitoneal laparoscopic versus open adrenalectomy for large pheochromocytoma: A retrospective propensity score-matched cohort study

A comparative study of retroperitoneal laparoscopic adrenalectomy via intra and extra perinephric fat approaches

OBJECTIVE

To investigate the safety and effectiveness of retroperitoneal adrenalectomy via extra and intra perinephric fat approaches to provide experience and basis for resection of adrenal tumors through the retroperitoneal cavity.

METHODS

The clinical data of 284 patients undergoing retroperitoneal adrenalectomy in our hospital from December 2017 to March 2023 were collected. The basic characteristics of the two groups of patients and the changes in perioperative indicators were retrospectively analyzed.

RESULTS

A total of 117 patients with intra perinephric fat approach (IPFA) were included,and 167 patients with extra perinephric fat approach (EPFA) were included. The estimated blood loss in the IPFA group (123.59 ± 50.76 ml) was higher than that in the EPFA group (99.10 ± 99.51 ml) (p = 0.015),and the operative time in the IPFA group(105.25 ± 42.25 min) was longer than that in the EPFA group(81.75 ± 30.45 min) (p < 0.001).The hospitalization expenses of IPFA patients (36,306.39 ± 7544.25RMB) were higher compared with patients receiving EPFA (32,122.77 ± 7284.00RMB) (p < 0.001).There were no significant differences between the two groups in terms of tumor size,blood transfusion times and postoperative hospitalization time.

CONCLUSION

Retroperitoneal laparoscopic adrenalectomy is a safe and effective procedure that can be performed via extra and intra perinephric fat approaches.IPFA is associated with higher estimated blood loss, and the operation time of EPFA is shorter than IPFA. The choice of surgical approach may depend primarily on the experience of the surgeon, the characteristics of adrenal tumor, and the nature of perirenal adipose tissue.

Prediction of postoperative myocardial injury in patients undergoing laparoscopic pheochromocytoma/paraganglioma resection: protocol for an ambispective cohort study

INTRODUCTION

Pheochromocytoma/paraganglioma (PPGL) resection remains a high-risk surgical procedure owing to severe haemodynamic instability, which can lead to myocardial injury after non-cardiac surgery (MINS). MINS is the most common and easily overlooked cardiovascular complication and results in increased postoperative mortality and prolonged inpatient hospitalisation. We aimed to develop and validate a predictive model for MINS in patients undergoing laparoscopic PPGL resection.

METHODS AND ANALYSIS

The PPGL-MINS study is a single-centre, observational, ambispective cohort study that includes patients undergoing elective laparoscopic PPGL resection under general anaesthesia at the Peking Union Medical College Hospital (PUMCH) between 1 January 2013 and 31 May 2025. We expect to enrol 700 patients, including at least 550 patients retrospectively and 150 patients prospectively. A prediction model will be developed for the retrospective cohort (training cohort) of patients from 1 January 2013 to 31 December 2022. Possible clinically relevant variables, particularly intraoperative blood pressure and heart rate, will be selected as candidate predictors. Stepwise and least absolute shrinkage and selection operator regression will be used for predictor selection. Multivariate logistic regression will be used to develop the prediction model, which will be presented as a nomogram. The developed model will be used to assess discrimination with the receiver operating characteristic curve and area under the curve value, calibration with the Hosmer-Lemeshow test and calibration curve, and clinical usefulness with decision curve analysis. Internal validation will be assessed with bootstrap. For external validation, we will use an independent prospective cohort (validation cohort) of patients from 1 March 2023 to 31 May 2025.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Research Ethics Committee of PUMCH (IRB-K2893). Written informed consent will be obtained from all participants in the prospective cohort before enrolment in the study. We aim to publish and disseminate the findings in peer-reviewed journals and at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT05752773.

Tumor metabolism in pheochromocytomas: clinical and therapeutic implications

Pheochromocytomas and paragangliomas (PPGLs) have emerged as one of the most common endocrine tumors. It epitomizes fascinating crossroads of genetic, metabolic, and endocrine oncology, providing a canvas to explore the molecular intricacies of tumor biology. Predominantly rooted in the aberration of metabolic pathways, particularly the Krebs cycle and related enzymatic functionalities, PPGLs manifest an intriguing metabolic profile, highlighting elevated levels of oncometabolites like succinate and fumarate, and furthering cellular malignancy and genomic instability. This comprehensive review aims to delineate the multifaceted aspects of tumor metabolism in PPGLs, encapsulating genetic factors, oncometabolites, and potential therapeutic avenues, thereby providing a cohesive understanding of metabolic disturbances and their ramifications in tumorigenesis and disease progression. Initial investigations into PPGLs metabolomics unveiled a stark correlation between specific genetic mutations, notably in the succinate dehydrogenase complex (SDHx) genes, and the accumulation of oncometabolites, establishing a pivotal role in epigenetic alterations and hypoxia-inducible pathways. By scrutinizing voluminous metabolic studies and exploiting technologies, novel insights into the metabolic and genetic aspects of PPGLs are perpetually being gathered elucidating complex interactions and molecular machinations. Additionally, the exploration of therapeutic strategies targeting metabolic abnormalities has burgeoned harboring potential for innovative and efficacious treatment modalities. This review encapsulates the profound metabolic complexities of PPGLs, aiming to foster an enriched understanding and pave the way for future investigations and therapeutic innovations in managing these metabolically unique tumors.

[Surgical treatment of pheochromocytoma]

This review article contains a summary of modern aspects of preoperative preparation, surgical treatment, and follow-up of patients with adrenal pheochromocytomas. The main component of preoperative preparation is the use of alpha-blockers. The need to prescribe them to all patients is increasingly disputed, especially for patients without severe hypertension. An increasing number of publications demonstrate positive results of treatment without the use of alpha-blockers, advocating an individual approach and the use of the drug according to certain indications. Minimally invasive endoscopic techniques of adrenalectomy have become widespread in surgical treatment. They are represented by laparoscopic and retroperitonescopic technic, including using their single-port modifications. The earliest possible intersection of the central vein in the past was considered the most important aspect of adrenalectomy for pheochromocytoma, currently, due to the development of surgical techniques and anesthesiological manuals, this has ceased to be a mandatory rule of successful surgery. Despite the significant influence of the intersection of this vessel on intraoperative hemodynamics, surgical tactics with its later intersection have their own justifications and do not lead to a deterioration in treatment results. The standard volume of surgical intervention for pheochromocytomas is total adrenalectomy, however, in the presence of hereditary syndromes, such as multiple endocrine neoplasia type 2 syndrome, neurofibomatosis type 1, von Hippel-Lindau syndrome, it is possible to perform cortical-sparing adrenalectomy.

Comparison of Perioperative Outcomes Between Laparoscopic and Robot-Assisted Adrenalectomy for Large Pheochromocytoma (≥ 5cm): A Retrospective Study

Purpose

The objective of this study was to compare perioperative outcomes in patients with large (≥5cm) pheochromocytomas who underwent adrenalectomy.

Patients and Methods

We retrospectively reviewed patients who underwent laparoscopic adrenalectomy (LA) and robot-assisted adrenalectomy (RA) for large pheochromocytoma (≥ 5cm) at our center between January 2015 to February 2023. We compared the perioperative outcomes between the two groups and investigated impact of high Nor-Metanephrine (NMN) levels on perioperative outcomes by analyzing this subgroup.

Results

A total of 115 patients were included in the study, with 48 patients in the robotic group and 67 patients in the laparoscopic group. The following significant difference were identified in favor of RA: shorter operative (excluding docking time) time (190.0 vs 220.0 min, p=0.002), lower estimated blood loss (50.0 vs 120.0 mL, p=0.013), however, RA group has higher surgical expenses (37933.0 vs 7936.0 CNY, p< 0.001). This finding remained consistent when analyzing patients with high NMN levels.

Conclusion

Patients with large pheochromocytoma may experience reduced blood loss and shorter operative time when undergoing robot-assisted adrenalectomy. However, it is important to note that the RA approach is associated with significantly higher costs.

Pheochromocytoma: a changing perspective and current concepts

This article aims to review current concepts in diagnosing and managing pheochromocytoma and paraganglioma (PPGL). Personalized genetic testing is vital, as 40-60% of tumors are linked to a known mutation. Tumor DNA should be sampled first. Next-generation sequencing is the best and most cost-effective choice and also helps with the expansion of current knowledge. Recent advancements have also led to the increased incorporation of regulatory RNA, metabolome markers, and the NETest in PPGL workup. PPGL presentation is highly volatile and nonspecific due to its multifactorial etiology. Symptoms mainly derive from catecholamine (CMN) excess or mass effect, primarily affecting the cardiovascular system. However, paroxysmal nature, hypertension, and the classic triad are no longer perceived as telltale signs. Identifying high-risk subjects and diagnosing patients at the correct time by using appropriate personalized methods are essential. Free plasma/urine catecholamine metabolites must be first-line examinations using liquid chromatography with tandem mass spectrometry as the gold standard analytical method. Reference intervals should be personalized according to demographics and comorbidity. The same applies to result interpretation. Threefold increase from the upper limit is highly suggestive of PPGL. Computed tomography (CT) is preferred for pheochromocytoma due to better cost-effectiveness and spatial resolution. Unenhanced attenuation of >10HU in non-contrast CT is indicative. The choice of extra-adrenal tumor imaging is based on location. Functional imaging with positron emission tomography/computed tomography and radionuclide administration improves diagnostic accuracy, especially in extra-adrenal/malignant or familial cases. Surgery is the mainstay treatment when feasible. Preoperative α-adrenergic blockade reduces surgical morbidity. Aggressive metastatic PPGL benefits from systemic chemotherapy, while milder cases can be managed with radionuclides. Short-term postoperative follow-up evaluates the adequacy of resection. Long-term follow-up assesses the risk of recurrence or metastasis. Asymptomatic carriers and their families can benefit from surveillance, with intervals depending on the specific gene mutation. Trials primarily focusing on targeted therapy and radionuclides are currently active. A multidisciplinary approach, correct timing, and personalization are key for successful PPGL management.

Hemodynamic parameters in patients undergoing surgery for pheochromocytoma/paraganglioma: a retrospective study

BACKGROUND

Pheochromocytoma (PHEO) and paraganglioma (PGL) are rare neuroendocrine tumors characterized by hemodynamic instability, caused by the paroxysmal release of catecholamines. Patients may develop cardiovascular complications in the perioperative phase due to the massive release of catecholamines, particularly during anesthetic induction and surgical manipulation of the tumor. The aim of this retrospective study was to evaluate the risk factors involved in perioperative hemodynamic instability in patients who underwent surgery for chromaffin tumors.

METHODS

Forty patients (median age 55 [36.50-64.50]) undergone surgery for PHEO/abdominal PGL from January 2011 to December 2016 at the AOU Careggi (Florence, Italy) were retrospectively evaluated. Systolic, diastolic, and mean blood pressure were considered at baseline and during surgery. Patients with blood pressure steadily < 140/90 mmHg before surgery were considered "adequately prepared". A preoperative therapy with doxazosin, a selective alpha-1 blocker, was started in all patients for at least 14 days prior to the surgery. The presence of hemodynamic instability was reported.

RESULTS

Comparing males and females, a significant difference in doxazosin daily dose (p = 0.018), systolic blood pressure (p = 0.048), and in the proportion of adequately prepared patients (p = 0.031) emerged. A positive correlation between preoperative daily dose of doxazosin, tumor size (B = 0.60, p < 0.001), and urinary normetanephrine levels (B = 0.64, p < 0.001) was also observed. Hemodynamic instability occurred in 30.0% of patients. The absence of adequate preparation (p = 0.012) before surgery, urinary normetanephrine levels (NMNur p = 0.039), and surgery time (minutes) (p = 0.021) resulted as risk factors of hemodynamic instability in our series. The use of intraoperative drugs was higher in patients with hemodynamic instability (p < 0.001). A pre-surgical SBP level of > 133 mmHg (OR = 6 CI95% 1.37-26.20, p = 0.017) and an intraoperative SBP and MBP levels of > 127 mmHg (OR = 28.80 CI95% 2.23-371.0, p = 0.010) and > 90 mmHg (OR = 18.90 CI95% 1.82-196.0, p = 0.014), respectively, were identified as effective thresholds to recognize patients at higher risk of HI.

CONCLUSIONS

A preoperative therapy with alpha-blockers is useful, but not sufficient to avoid surgical risks. Patients with higher pre-surgical levels of NMNur, pre-surgical SBP > 133 mmHg, and/or intraoperative SBP > 127 mmHg and MBP > 90 mmHg, should be carefully monitored. A multidisciplinary approach is indispensable to optimize the management of PHEOs/abdominal PGLs in order to reduce surgical complications.

Management of pheochromocytomas and paragangliomas: Review of current diagnosis and treatment options

Pheochromocytomas (PCCs) are rare neuroendocrine tumors derived from the chromaffin cells of the adrenal medulla. When these tumors have an extra-adrenal location, they are called paragangliomas (PGLs) and arise from sympathetic and parasympathetic ganglia, particularly of the para-aortic location. Up to 25% of PCCs/PGLs are associated with inherited genetic disorders. The majority of PCCs/PGLs exhibit indolent behavior. However, according to their affiliation to molecular clusters based on underlying genetic aberrations, their tumorigenesis, location, clinical symptomatology, and potential to metastasize are heterogenous. Thus, PCCs/PGLs are often associated with diagnostic difficulties. In recent years, extensive research revealed a broad genetic background and multiple signaling pathways leading to tumor development. Along with this, the diagnostic and therapeutic options were also expanded. In this review, we focus on the current knowledge and recent advancements in the diagnosis and treatment of PCCs/PGLs with respect to the underlying gene alterations while also discussing future perspectives in this field.

Is transperitoneal laparoscopic adrenalectomy for pheochromocytoma really more challenging? A propensity score-matched analysis

PURPOSE

Minimally invasive surgery is the gold standard treatment for adrenal masses, but it may be a challenging procedure in the case of pheochromocytoma (PHEO). The aim of the present study is to report the results of transperitoneal laparoscopic adrenalectomy (TLA) in cases of PHEO in comparison to other types of adrenal lesions.

METHODS

From 1994 to 2021, 629 patients underwent adrenalectomy. Twenty-two and thirty-five patients, respectively, were excluded because they underwent bilateral and open adrenalectomy, leaving 572 patients for inclusion. Of these, 114 patients had PHEO (Group A), and 458 had other types of lesions (Group B). To adjust for potential baseline confounders, a propensity score matching (PSM) analysis was conducted.

RESULTS

After PSM, 114 matched pairs of patients were identified from each group. Statistically significant differences were not observed when comparing the median operative time (85 and 90 min in Groups A and B, respectively, p = 0.627), conversion rate [6 (5.3%) in each group, p = 1.000], transfusion rate [4 (3.5%) and 3 (2.6%) in Groups A and B, respectively, p = 1.000], complication rate [7 (6.1%) and 9 (7.9%) in Groups A and B, respectively, p = 0.796), median postoperative hospital stay (3.9 and 3.6 days in Groups A and B, respectively, p = 0.110), and mortality rate [1 (0.9%) in each group, p = 1.000].

CONCLUSIONS

Based on this analysis, the results of TLA for PHEO are equivalent to those of TLA for other types of adrenal lesions, but the fundamental requirements are multidisciplinary patient management and adequate surgeon experience. Further prospective studies are required to draw definitive conclusions.

Management of Patients with Treatment of Pheochromocytoma: A Critical Appraisal

Simple Summary

Preoperative medical preparation with an alpha blockade has been implemented early 1960s to prevent intraoperative hemodynamic instability and consequently decrease morbi-mortality in patients at a high risk of complications. Indeed, surgery at that time consisted of open adrenalectomies with a high morbidity and mortality rate. Current clinical guidelines are based on these early experiences. However, emerging technologies have permitted a drastic reduction of the morbi-mortality rate in patients treated for pheochromocytoma. However, the clinical guidelines have not evolved at the same rate. The aim of this systematic review is to assess the evolution of the management of pheochromocytomas and to appraise the current clinical guidelines to the current clinical practices.

Abstract

The management of pheochromocytomas has significantly evolved these last 50 years, especially with the emergence of new technologies such as laparoscopic procedures in the 1990s. A preoperative blockade using antihypertensive medications to prevent intraoperative hemodynamic instability and cardiocirculatory events is recommended by current clinical guidelines. However, these guidelines are still based on former experiences and are subject to discussion in the scientific community. The aim of this systematic review was to assess the evolution of the management of pheochromocytomas. Laparoscopic procedure is established as the standard of care in current practices. Preoperative medical preparation should be questioned because it does not significantly improve intraoperative events or the risk of postoperative complications in current clinical practice. Current clinical recommendations should be revised and upgraded to current clinical practices.

Safety and effectiveness of minimally invasive adrenalectomy versus open adrenalectomy in patients with large adrenal tumors (≥5 cm): A meta-analysis and systematic review

BACKGROUND

This systematic review and meta-analysis compared the safety and effectiveness of minimally invasive adrenalectomy (MIA) with open adrenalectomy (OA) in patients with large adrenal tumors (≥5 cm).

MATERIALS AND METHODS

We performed a systematic review and cumulative meta-analysis of the primary outcomes according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines. Five databases including Medline, PubMed, Cochrane Library, Scopus, and Web of Science were systematically searched. The time frame of the search was set from the creation of the database to March 2022.

RESULTS

Ten studies including 898 patients were included. Compared to OA, MIA is superior for length of stay [LOS WMD = -3.52, 95% CI (-4.61, -2.43), P < 0.01], drainage time [DT WMD = -0.68, 95% CI (-1.27, -0.09), P < 0.05] and fasting time [FT WMD = -0.95, 95% CI (-1.35, -0.55), P < 0.01], estimated blood loss [EBL WMD = -314.22, 95% CI (-494.76, -133.69), P < 0.01] and transfusion [WMD = -416.73, 95% CI (-703.75, -129.72), P < 0.01], while operative time (OT) and complications are not statistically different. For pheochromocytoma, MIA remains superior for LOS [WMD = -3.10, 95% CI (-4.61, -1.60), P < 0.01] and EBL [WMD = -273.65, 95% CI (-457.44, -89.86), P < 0.01], while OT and complications are not significantly different.

CONCLUSION

MIA offers advantages over OA in the management of large adrenal tumors, including in the case of a specific large adrenal tumor - large pheochromocytoma.

Surgical treatment of large pheochromocytoma (>6 cm): A 10-year single-center experience

Objective

Clinical practice guidelines recommend open adrenalectomy (OA) for large pheochromocytoma (LPCC) > 6 cm in size. Although laparoscopic adrenalectomy (LA) for the treatment of LPCC has been reported, its role remains unclear. This study aimed to compare the effectiveness of LA and OA, and summary the surgical treatment experience.

Methods

Data concerning LPCC, from January 2010 to June 2019 of a single institution, were retrospectively reviewed. Altogether 82 patients with a tumor larger than 6 cm were included (52 patients in LA group and 30 patients in OA group). Groups were balanced by propensity score matching (PSM) into 15 pairs. Patients’ demographics, preoperative characteristics, and prognosis were analyzed.

Results

Before PSM, the OA group had larger tumor sizes (median [interquartile range, IQR]: 8.9 [7.3–10.3] vs. 7.2 [6.7–8.0] cm; p=0.000) and higher vanillylmandelic acid level (median [IQR]: 114.3 [67.8–326.4] vs. 66.6 [37.8–145.8] μmol/24 h; p =0.004) and needed a higher cumulative dose of prazosin (median [IQR]: 83.5 [37.0–154.0] vs. 38.0 [21.0–81.0] mg; p=0.028). After PSM, the baseline data showed no significant differences between both groups. The LA group had relatively more stable blood pressure in surgery, with a lower fluctuation of systolic blood pressure (mean±standard deviation [SD]: 70.9±25.1 vs. 107.4±46.2 mmHg, p=0.012) and a lower percentage of hemodynamic instability (46.7% vs. 86.7%, p=0.020). The LA group had shorter postoperative hospital stays (mean±SD: 6.4±2.7 vs. 10.1±3.4 days; p=0.003) than the OA group. Differences regarding metastasis rate (6.7% vs. 0, p=1.000) were not statistically significant between LA and OA groups. The median (IQR) follow-up time of 82 patients was 72.5 (47.0–103.5) months. Binary logistic regression showed that right-side tumors or those >8 cm in size were independent risk factors of OA.

Conclusion

LA is a safe, minimally invasive procedure for LPCC and has relatively better perioperative characteristics in large medical centers. Patients with tumors on the right side or larger than 8 cm are more likely to undergo OA initially.

The association between the type of anesthesia and hemodynamic instability during pheochromocytoma surgery: a retrospective cohort study

BACKGROUND

Pheochromocytoma often carries a risk for perioperative hemodynamic instability (HDI). The aim of this study is to evaluate the risk factors of intraoperative HDI during minimally invasive posterior retroperitoneal adrenalectomy (PRA) for pheochromocytoma.

MATERIALS AND METHODS

This retrospective study analyzed the prospectively collected data of 172 patients who underwent laparoscopic PRA or robotic PRA for pheochromocytoma between January 2014 and December 2020 at a single tertiary center. The patients were divided into two groups according to the intraoperative hypertensive event of systolic blood pressure (> 160 mmHg). The clinical manifestations and perioperative hemodynamic conditions were analysed.

RESULTS

In the multivariate logistic regression analysis, the tumor size (> 3.4 cm) [OR 3.14, 95% confidence intervals (CI) (1.48-6.64), p = 0.003], type of preoperative alpha-blocker (selective type) [OR 3.9, 95% CI (1.52-10.02), p = 0.005], preoperative use of beta-blockers [OR 3.94, 95% CI (1.07-14.49), p = 0.039] and type of anesthesia [total intravenous anesthesia (TIVA) vs. balanced anesthesia (BA)] [OR 2.57, 95% CI (1.23-5.38), p = 0.012] were determined as independent risk factors of intraoperative hypertensive events during minimally invasive adrenalectomy.

CONCLUSIONS

The type of anesthesia was independently associated with intraoperative HDI along with larger tumor size, type of preoperative alpha-blocker and the use of preoperative beta-blockers. TIVA increased the risk of intraoperative hypertensive events compared with BA. Thus, the consideration of the type of anesthesia prior to adrenal surgery for pheochromocytoma along with the use of preoperative non-selective alpha-blockers may be beneficial in minimizing the risk of intraoperative HDI.

Is laparoscopic adrenalectomy for pheochromocytoma safe and effective in geriatric patients?

OBJECTIVES

The study aimed to assess the haemodynamic changes of laparoscopic adrenalectomy (LA) in geriatric patients with pheochromocytoma (PHEO). To the best of our knowledge, this is the first study to evaluate the haemodynamic outcomes of LA in this patient population.

METHODS

Data of 350 patients who underwent single-side transperitoneal LA between 2000 and 2020 were reviewed retrospectively. Patients with a histopathological diagnosis of PHEO were included in the study and classified into two groups according to their ages at the date of surgery. Patients older than 65 years were accepted as elderly according to the World Health Organisation (WHO) recommendations.

RESULTS

A total of 54 patients underwent LA for PHEO. Fifteen patients were enrolled in the elderly and 39 in the young groups. There were no significant differences in terms of the operation site (0.564), tumour size (0.878), perioperative results such as mean anaesthesia; operation times, blood loss and haemodynamic changes. There were no significant differences in mean hospitalisation and intensive care unit times. One patient in both groups had grade 1 complication according to Clavien Dindo classification (prolonged ileus, managed with medical treatment and transfusion during surgery, respectively).

CONCLUSION

Young and elderly patients had similar outcomes in terms of haemodynamic changes that occurred with LA. LA in elderly patients with PHEO is as safe and effective as in younger patients.

Application of retroperitoneal laparoscopy and robotic surgery in complex adrenal tumors

As a surgical method for the treatment of adrenal surgical diseases, laparoscopy has the advantages of small trauma, short operation time, less bleeding, and fast postoperative recovery. It is considered as the gold standard for the treatment of adrenal surgical diseases. Retroperitoneal laparoscopy is widely used because it does not pass through the abdominal cavity, does not interfere with internal organs, and has little effect on gastrointestinal function. However, complex adrenal tumors have the characteristics of large volume, compression of adjacent tissues, and invasion of surrounding tissues, so they are rarely treated by retroperitoneal laparoscopy. In recent years, with the development of laparoscopic technology and the progress of surgical technology, robotic surgery has been gradually applied to the surgical treatment of complex adrenal tumors. This paper reviews the clinical application of retroperitoneal laparoscopic surgery and robotic surgery in the treatment of complex adrenal tumors.

A comparison of outcomes between laparoscopic and open adrenalectomies in dogs

OBJECTIVE

To compare short- and long-term outcomes of dogs with adrenal tumors treated by adrenalectomy with laparoscopy or laparotomy.

STUDY DESIGN

Retrospective study of dogs that underwent adrenalectomy with laparoscopy or laparotomy.

SAMPLE POPULATION

Fourteen dogs treated with laparoscopic adrenalectomy (LA) and twenty-six dogs treated with open midline adrenalectomy (OA).

METHODS

Dogs treated with LA were matched with 1 or 2 dogs treated with OA on the basis of histological nature, size, and side of the tumor. Intraoperative complications, postoperative complications, and long-term survival were compared between LA and OA.

RESULTS

Intraoperative hypotension occurred in 2 of 14 (14.3%) dogs in the LA group and in 16 of 26 (61.5%) dogs in the OA group (P = .007). The surgical time was 69.8 ± 21.8 minutes for the LA group and 108.6 ± 42 minutes for the OA group (P = .0003). The hospitalization time was 39.3 ± 14.9 hours for the LA group and 46.3 ± 25.1 hours for the OA group (P = .1453). The 1- and 2-year survival rates were 77% and 77%, respectively, for the LA group and 77% and 66%, respectively, for the OA group (P = .6144).

CONCLUSION

Laparoscopic adrenalectomy was associated with a shorter surgical time and a reduced incidence of hypotension compared with open adrenalectomy in this case-matched study. Short- and long-term outcomes were not affected by the surgical technique used to complete the adrenalectomy.

CLINICAL SIGNIFICANCE

Laparoscopy can be recommended for adrenalectomy in dogs; however, appropriate case selection is required.

Preoperative intravenous rehydration for patients with pheochromocytomas and paragangliomas: is it necessary? A propensity score matching analysis

Background

Preoperative intravenous rehydration for patients with pheochromocytomas and paragangliomas (PPGLs) is widely used in many medical centers, but its usefulness has not been well evaluated. The objective of this study was to compare the perioperative hemodynamics and early outcome between patients who received preoperative intravenous rehydration and those without for resection of PPGLs.

Methods

In this retrospective propensity score-matched cohort study, the data of patients who underwent surgery for PPGLs were collected. Patients were divided into two groups depending on whether they received or did not receive intravenous rehydration preoperatively. The primary endpoint was intraoperative hypotension, described as the cumulative time of mean arterial pressure < 65 mmHg averaged by surgery duration.

Results

Among 231 enrolled patients, 113 patients received intravenous rehydration of ≥2000 ml daily for ≥2 days before surgery and 118 patients who did not have any intravenous rehydration before surgery. After propensity score matching, 85 patients remained in each group. The median cumulative time of mean arterial pressure < 65 mmHg averaged by surgery duration was not significantly different between rehydrated patients and non-rehydrated patients (median 3.0% [interquartile range 0.2–12.2] versus 3.8% [0.0–14.2], median difference 0.0, 95%CI − 1.2 to 0.8, p = 0.909). The total dose of catecholamines given intraoperatively, volume of intraoperative fluids, intraoperative tachycardia and hypertension, percentage of patients who suffered from postoperative hypotension, postoperative diuretics use, and postoperative early outcome between the two groups were not significantly different either.

Conclusions

For patients with PPGLs, preoperative intravenous rehydration failed to optimize perioperative hemodynamics or improve early outcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-020-01212-6.

Laparoscopic versus open surgery for pheochromocytoma: a meta-analysis

Background

Surgical resection is the main treatment for pheochromocytoma (PHEO). Although open surgery (OS) has been shown to be safe and feasible, the safety and efficacy of laparoscopic surgery (LS) for PHEO remain controversial due to the uncertain effects of pneumoperitoneum on haemodynamics and the complexity of the tumour itself. This study was performed to compare the treatment outcomes of OS with those of LS for patients with PHEO.

Methods

A systematic search through November 11, 2019, was conducted. All studies comparing outcomes of LS and OS for PHEO were included according to eligibility criteria. This meta-analysis was conducted using Review Manager Software, version 5.3, and STATA software, version 12.0. The quality of the included studies was assessed using the Newcastle-Ottawa scale.

Results

Fourteen studies involving 626 patients were included in this meta-analysis. LS was associated with lower rates of intraoperative haemodynamic instability (IHD) [odds ratio (OR) = 0.61, 95% CI: 0.37 to 1.00, P = 0.05], less intraoperative blood loss [weighted mean difference (WMD) = − 115.27 ml, 95% confidence interval (CI): − 128.54 to − 101.99, P < 0.00001], lower blood transfusion rates [OR = 0.33, 95% CI: 0.21 to 0.52, P < 0.00001], earlier ambulation (WMD = − 1.57 d, 95% CI: − 1.97 to − 1.16, P < 0.00001) and food intake (WMD = − 0.98 d, 95% CI: − 1.36 to − 0.59, P < 0.00001), shorter drainage tube indwelling time (WMD = − 0.51 d, 95% CI: − 0.96 to − 0.07, P = 0.02) and postoperative stay (WMD = − 3.17 d, 95% CI: − 4.76 to − 1.58, P < 0.0001), and lower overall complication rates (OR = 0.56, 95% CI: 0.35 to 0.88, P = 0.01). However, no significant differences in operative time, postoperative blood pressure control, rates of severe complications, postoperative hypotension or cardiovascular disease (CVD) were found between the two groups.

Conclusions

LS is safe and effective for PHEO resection. Compared with OS, LS caused less IHD, providing an equal chance to cure hypertension while also yielding a faster and better postoperative recovery.

Is 6 cm Diameter an Upper Limit for Adrenal Tumors to Perform Laparoscopic Adrenalectomy?

Background: We aimed to compare the results of patients who underwent laparoscopic adrenalectomy (LA) for masses ≥6 cm versus <6 cm in diameter in our tertiary referral university hospital. Materials and Methods: Three hundred thirty consecutive patients were divided into two groups according to tumor size (≥6 and <6 cm in diameter). Demographic variables, body mass index (BMI), lesion localization (right/left), tumor diameter, pathological diagnosis and surgical outcomes, including operation time, estimated blood loss (EBL), conversion to open surgery, complications, and length of hospital stay were compared between groups. Results: Between February 2008 and March 2020, 53 patients (29 male-24 female) with ≥6 cm (L group) adrenal tumor and 277 patients (105 male-172 female) with <6 cm tumor (S group) underwent transperitoneal LA. One hundred sixty-eight (50.9%) tumors localized on the left side. In L group mean tumor size in female and male patients was 87.5 ± 40.8 mm (range 50-225 mm) and 67.3 ± 18.4 mm (range 10-100 mm), respectively (P < .05). Age, American Society of Anesthesiology scores, BMI, and mean operation time were similar between groups (P > .05). Postoperative complications were more often in L group (P = .005). EBL in group L and group S was 86 ± 70.4 mL (range 10-500 mL) and 55 ± 44.2 mL (range 10-300 mL), respectively (P = .003). Length of hospital stay in group L and group S was 3.7 ± 3.5 days (range 1-26) and 3 ± 1.6 days (range 1-9), respectively (P = .086). Significant variables in multivariate analysis, including gender (male), EBL, and postoperative complication rate, were entered into multivariate regression analysis, which presented that EBL and postoperative complication rates were independent significants for the L group. Conclusion: Six centimeters should not be considered as an upper limit of transperitoneal lateral LA and may be safely performed in centers with experience. Further studies are needed to confirm our data.

Risk Predictors of Prolonged Hypotension After Open Surgery for Pheochromocytomas and Paragangliomas

BACKGROUND

Prolonged hypotension is a common complication after surgery for pheochromocytomas and paragangliomas (PPGLs). It places patients at an increased risk of major morbidities and even death. The objective of the study was to investigate the risk predictors of prolonged hypotension in patients undergoing open surgery for PPGLs.

METHODS

The present study adopted a retrospective, single-center design. Patients who underwent open surgery for PPGLs were enrolled from January 1, 2002, to December 31, 2018, at Peking University First Hospital. Perioperative variables were screened from patients' electronic medical records. Prolonged hypotension was defined as hypotension that required continuous catecholamine support for at least 30 min to maintain a systolic blood pressure of > 90 mmHg after surgery.

RESULTS

A total of 162 patients were included in the study. Fifty-two patients (31.1%) had prolonged hypotension with a median vasopressor support duration of 14 h (IQR = 4-30 h). Body mass index <24 kg/m² (OR = 3.015, 95% CI 1.217-7.467; P = 0.017), larger tumor size (OR = 1.146, 95% CI 1.014-1.295; P = 0.029), and higher plasma norepinephrine concentration (OR = 1.053, 95% CI 1.019-1.087; P = 0.002) were associated with prolonged hypotension. Patients with prolonged hypotension had a higher incidence of complication, were more frequently admitted to the intensive care unit, underwent mechanical ventilation for a longer duration, and had a longer postoperative hospital stay when compared to those without.

CONCLUSION

Body mass index < 24 kg/m², larger tumor size, and higher plasma norepinephrine concentration are independent risk predictors of prolonged hypotension in patients undergoing open surgery for PPGLs.

Transperitoneal laparoscopic adrenalectomy for the resection of large size pheochromocytoma: Case report and literature review

INTRODUCTION

Pheochromocytomas are rare neuroendocrine tumors that form in chromaffin cells of the neural crest during the embryological period. In the overall population, incidence rate is 0.1%; lack of early diagnosis or adequate treatment can lead to life-threatening complications. The secretion of catecholamines, such as adrenaline or norepinephrine, produces paroxysmal headache, palpitations and arterial hypertension. Secondary, hyperglycemic crises may also appear, thus contributing to misdiagnosis of diabetes mellitus or diabetic ketoacidosis. Surgery prevails as primary treatment; despite its subsequent high mortality rate of up to 50% during the intra and postoperative periods.

CASE REPORT

We describe the case of a 55-year-old man, diagnosed in 2012 with arterial hypertension and almost uncontrollable labile arterial hypertension, who had been medicated with second and third-line antihypertensive drugs, but, who, nonetheless showed no clinical improvement. Biochemical profile studies showed elevated normetanephrine and metanephrine levels; and an abdominal MRI, a markedly vascularized, 72 × 62 mm diameter solid mass in the right adrenal fossa; thereby leading to its classification as a large, noradrenergic phenotype pheochromocytoma.

DISCUSSION

In 2018, at the Fundación de Santa Fe de Bogotá Hospital, patient underwent Transperitoneal Laparoscopic Adrenalectomy, which proceeded without complications. In the 6-month postoperative follow-up, patient remained asymptomatic for cardiovascular risk and maintained stable blood pressure within goals; consequently, antihypertensive therapy was suspended.

CONCLUSION

Despite advances in surgical technique and perioperative management, minimally invasive surgery for resection of large pheochromocytoma is a challenging procedure, due to risk of intraoperative hemodynamic instability.

Laparoscopic and robot-assisted transperitoneal lateral adrenalectomy: a large clinical series from a single center

Since Gagner performed the first laparoscopic adrenalectomy (LTLA) in 1992, laparoscopy has become the gold-standard procedure in the treatment of adrenal surgical diseases. Among all laparoscopic approaches, the transperitoneal lateral adrenalectomy (LTLA) is currently the most widespread procedure. The aim of this article is to analyze our experience in laparoscopy and robot-assisted laparoscopy for the management of surgical adrenal diseases and to value the safety and feasibility of those surgical approaches. From May 2011 until December 2018 were performed 112 adrenalectomies for adrenal tumors by the second division of General Surgery of tertiary care "A. Cardarelli" Hospital of Naples. Out of these, eight operations were carried out with an open surgery approach. Laparoscopic surgery was performed in 104 patients: 64 patients underwent to laparoscopic surgery (LTLA) and 40 patients were treated with a robot-assisted laparoscopy approach. Operative time, intraoperative blood loss, conversion rate, complications, and length of hospital stay were analyzed. Most patients were female and the mean age was 57.2 years in LTLA group, while in the r-LTLA group, the mean age was 55.7 years. Among the adrenal tumors, 55 were left-sided and 49 were right-sided. Median operative time was shorter in r-LTLA (102.2 ± 44.5 min) than in LTLA (128.5 ± 46.5 min). Conversion from LTLA to open surgery occurred in four cases. There were no statistical differences about tumor size and post-operative complications in the analyzed groups. A shorter hospitalization and intermediate care were recorded in the r-LTLA group. LTLA and r-LTLA are safe and effective approaches which ensure successful outcomes for the treatment of adrenal gland tumors.

Diagnosis and treatment of neuroendocrine tumors - A series of 13 clinical cases (2014-2017)

Paragangliomas and pheocromocytomas are rare neuroendocrine tumors with different clinical presentation, being responsible for secondary arterial hypertension with target-organ lesions. Surgery is a curative therapy in these tumors and demands a multidisciplinary approach. These tumors are more frequent between the 4th and 5th decades of life and their clinical manifestations are related to catecholamines production: headache, palpitations, variable blood pressure. This article presents 13 clinical cases of patients with neuroendocrine tumors, with an median-age of 56,7 years, submitted to surgery between 2014 and 2017. The diagnosis was made based on clinical suspicion, serum and urinary catecholamines and metanephrins, imagiologic evaluation with CT or abdominal and pelvic MRI and MIBG scintigraphy. After surgery, the majority of patients remained with normal blood pressure, without anti-hypertensive therapy and follow-up was maintained in Outpatient Clinic, with periodic blood tests and imaging reevaluation.

Comparison of retroperitoneal laparoscopic versus open adrenalectomy for large pheochromocytoma: a single-center retrospective study

Background

It remains unclear whether retroperitoneal laparoscopic adrenalectomy (RLA) is safe and effective for the treatment of large pheochromocytoma (PHEO). This retrospective study aimed to identify the advantages and disadvantages of RLA compared to open adrenalectomy (OA).

Methods

This study included 147 patients who underwent RLA (n = 101) or OA (n = 46) for PHEO larger than 5 cm. Groups were balanced by propensity score matching (PSM) into 46 pairs. Perioperative variables and long-term follow-up results were compared between the two groups.

Results

After PSM, patients in the RLA group had a shorter operative time (218 vs. 245 min, P = 0.040), quicker bowel recovery (2 vs. 3 days, P = 0.046), and a shorter hospital stay (8 vs. 9 days, P = 0.010) compared to the OA group. The results of multiple linear regression analyses showed that the operative method (OA vs. RLA) had an influence on the above three postoperative variables (β = 31.84, P = 0.046; β = 0.76, P = 0.044; and β = 1.25, P = 0.025, respectively). There was no significant difference in the proportion of patients with improved blood pressure (82.61% vs. 69.57%, P = 0.143) between the two groups.

Conclusions

Both RLA and OA provide similar perioperative and long-term outcomes for the surgical management of large PHEO. RLA is an efficacious and safe surgical method for patients with PHEO larger than 5 cm in diameter.