Does adrenal mass size really affect safety and effectiveness of laparoscopic adrenalectomy?

Development and validation of a preoperative "difficulty score" for laparoscopic transabdominal adrenalectomy: a multicenter retrospective study

Background

A difficulty score for laparoscopic adrenalectomy (LA) is lacking in the literature. A retrospective cohort study was designed to develop a preoperative “difficulty score” for LA.

Methods

A multicenter study was conducted involving four Italian tertiary centers for adrenal disease. The population was randomly divided into two subsets: training group and validation one. A multicenter study was undertaken, including 964 patients. Patient, adrenal lesion, surgeon’s characteristics, and the type of procedure were studied as potential predictors of target events. The operative time (pOT), conversion rate (cLA), or both were used as indicators of the difficulty in three multivariate models. All models were developed in a training cohort (70% of the sample) and validated using 30% of patients. For all models, the ability to predict complicated postoperative course was reported describing the area under the curve (AUCs). Logistic regression, reporting odds ratio (OR) with p-value, was used.

Results

In model A, gender (OR 2.04, p = 0.001), BMI (OR 1.07, p = 0.002), previous surgery (OR 1.29, p = 0.048), site (OR 21.8, p < 0.001) and size of the lesion (OR 1.16, p = 0.002), cumulative sum of procedures (OR 0.99, p < 0.001), extended (OR 26.72, p < 0.001) or associated procedures (OR 4.32, p = 0.015) increased the pOT. In model B, ASA (OR 2.86, p = 0.001), lesion size (OR 1.20, p = 0.005), and extended resection (OR 8.85, p = 0.007) increased the cLA risk. Model C had similar results to model A. All scores obtained predicted the target events in validation cohort (OR 1.99, p < 0.001; OR 1.37, p = 0.007; OR 1.70, p < 0.001, score A, B, and C, respectively). The AUCs in predicting complications were 0.740, 0.686, and 0.763 for model A, B, and C, respectively.

Conclusion

A difficulty score based on both pOT and cLA (Model C) was developed using 70% of the sample. The score was validated using a second cohort. Finally, the score was tested, and its results are able to predict a complicated postoperative course.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08678-6.

Laparoscopic adrenalectomy for giant adrenal tumours: Technical considerations and surgical outcome

Background:

Giant adrenal tumours are tumours with size ≥6 cm. These are rare cancer associated with malignancy in 25% of cases.

Patients and Methods:

A retrospective review was conducted on the medical records of patients admitted to our high-volume centre of Careggi University Hospital with a giant adrenal tumour and submitted to adrenalectomy between January 2008 and December 2018. The group of patients who underwent to laparoscopic adrenalectomy was compared with a group of patients that was submitted to open adrenalectomy.

Results:

In the past 10 years, we performed about 245 adrenalectomies for benign and malignant adrenal tumours. Fifty (20.4%) of these were giant tumours. The medium size was 9.9 cm (7–22 cm). The mean age was 57 years (21–81 years). Thirty-four (68%) of these cancers were laparoscopically removed and 16 (32%) with an open approach. The surgical outcomes in these patients were optimal if compared to the group of patients submitted to open approach in terms of good pain control, hospital stay, mean operative time and bloodless. No difference was observed about post-operative complications in the two groups. The follow-up after 30 months for malignant tumours did not show local recurrences.

Conclusion:

Our results pinpoint the advantages of performing a laparoscopic adrenalectomy for giant adrenal tumours. The tumour size is only a predictive parameter of possible malignancy, and the laparoscopic approach is a safe and feasible method in terms of surgical and oncological, only if performed by expert surgeons and in high-volume centres.

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.

Laparoscopic Adrenalectomy for Adrenal Cancer—A Systematic Review

Laparoscopic adrenalectomy is increasingly employed for removal of adrenal masses. As adrenal tumors increase in size, however, their malignant potential likewise increases, raising concerns for the use of laparoscopy for removal of large adrenal malignancies. We present a systematic review of the use of laparoscopic adrenalectomy of large malignant tumors. A PubMed search was undertaken and two independent reviewers reviewed the manuscripts and a methodological index for nonrandomized studies score was determined. Manuscripts with scores greater than eight were included. The primary end points were rate of cancer recurrence, rate of conversion to open, complications, and surgical technique. Our initial search produced 412 manuscripts. After abstract review, 44 manuscripts were scored, of which 19 manuscripts were used. A total of 2183 tumors were removed, of which 517 were malignant. Average follow-up time was 38.7 months. The recurrence rate was 12.9 per cent. The rate of conversion was 3.6 per cent. The main techniques used were transabdominal and retroperitoneal. No significant differences in rate of recurrence or complications were seen when compared with open. Laparoscopic adrenalectomy may be performed for large and malignant tumors; however, most manuscripts on this subject lack significant scientific rigor and follow-up.

Complications associated with laparoscopic adrenalectomy: Description and standardized assessment

OBJECTIVE

Laparoscopic adrenalectomy (LA) is the procedure of choice for surgical management of the adrenal masses. Our objective is to show a standardized assessment of perioperative complications in one LA series.

MATERIAL AND METHODS

322 LA were performed consecutively between June of 1993 and September of 2012 in patients diagnosed with suprarenal tumour. In order to evaluate perioperative complications, data were collected prospectively and analysed retrospectively. Intraoperative complications were defined using Satava classification and Clavien-Dindo classification of postoperative complications.

RESULTS

Twenty five LA showed perioperative complications (7.3%); 11 (3.2%) were intraoperative complications, most of them vascular diaphragmatic lesions (Satava Grade 2); and 14 (4.1%) were postoperative complications. Six patients showed complications requiring surgery (Clavien IIIa/IIIb) and/or support in Intensive Care Unit (Clavien IV). Conversion to open surgery was necessary in one case (.3%). Despite all appropriate preoperative endocrine measures were taken, an uncontrolled hypertensive crisis and cardio-respiratory arrest recovered were developed during surgery in one patient carrier of pheochromocytoma who died from massive cerebral infarction at 5 days (Clavien V).

CONCLUSIONS

Standardized criteria of surgical complications are necessary. Standardization is possible by combined application of two tools. We believe that this evaluation concept of the surgery morbidity must be used systematically in order to achieve a new standard refined, concise and comparative for reports of adverse perioperative events.

Past and present in abdominal surgery management for Cushing's syndrome

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.

Laparoscopic adrenalectomy for the management of benign and malignant adrenal tumors

Laparoscopic adrenalectomy has become the preferred approach for removal of the adrenal gland. Many published studies support the use of laparoscopic adrenalectomy, with comparisons to open adrenalectomy suggesting many advantages to laparoscopy, including less postoperative pain, shorter hospital stay and earlier return to work. Adrenalectomy is usually required for the removal of adrenal tumors causing excess hormone production or because a malignant adrenal tumor cannot be excluded. Current controversies include the appropriateness of laparoscopic adrenalectomy for large or malignant tumors, the role of partial adrenalectomy and the management of some conditions with uncertain natural history (such as subclinical hypercortisolism). With the increased use of sensitive cross-sectional imaging, the detection of clinically inapparent adrenal masses is likely to continue to increase. Due to the fact that malignancy cannot be excluded with certainty in some patients with cortical adenomas, it is expected that the rate of laparoscopic adrenalectomy will continue to increase.

Expanding the indications for laparoscopic retroperitoneal adrenalectomy: experience with 81 resections

BACKGROUND

Laparoscopic retroperitoneal (RP) adrenalectomy has gained popularity as the preferred approach over transabdominal (TA) method; however, surgeons have been reluctant to offer this operation to obese patients because of the concerns over inadequate working space and overall perceived higher rate of complications. The aim of the present study was to evaluate the feasibility and safety of RP adrenalectomy compared with TA adrenalectomy, specifically in morbidly obese patients.

METHODS

All laparoscopic adrenalectomies performed at our institution between 2004 and 2012 were reviewed retrospectively. Presenting features, operative characteristics, and postoperative outcomes were evaluated. Complications were graded using Clavien system. Continuous variables were compared using Student t-test. Categorical variables were compared using χ(2)-test. Prediction models were constructed using linear or logistic regression as appropriate.

RESULTS

Eighty-one RP and 130 TA procedures were performed, 26 (12.3%) and 60 (28.4%), respectively in obese patients (BMI > 30). Among the obese patients, operative time and estimated blood loss were less for RP (90 versus 130 min; P < 0.001 and 0 versus 50 mL; P < 0.001). Differences in the length of stay, overall mortality, incidence and severity of postoperative complications, and rates of readmission were not statistically significant between RP and TA procedures for all comers and in the obese patients. Controlling the operative characteristics and patient-specific factors, neither operative approach nor obesity was found to independently predict the postoperative complications.

CONCLUSIONS

Laparoscopic RP adrenalectomy is a safe and feasible technique for obese patients. In the obese patients and for all comers, it offers shorter operative time, decreased estimated blood loss, with comparable length of stay and morbidity and mortality rates. We therefore recommend that this technique should be considered for patients undergoing adrenal resection.

Laparoscopic adrenalectomy for large tumours: Single team experience

BACKGROUND

Laparoscopic adrenalectomy (LA) has become the procedure of choice to treat benign functioning and non-functioning adrenal tumours. With improving experience, large adrenal tumours (> 5 cm) are being successfully tackled by laparoscopy. This study aims to present our single unit experience of LA performed for large adrenal masses.

MATERIALS AND METHODS

Forty-six laparoscopic adrenalectomies performed for large adrenal lesions more than 5 cm during the period 2001 to 2010 were reviewed.

RESULTS

A total of 46 adrenalectomies were done in 42 patients. The mean tumour size was 7.03 cm (5-15 cm). Fourteen patients had tumour size more than 8 cm. The lesions were localised on the right side in 17 patients and on the left side in 21 patients with bilateral tumours in 4 patients. Functioning tumours were present in 32 of the 46 patients. The average blood loss was 112 ml (range 20-400 ml) with the mean operating time being 144 min (range 45 to 270 min). Five patients required conversion to open procedure. Three of the 46 patients (6.52%) on final histology had malignant tumours.

CONCLUSION

LA is safe and feasible for large adrenal lesions. Mere size should not be considered as a contraindication to laparoscopic approach in large adrenal masses. Graded approach, good preoperative assessment, team work and adherence to anatomical and surgical principles are the key to success.

[Laparoscopic adrenalectomy in giant masses]

BACKGROUND

Laparoscopic adrenalectomy is considered the treatment of choice in the surgical management of the most majority of the adrenal diseases. Nevertheless, one of the much discussed topics is the dimensional cut-off for the laparoscopic treatment and it is not clear if laparoscopy should be used in large adrenal masses.Introduction. Laparoscopic adrenalectomy is the goal standard in benign adrenal masses smaller than 6 cm, while its advantages in masses larger than this cut-off and in malignant lesions is still discussed.

MATERIALS AND METHODS

We present six cases of laparoscopic adrenalectomy since November 2008 for masses between 7 and 15 cm; 4 men and 2 women. 3 right and 3 left. A complete adrenal endocrinological evaluation demonstrated that the lesions were not secreting tumors. All patients were studied with CT scan.The technique was performed using a flank approach with a 45° tilt. We used 5 trocars in patients who had the masses on the right side, and 4 in those who had the lesions on the left side. After creating an adequate pneumoperitoneum through an open access, the posterior peritoneum cutting, mobilization of the colon, medial dissection of the adrenal gland, and ligation of the main adrenal vein were performed. The adrenal gland was carefully dissected by Ultracision. The mass was extracted by endobag through an additional subcostal port. The mean operative time was 120 minutes. Blood loss was about 50 cc. The drainage was removed on day 2 after surgery and the patient was discharged on day 3. No postoperative complication occurred. The anatomopathologic exam gave evidence of myelolipoma and hemorrhagic cyst.

DISCUSSION

The benefits of the laparoscopic approach are widely demonstrated and consist of a shorter hospital stay, reduced morbility, decreased analgesic requirement, and reduced intraoperative blood loss. One of the most discussed topics is the dimensional cut-off and it is not clear if the laparoscopy approach should be used in large adrenal masses (considering the longer operative time and increasing blood loss). Many surgeons performed laparoscopic adrenalectomy for masses of up to 13 cm, thus demonstrating that this procedure is safe and effective. A limitation of laparoscopic approach for adrenal giant masses is the increased risk to treat an adrenal cortical carcinoma.

CONCLUSIONS

Our experience, supported by the literature, demonstrates that the laparoscopic adrenalectomy is a feasible and effective surgical technique also in the case of giant masses. Preoperative diagnosis has a predominant role to determine the contraindication of this technique (invasive adrenal carcinoma).

Comparison of single-surgeon series of transperitoneal laparoendoscopic single-site surgery and standard laparoscopic adrenalectomy

OBJECTIVE

To assess the feasibility, safety, and efficacy of transperitoneal laparoendoscopic single-site (LESS) adrenalectomy and determine whether it shows any objective advantage compared with standard laparoscopy.

METHODS

From August 2009 to May 2011, 13 transperitoneal LESS adrenalectomies were performed through a 2-3-cm skin incision using the TriPort access system. This cohort was compared with a contemporary 1:2 matched-pair group of 26 patients undergoing standard laparoscopic adrenalectomy by the same urologist. The perioperative outcomes, including cosmetic satisfaction scores, were statistically analyzed.

RESULTS

The 2 groups were comparable with respect to patient demographics, estimated blood loss, and postoperative hospitalization (P > .05). The LESS procedures had a longer mean operative time (148.5 vs 112.9 minutes, P = .032) but a significantly lower postoperative visual analog pain scale score (2.3 vs 3.7, P = .001), fewer patients requiring analgesics (30.8% vs 73.1%, P = .011), and an earlier resumption of oral intake (21.6 vs 26.0 hours, P = .002). The mean length of the scar in the LESS group was much smaller (2.3 vs 5.9 cm, P < .0001) with a statistically significant greater mean cosmetic satisfaction score (9.5 vs 9.1, P = .042).

CONCLUSION

The perioperative outcomes of transperitoneal LESS adrenalectomy for small adrenal tumors were comparable to those with the standard laparoscopic approach. It also provides better postoperative pain control, faster recovery of bowel function, and better cosmetic satisfaction than standard laparoscopy, albeit with a longer operative time.

Laparoscopic adrenalectomy: lessons learned from 306 cases

INTRODUCTION

Laparoscopic adrenalectomy has become the standard of care for the surgical treatment of benign adrenal pathology. We present the following case series documenting our experience in refinement of this approach.

PAIENTS AND METHODS

Analysis of patient records identified those in whom laparoscopic adrenalectomy was performed from January 1997 through February 2010. Study variables included indications, operative time, blood loss, length of hospital stay, histopathological evaluation, and complications.

RESULTS

Laparoscopic adrenalectomy was performed in 306 patients using the transperitoneal lateral approach. No major operative complications were noted, and postoperative complications included a pulmonary embolism and 2 cases of pneumonia. Conversion to the open approach was necessitated in two cases. The median operative time was 95±29 minutes (range, 45-145 minutes). Estimated blood loss was 60 mL (range, 30-150 mL). The mean size of the removed gland was 5.9±1.6 cm (range, 3-13 cm). The mean size of the tumor was 5±2 cm (range, 0.5-12 cm). The median hospitalization was 4±3.7 days (range, 2-22 days). Adrenal pathology included adenoma (n=164), pheochromocytoma (n=79), hyperplasia (n=35), metastatic carcinoma (n=22), cyst (n=9), myelolipoma (n=9), hemangioma (n=3), ganglioneuroma (n=3), and melanoma (n=2).

CONCLUSION

Laparoscopic adrenalectomy is a safe and feasible approach to adrenal pathology, providing the patients with all the benefits of minimally invasive surgery.

Anatomic retroperitoneoscopic adrenalectomy for selected adrenal tumors >5 cm: our technique and experience

OBJECTIVES

To introduce our experience in using anatomic retroperitoneoscopic adrenalectomy (ARA) for adrenal tumors >5 cm and evaluate this procedure's safety and efficiency.

METHODS

Of the 1400 ARAs performed in the past 8 years, 110 were performed on patients who had adrenal tumors with a diameter >5 cm. The perioperative indexes of these patients were retrospectively collected and analyzed.

RESULTS

The mean tumor size on postoperative pathologic examination was 7.2 ± 2.1 cm (range 5-14). Only 1 patient with right-sided adrenal pheochromocytoma (7.8 cm diameter) required conversion to open surgery owing to the tumor's severe adhesions to the liver and inferior vena cava. The mean operative time and evaluated blood loss was 70.8 ± 18.6 minutes and 81.3 ± 46.1 mL, respectively. The average postoperative interval to oral intake and drainage withdrawal was 2.1 and 2.2 days, respectively. No patient died during the operation. Major intraoperative complication (ie, injury to the vena cava) occurred in 1 patient, necessitating open surgery. Minor complications during the perioperative period occurred in 10 patients (9.1%).

CONCLUSIONS

When performed by experienced surgeons, ARA is a safe and feasible procedure for large adrenal masses with a diameter >7 cm; however, this procedure results in a longer operation time and greater blood loss compared with ARA performed on smaller masses. Open surgery is indicated when the tumor adheres to, or has infiltrated, the surrounding tissues.

Laparoendoscopic single site (LESS) adrenalectomy: technique and outcomes

PURPOSE

To describe the surgical technique, to analyze outcomes and to provide an overview of the current status of laparoendoscopic single site (LESS) adrenalectomy.

METHODS

A comprehensive PubMed search was performed for all relevant urological literature regarding LESS and adrenal surgery. In addition, experience gained at the authors' own institutions was considered. Clinical descriptive and comparative reports on LESS adrenal surgery procedures were analysed.

RESULTS

LESS adrenal surgery has been effectively performed for a number of indications. A wide variety of approaches (transperitoneal versus retroperitoneal, multichannel trocar versus multiple ports, trans- or extraumbilical) have been described. LESS adrenalectomy seems to be safe, taking more time than the standard laparoscopic counterpart but appears to offer the patient less postoperative discomfort. Technical difficulties of the procedure include the requirement of more time for adjustment of articulating instruments, longer 'one-handed' manipulation time, and a high peroperative tissue re-grasping rate.

CONCLUSIONS

The feasibility and safety of LESS adrenalectomy has been demonstrated. Only long-term follow-up outcomes will prove its benefits over conventional laparoscopy and define the role and the oncological safety of LESS adrenal surgery.

Is laparoscopy contraindicated in giant adrenal masses?

The first laparoscopic adrenalectomy was performed and described by Gagner in 1992. Since then, this technique has become more and more widespread and there is common agreement in the literature that it is the gold standard for adrenalectomy. Laparoscopic adrenalectomy is indicated in benign adrenal masses, and it is routinely performed in masses smaller than 5 to 7 cm. The laparoscopic procedure in masses larger than this cut-off is discussed, although many investigators agree about its feasibility, safety and effectiveness. We present this case: man, 39 years old, large palpable mass in the right hypochondrium. Computed tomography scan (CT) suggested the diagnosis of giant adrenal myelolipoma (15x12x7 cm). Complete adrenal endoclinologic evaluation showed that the lesion was not a secreting tumor. Laparoscopic adrenalectomy was performed with good results.

Laparoendoscopic single-site retroperitoneoscopic adrenalectomy: a matched-pair comparison with the gold standard

Background

Laparoscopic adrenalectomy has become the gold-standard for the surgical treatment of most adrenal lesions. This study evaluated the operative outcome of laparoendoscopic single-site (LESS) retroperitoneoscopic adrenalectomy (LESS-ARA) in comparison with the current standard operation procedure.

Methods

Between June and December 2009, 19 patients underwent LESS-ARA, and their outcomes were compared with a contemporary 1:2 matched-pair cohort of 38 patients who underwent standard ARA by the same surgeon. In LESS-ARA, a multichannel port was inserted through a 2.5- to 3.0-cm transverse skin incision below the tip of the 12th rib. The LESS-ARA procedure was performed using a 5-mm 30º laparoscopic camera and two standard laparoscopic instruments. The following parameters were compared between the two groups: demographics, details of the surgery, perioperative complications, postoperative visual analog pain scale score, analgesic requirement, and short-term measures of convalescence.

Results

The finding showed that LESS-ARA and standard ARA were comparable in terms of the estimated blood loss (30 vs 17.5 ml; p = 0.64), postoperative hospital stay (6 vs 6 days; p = 0.67), and postoperative complications (2 vs 3 patients; p = 1.00) for patients with similar baseline demographics and median tumor size (2.1 vs 3.0; p = 0.18) cm. The intraoperative hemodynamic values were similar in the two groups. The LESS-ARA group had a longer median operative time (55 vs 41.5 min; p = 0.0004), whereas the in-hospital use of analgesics was significantly less (5 vs 12 morphine equivalents; p = 0.03).

Conclusions

The LESS retroperitoneoscopic adrenalectomy approach is feasible and offers a superior cosmetic outcome and better pain control, with perioperative outcomes and short-term measures of convalescence similar to those of the standard approach, albeit with a longer operative time.

Diagnosis and surgical management for primary hyperaldosteronism

The evaluation of primary hyperaldosteronism presents a challenge to endocrinologists, radiologists, and urologic surgeons. A multidisciplinary approach with biochemical screening and radiologic evaluation is essential in order to assess the nature and function of hypersecreting adrenal glands. Furthermore, it is of great importance to identify individuals that are morbidly affected by aldosterone hypersecretion. Traditionally, open adrenalectomy was the preferred option for these patients. More recently, laparoscopic adrenalectomy has offered a minimally invasive approach, with its resultant advantages of improved perioperative parameters. Herein we describe the evaluation and surgical management for patients with a suspected diagnosis of primary hyperaldosteronism.

Hypercoagulable state in Cushing's syndrome: a systematic review

CONTEXT

It has been debated whether an increased risk of venous thromboembolism (VTE) exists in patients with Cushing's syndrome.

OBJECTIVE

We aimed to summarize published literature on the effects of endogenous hypercortisolism on coagulation and fibrinolysis, as well as on the clinical outcome of VTE.

DATA SOURCES

We searched the MEDLINE and EMBASE databases up to July 2008. Review of reference lists further identified candidate studies.

STUDY SELECTION

Two investigators independently performed study selection and data extraction. Eligible studies had to include Cushing's syndrome patients and either evaluate hemostatic parameters in comparison with control persons or posttreatment levels or describe the occurrence of VTE.

DATA EXTRACTION

The Newcastle-Ottawa Scale was used to assess study quality. A scoring system divided studies into categories of low, medium and high quality.

DATA SYNTHESIS

Of 441 identified publications, 15 reports were included. They contained information on eight cross-sectionals, two intervention, and eight cohort studies. No high-quality studies were identified. Hypercoagulability was suggested by high levels of factor VIII, factor IX, and von Willebrand factor and by evidence of enhanced thrombin generation. A risk of 1.9 and 2.5% was reported for VTE not provoked by surgery, whereas risk of postoperative VTE varied between 0 and 5.6%, with one outlier of 20%. VTE was reported as the cause of death in 0-1.9% of Cushing's syndrome patients.

CONCLUSIONS

Available studies suggest a high risk of venous thrombosis in patients with Cushing's syndrome. Glucocorticoid-induced hypercoagulability as well as surgery and obesity almost certainly contribute to this thrombotic tendency.

Laparoscopic adrenalectomy for large adrenal masses

Open adrenalectomy has been the gold-standard therapy for adrenal neoplasms. Minimally invasive treatments, however, have assumed a more central role in the management of these lesions. The traditional benefits of laparoscopy, including reduced blood loss, shorter hospital duration, and improved convalescence, extend to adrenal disease without compromising the oncologic efficacy of the surgery. Contemporary series suggest that minimally invasive surgery is also a reasonable therapeutic modality for larger adrenal masses. Laparoscopic adrenalectomy for these large masses is a technically demanding procedure that should be undertaken by experienced laparoscopic surgeons familiar with retroperitoneal anatomy and adept with vascular techniques in the event of an open conversion. Oncologic outcomes collectively suggest that in the setting of adequate surgical resection, recurrence patterns relate more to disease-process biology than surgical approach. Neither size criteria, suspicion of malignancy, nor locally invasive disease should be considered an absolute contraindication to laparoscopic adrenalectomy.

Perioperative results of 214 laparoscopic adrenalectomies by anterior transperitoneal approach

BACKGROUND

The present study attempts to evaluate the perioperative results of the anterior approached laparoscopic adrenalectomy (LA) in a large cohort of patients, and report the advantages and disadvantages of this route.

METHODS

204 patients, 125 female and 79 male with a mean age 52.8 years (range, 19-75 years), underwent LA by the anterior transperitoneal approach from 1994 to 2005 in our institution. There were 100 right and 114 left LAs. Ten patients underwent bilateral LA. Associated surgical procedures were performed in 17 cases. During the same period 47 LAs had been performed by different approaches (flank and submesocolic).

RESULTS

Mean operative time was 80 minutes for right (40-150), 109 minutes for left (64-300) and 194 minutes for bilateral adrenalectomy. Intraoperative major complications were observed in six patients. Mortality occurred in one diabetic patient who was converted to open surgery because of a colonic perforation and subsequently developed a Candida sepsis in the postoperative course. The mean size of lesion removed was 6.2 cm (1.5-12 cm). Oral intake started within 24 hours and the mean hospital stay was 2.5 days (1-8 days). Histology results were as follows: nonsecreting adenoma 65, Cushing's adenoma 58, Conn's adenoma 53, pheochromocytoma 24, metastases 9, myelolipoma 3, adrenogenital syndrome 1, carcinoma 1.

CONCLUSIONS

LA by anterior transperitoneal approach is safe and effective in our experience, despite the inherent limitation that this was not a prospective randomized study. The main advantage of this route is early ligature of the adrenal vein on both sides, enabling the performance of associated surgical procedures and bilateral adrenalectomy.

Is laparoscopic adrenalectomy safe and effective for adrenal masses larger than 7 cm?

BACKGROUND

Laparoscopic adrenalectomy (LA) has become the gold standard treatment for small (less than 6 cm) adrenal masses. However, the role of LA for large-volume (more than 6 cm) masses has not been well defined. Our aim was to evaluate, retrospectively, the outcome of LA for adrenal lesions larger than 7 cm.

PATIENTS AND METHODS

18 consecutive laparoscopic adrenalectomies were performed from 1996 to 2005 on patients with adrenal lesions larger than 7 cm.

RESULTS

The mean tumor size was 8.3 cm (range 7-13 cm), the mean operative time was 137 min, the mean blood loss was 182 mL (range 100-550 mL), the rate of intraoperative complications was 16%, and in three cases we switched from laparoscopic procedure to open surgery.

CONCLUSIONS

LA for adrenal masses larger than 7 cm is a safe and feasible technique, offering successful outcome in terms of intraoperative and postoperative morbidity, hospital stay and cosmesis for patients; it seems to replicate open surgical oncological principles demonstrating similar outcomes as survival rate and recurrence rate, when adrenal cortical carcinoma were treated. The main contraindication for this approach is the evidence, radiologically and intraoperatively, of local infiltration of periadrenal tissue.

Case Report: Retroperitoneoscopic Partial Adrenalectomy for Large Adrenocortical Oncocytoma

A young woman had mild hypertension, and on evaluation, a large tumor arising from the right adrenal gland was found. The tumor was hormonally inactive. Retroperitoneoscopic partial adrenalectomy was carried out. The histopathology report described adrenocortical oncocytoma.

Adrenal incidentaloma: surgical update

Nowadays, the role of surgery in the treatment of adrenal incidentalomas (AI), considering their biologic behavior, is still debated. Surgery is mandatory in cases of hyperfunctioning adrenal masses, in the presence of suspect radiological malignancy, in cases of discordant computed tomography (CT) and scintigraphy findings and when the maximum diameter is 4 cm or more. On the other hand, studies have suggested relative inaccuracy of conventional CT in evaluating the size. The aim of this paper was to evaluate the safety and effectiveness of laparoscopic adrenalectomy (LA) in the treatment of AI by reviewing our experience. Over the period from 1995 to 2005 we laparoscopically managed 78 AI by anterior transperitoneal approach. Two LA (2.6%) were converted to open surgery. Neither intra- nor post-operative major complications were observed. The mean size of lesions was 5.5 cm (range 3-9). Twenty-one large adrenal lesions (exceeding 6 cm) were removed (27%). Definitive histology resulted as follows: adrenocortical adenoma (63), pheochromocytoma (5), nodular hyperplasia (4), myelolipoma (3), cysts (2), and adrenocortical carcinoma (1, with a size of 3 cm). The patients were followed-up by hormonal and radiological evaluation every 12 months (6 for malignancy); their follow-up (median 60.4 months, range 6-123) was uneventful. Also larger AI were treated safely. Laparoscopy has been safe and effective in the treatment of AI in our experience, according to specific literature.

Analysis of large versus small pheochromocytomas: Operative approaches and patient outcomes

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.

Laparoscopic adrenalectomy

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.

Indications and Results of Surgery for Incidentally Found Adrenal Tumors

INTRODUCTION

The accidental discovery of an adrenal mass called incidentaloma has become an increasingly frequent clinical problem with the question of a correct and appropriate therapeutic approach being the subject of controversial discussions.

MATERIALS AND METHODS

Clinical charts of 52 patients (22 male, 30 female) who underwent adrenalectomy for an incidentaloma at our institution between 1987 and 2001 were reviewed.

RESULTS

Median age was 56.4 years. Reasons for surgery were unclear significance in 22 patients, suspicion of malignancy in 5, increase in size in 8, maximum tumor diameter of more than 5 cm in 7, fear of malignancy in 1, and subclinical secretion of cortisol in 5 patients. No data were available for 4 patients. Surgical resection was performed using a conventional transabdominal approach in 28 patients, a conventional dorsal approach in 17 patients, and an endoscopic retroperitoneal approach in 7 patients. Histopathologic examination ruled out adrenal adenoma in 32 patients, adrenal myelolipoma in 12, unilateral nodular hyperplasia in 4, cystic lesion in 3, and adrenocortical carcinoma in 1 patient. The mean size of all lesions was 5.5 cm. Evaluating the criteria for surgical treatment regarding age of the patients and size of the lesions, 25 patients (48%), including the patient with the adrenocortical carcinoma, were younger than 60 years and had an adrenal lesion exceeding 4 cm in size. During postoperative follow-up that was available for 39 patients, 3 developed contralateral tumors that were treated by resection in 1 and by close follow-up in 2.

CONCLUSIONS

Size should not be the sole criterion; treatment should be tailored to the individual patient. Especially in patients younger than 60 years with an adrenal lesion exceeding 4 cm in size, an adrenalectomy, predominantly via an endoscopic approach, should be carried out, because a repeated and life-long close follow-up of an anxious patient who has been informed of the diagnosis will in some cases exceed the cost of a single endoscopic operation.

Benefits of Laparoscopic Adrenalectomy: A 10-year Single Institution Experience

INTRODUCTION

We aimed to compare the outcomes of laparoscopic and open adrenalectomies and to assess the impact of the availability of advanced laparoscopy on adrenal surgery at our institution.

MATERIALS AND METHODS

A retrospective analysis of data of all patients who underwent adrenalectomy at the University of Massachusetts Medical Center over a 10-year period.

RESULTS

Sixty-four consecutive patients underwent adrenalectomy during the study periods. There were 19 open (OA) and 45 laparoscopic (LA) adrenalectomies performed. There was no significant difference between the average size of adrenal masses removed for the LA and the OA groups [4.3 vs. 5.5 cm, respectively (P=0.23)]. LA proved superior to OA, resulting in shorter operative times (171 vs. 229 min, P=0.02), less blood loss (96 vs. 371 mL, P<0.01), shorter time to regular diet (1.9 vs. 4.4 d, P<0.001), and shorter hospital stay (2.5 vs. 5.8 d, P=0.02). In addition, the average annual number of adrenalectomies increased significantly since the establishment of our advanced laparoscopic program (10.0 vs. 2.0, P=0.02).

CONCLUSIONS

LA offers superior results when compared to OA in terms of operative time, blood loss, return of bowel function, duration of hospital stay, and functional recovery. The availability of advanced laparoscopy has resulted in a significant increase in the number of adrenalectomies performed at our institution without a shift in surgical indications.

Laparoscopic adrenalectomy for functioning and non-functioning adrenal tumors: analysis of surgical aspects based on histological types

BACKGROUND

The aim of this study was to evaluate whether hormonal functions of the tumor influence the operative results of laparoscopic adrenalectomy, and to analyse the clinical outcomes in patients with various hormonally active adrenal tumors.

METHODS

Clinical and pathological records of 68 patients were reviewed. The average age of patients was 40 years (range 20-75); 39 were women and 29 men. For the comparison, patients were divided into the non-functioning tumor group (n = 22) and the functioning tumor group (n = 46).

RESULTS

All laparoscopic adrenalectomies were finished successfully, and no open surgery was necessary. The median operative time and blood loss in the two groups were similar; however, in subgroup analysis, operative time for pheochromocytoma was significantly longer than that for non-functioning tumor (P = 0.044). No difference was noted in intra- and postoperative data between the groups. Of the 22 patients with aldosteronoma, 18 (81.8%) became normotensive and no longer required postoperative blood pressure medications. Adrenalectomy led to an overall reduction in the median number of antihypertensive medications (P < 0.001). All patients with Cushing adenoma had resolution or improvement of the signs and symptoms during follow-up periods. There was no evidence of biochemical or clinical recurrence in any patient with pheochromocytoma.

CONCLUSION

The results of this retrospective review document that laparoscopic adrenalectomy is a safe and effective treatment for functioning as well as non-functioning adrenal tumors, although endocrinologic features may play a significant role.

Laparoscopic resection of adrenal cortical carcinoma: a cautionary note

BACKGROUND

While laparoscopic removal of small, benign, functioning adrenal tumors is accepted, laparoscopic resection of adrenal tumors that may be adrenal cortical carcinoma (ACC) remains controversial.

METHODS

The records of all patients with ACC evaluated at a single institution from 1991 through 2004 were reviewed retrospectively.

RESULTS

Among 170 patients with ACC, 153 patients underwent open anterior adrenalectomy, 6 underwent laparoscopic adrenalectomy, 1 was treated via an open flank approach, and 10 had no operation. At a median follow-up of 28 months, 115 (86%) of 133 patients who had undergone open anterior resection of primary ACC had had a recurrence. Local recurrence and peritoneal carcinomatosis were components of initial failure in 46 (35%) and 11 patients (8%), respectively. In contrast, all 6 patients who underwent laparoscopic resection of ACC had recurrences, and peritoneal carcinomatosis was a component of initial failure in 5 (83%) of them (open vs laparoscopic resection, Fisher exact test P = .0001).

CONCLUSIONS

Laparoscopic resection of ACC is associated with a high risk of peritoneal carcinomatosis. Open adrenalectomy remains the standard of care for patients presenting with an adrenal cortical tumor for which ACC is in the differential diagnosis.

Adrenalectomía laparoscópica

Laparoscopic extirpation of the suprarenal gland is considered the 'gold standard' of surgery for benign conditions, but its indication in suprarenal cancer is still controversial. In this article, we review the pros and cons of the laparoscopic approach in the different disorders that affect the adrenal gland, pheochromocytoma, cancer, partial and bilateral adrenalectomy, etc.

Laparoscopic adrenalectomy in patients with large adrenal tumors

OBJECTIVES

The maximum size of adrenal tumors that should be removed by laparoscopic adrenalectomy is controversial. We conducted a retrospective comparison of the results of laparoscopic adrenalectomy between patients with adrenal tumors > or =6 cm ('large tumors') and patients with adrenal tumors <6 cm ('small tumors').

METHODS

The participants in the study were 16 patients with large tumors and 111 patients with small tumors. The patients comprised 59 men and 68 women (mean age, 49.0 years; age range, 23-79) with varying diagnoses. Of the 16 patients with large tumors, five had Cushing's syndrome, four had pheochromocytomas, six had a non-functional tumor and one had malignant lymphoma. Adrenal tumors were confirmed by hormonal assays, biochemical tests and computed tomography. Of the 16 large tumors, five tumors were on the right and 11 were on the left.

RESULTS

We found no significant differences in general demographic parameters between patients with large and small tumors. The mean duration of surgery was not significantly different between two groups. (large tumors, 210 min; small tumors,175 min). The mean volume of blood loss was 212 mL for large tumors and 30 mL for small tumors (P < 0.001, significant difference). There was no significant difference in time until walking, duration of hospitalization or number of using analgesics used. The time to first oral intake of group 1 (<6 cm) was significantly shorter than group 2 (> or =6 cm). Tumor size (> or =7.5 cm) was an independent predictor of a longer operation and greater blood loss in large tumors.

CONCLUSIONS

Laparoscopic adrenalectomy for large tumors was safe and minimally invasive.

Laparoscopic Adrenalectomy for Large Adrenal Tumors

BACKGROUND AND PURPOSE

Laparoscopic adrenalectomy remains a controversial procedure for large tumors. We examined the outcome and complications of laparoscopic adrenalectomy for such lesions.

PATIENTS AND METHODS

A total of 178 patients underwent laparoscopic adrenalectomy, of whom 29 patients had large (>or =5 cm) tumors. Their mean age was 47.9 years (range 21-72 years), and the mean tumor size was 6.5 cm (range 5.0-11.0 cm). They were compared with patients whose adrenal tumors were <5 cm.

RESULTS

The large-tumor group had a mean operating time of 176 +/- 48 minutes (range 84-278 minutes) and a mean blood loss of 136.6 mL (range 10-800 mL) and required a mean of 1.8 days before starting oral intake. None of these values is significantly different from the results in the control group (P > 0.05). The length of recovery was significantly longer in the large-tumor group (5.4 v 4.5 days; P < 0.05), but this was not true if a patient with a 23-day postoperative stay is excluded. The overall incidence of complications was 12% in the large-tumor group, which was not significantly different from that in the control group (P > 0.05).

CONCLUSIONS

The operating time, blood loss, and incidence of complications after laparoscopic adrenalectomy did not differ between the patients with large and small adrenal tumors, indicating that experienced surgeons can safely and effectively use laparoscopy for larger tumors. However, it is necessary to consider carefully whether laparoscopic surgery is indicated for tumors that show infiltration on preoperative imaging or for patients who have undergone previous upper-retroperitoneal surgery.

Laparoscopic telementored adrenalectomy: The Italian experience

BACKGROUND

Laparoscopy is widely accepted as the gold standard for adrenalectomy. Telementoring has been developed to reduce the complications associated with surgeon inexperience. We report our preliminary experience with laparoscopic telementored adrenalectomy.

METHODS

From July 2002 to May 2003, eight laparoscopic telementored adrenalectomies were performed between two separate operating sites 430 km apart. Six of these procedures were monolateral laparoscopic adrenalectomies, and one was bilateral. All cases were performed by an expert open surgeon who was skilled in laparoscopic procedure but who had no experience in laparascopic adrenalectomy

RESULTS

All the procedures were successfully performed in a telementored fashion. The mean operative times, blood loss, and postoperative morbidity results were comparable to those for standard laparoscopic adrenalectomies reported in the literature.

CONCLUSIONS

This preliminary experience has demonstrated the feasibility of national telementoring. It is a viable method that can potentially add to surgical education and decrease the likelihood of complications due to inexperience with new techniques.

Laparoscopic Adrenal Surgery: New Frontiers

After about 10 years of experience, laparoscopic adrenalectomy has become the gold standard for the treatment of adrenal lesions. Here, we describe the presenting features, imaging methods, and current surgical approaches to diseases of the adrenal gland. There is general agreement on the suitability of the laparoscopic approach for benign adrenal lesions, but controversy exists about using laparoscopy for suspected adrenal malignancy, metastasis, and partial adrenalectomy. This article reviews the literature on laparoscopic adrenalectomy. In particular, we focus our attention on the new surgical approaches to the gland. We evaluate the indications, operative techniques, and tools for partial adrenalectomy, and we discuss new surgical strategies such as cryosurgery and radiofrequency ablation.

¿Qué ha cambiado en la adrenalectomía? De la cirugía abierta a la laparoscópica

INTRODUCTION

After the introduction of the laparoscopic approach in adrenal surgery, this technique has become the gold standard in surgical adrenal diseases. Nevertheless, comparative studies with open surgery are scarce and the impact of laparoscopic techniques on these diseases is unknown.

OBJECTIVE

To evaluate our experience of adrenal surgery over a 14-year period, before and after the introduction of laparoscopic adrenalectomy, and to analyze the influence of this technique on the surgical management of adrenal diseases.

PATIENTS AND METHOD

From January 1990 to June 2004, 78 patients underwent adrenalectomy. Between 1990 and 1998, open adrenalectomy was performed in 24 patients, while between 1999 and 2004, 54 patients underwent the laparoscopic approach and 1 underwent open surgery. Data for the open group were retrospectively reviewed while those for the laparoscopic group were prospectively registered in the advanced laparoscopic surgery database of Hospital Sant Pau (HSP).

RESULTS

The mean age was 47 years (16-75) in the open group and was 49 years (17-77) (p = NS) in the laparoscopic group. Distribution by surgical indication was similar in both periods concerning primary hyperaldosteronism, hypercortisolism, and pheochromocytoma, with a significant increase in surgical cases indicated by malignancy (1 vs 4) or incidentaloma (2 vs 13) (p<.001). Operating time was reduced from 150 min (65-210) in the open group to 90 min (30-300) in the laparoscopic group (p<.01). Morbidity was also reduced (20% vs 6%, p<.01). The size of lesions resected by open or laparoscopic surgery (4 cm [0.4-16] vs 3.5 cm [1.2-14]) was similar. The mean length of hospital stay was reduced from 8 days (3-13) to 3 days (2-12) (p<.01). The number of adrenalectomies performed in HSP was 24 in the first period (1990-1997) vs 40 in the second (1998-2004). This represented an increase from 3/year to 6.6/year mainly due to the increase in the number of incidentalomas.

CONCLUSIONS

The laparoscopic approach has improved immediate surgical results (operating time, morbidity, and length of hospital stay). There was a clear increase in the number of adrenalectomies, and especially of incidentalomas, due to improved diagnostic techniques and the availability of a less aggressive approach.

[Laparoscopic adrenalectomy for large tumors]

AIM OF THE STUDY

To analyze indications and results of laparoscopic adrenalectomy for large tumors (> 6 cm).

METHODS

It is a retrospective study including patients between January 1994 and December 2003 operated on for large adrenal lesions > or =6 cm. The size was given by the pathologist. All the patients had a flank transperitoneal approach. Analysed Parameters were: operative difficulties; operative time; conversion rate; postoperative morbidity, follow-up and histologic data.

RESULTS

Fourteen patients (10 female and 4 male) were included. Mean age at the time of the diagnosis was 52 years (range: 17-79). Mean size of the lesions was 7 cm (range: 6-10 cm). Mean operative time was 132 mn (range: 120-240 mn). None of the patients experienced surgical complications. Two conversions were needed (for vena cava attachments in one case and because of a retrocava localization in the other case). Three patients had morbidity: one intraperitoneal hemorrhage occurring at the second postoperative day and needing laparotomy; one left pneumopathy; and one case of neuralgia due to a port insertion. Mean hospital stay was 4,5 days. Histologic data showed: five ganglioneuromas, three pheochromocytomas, three adenomas, two adrenocortical carcinomas, and one postpancreatitis cytosteatonecrosis.

CONCLUSION

Laparoscopic adrenalectomy is feasible for large lesions > or =6 cm when no evidence of malignity is demonstrated neither by the preoperative imaging study nor by the surgical exploration.

Is laparoscopic adrenalectomy feasible for adrenocortical carcinoma or metastasis?

OBJECTIVE

To review our experience with laparoscopic adrenalectomy (LA), to evaluate the effectiveness and safety of this procedure in patients with adrenal malignancy.

PATIENTS AND METHODS

The study included patients who underwent LA from 1995 to 2002, with histologically identified adrenocortical cancer (ACC) or metastasis. Indications for LA were adrenal masses with no radiological evidence of involvement of the surrounding structures, or solitary metastasis with well-controlled primary cancer. The variables evaluated were: size of the lesion, operative duration, estimated blood loss, intraoperative complications, local, port-site and intra-abdominal recurrence, distant metastasis, and survival time.

RESULTS

Fourteen malignant adrenal lesions in 205 LAs (7%) were confirmed with histological diagnoses that showed a primary ACC in six and metastasis in another seven (in one there was bilateral metastasis). The mean (sd) size of the malignant lesions was 5.9 (2.8) cm. The 12 unilateral procedures required a mean operative duration of 164 (47) min; the bilateral procedure lasted 215 min. There was one conversion to open surgery caused by local infiltration, whereas there were no intraoperative complications. The mean follow-up was 30 months, during which three patients died, one from endoperitoneal and trocar port-site seeding.

CONCLUSION

When the malignancy is confined to the adrenal gland, LA seems to be a feasible option if the principles of oncological surgery are respected. Nevertheless, further investigations are required to evaluate the appropriateness of this operation.

Laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy (LA) has become the procedure of choice for small benign lesions. Compared with open adrenalectomy (OA), it appears to achieve superior results in terms of recovery, cosmesis and morbidity.

METHODS

A Medline literature search (PubMed database, 1990-2003) was undertaken to identify relevant English language papers. Studies comparing LA with OA were categorized according to their level of evidence. Variables of outcome were analysed systematically for various adrenal pathologies.

RESULTS

No prospective randomized studies comparing LA with OA were identified. According to 20 comparative case-control studies (level 3b) and many case-series reports (level 4), the results of LA were reproducible and it has consistently been associated with faster recovery and lower morbidity than OA. The clinical outcome in hormonally active lesions was similar. The lateral transabdominal approach was the laparoscopic technique of choice; it was practised by 78.6 per cent of surgeons. Lesion sizes of 10-12 cm were cited as the upper limit for LA in many large series. Experience of 70 malignancies demonstrated the feasibility of LA, with short-term oncological results comparable to those of conventional surgery.

CONCLUSION

Despite a lack of a high level of evidence in its favour, LA has practically replaced OA in the management of small and medium-size benign functioning and non-functioning adrenal lesions, as it has proved to be as effective as OA with less associated morbidity. Although limited experience with large and malignant tumours shows some promise, present data are insufficient for clear conclusions to be drawn.

Laparoscopic Approach Reduces Likelihood of Perioperative Complications in Patients Undergoing Adrenalectomy

Laparoscopy has been reported advantageous over the conventional open technique for adrenalectomy. However, most comparative series include the relatively more challenging cases in the open group. The aim of this study is to assess the actual role of laparoscopy in reducing perioperative complications compared to open surgery in patients undergoing adrenalectomy. Between January 1992 and December 2002, we performed 148 adrenalectomies in 138 patients. Depending on the approach, patients were divided into laparoscopic (LA) or open adrenalectomy (OA) groups. Demographics, tumor characteristics, operative data, and outcomes were analyzed. Linear and logistic regressions identified factors influencing perioperative outcomes. Multivariate-adjusted logistic regression assessed independent relationship between factors and perioperative outcomes. A total of 78 cases were performed laparoscopically and 70 open. Patients were matched for age and sex. Tumor size was smaller (3 ± 2 vs 5 ± 3 cm), operative time was shorter (133 ± 65 vs 165 ± 100 min), estimated blood loss was less (114 ± 152 vs 350 ± 417 cc), length of stay was shorter (3 ± 2 vs 7 ± 3 days), and overall complication rate was lower (7% vs 20%) in the LA compared to the OA group. The incidence of cancer in tumors ≥6 cm (31%) was higher than in those <6 cm (4%). All patients with cancer underwent OA. LA was the only factor independently associated with a decreased likelihood of intraoperative bleeding and postoperative pulmonary complications. Large and malignant adrenal tumors are more frequently removed through an open approach. However, this fact has no influence on the advantages of the LA over the OA. Laparoscopy reduces perioperative adrenalectomy perioperative complication rates. It has a positive impact on intraoperative bleeding and postoperative pulmonary complications.

Laparoscopic adrenalectomy for malignancy

Laparoscopic adrenalectomy for primary malignancies and tumors metastatic to the adrenal is controversial. Most studies demonstrate that results of laparoscopic adrenalectomy for malignant lesions are similar to those of open adrenalectomy, without its morbidity. The results of laparoscopic adrenalectomy for tumor metastases suggest that it may benefit patients who have a metachronous metastasis from any of a variety of primary tumors. Selective laparoscopic adrenalectomy for potentially malignant tumors requires seeking signs of local invasion, lymphadenopathy, or distant metastasis; there are no other reliable preoperative criteria of malignancy. Diagnostic laparoscopy may be useful, and in some cases, may establish a diagnosis. Laparoscopic adrenalectomy should be cautiously performed, with the goals of achieving complete tumor resection without disruption of the adrenal capsule.

Bilateral adrenalectomy for Cushing's syndrome: a comparison between laparoscopy and open surgery

We report our experience with bilateral adrenalectomy for treatment of Cushing's syndrome and we compare the outcome of laparoscopy with open surgery in terms of effectiveness and safety. A series of 23 patients underwent bilateral adrenalectomy for treatment of Cushing's syndrome [Cushing's disease in 16, ectopic ACTH syndrome in 2, and ACTH-independent macronodular adrenal hyperplasia (AIMAH) in 5 cases]. From 1993 to 1996, all patients were treated using an open approach (Group A), while from 1997 all patients were treated using a transperitoneal laparoscopic approach (Group B). The comparison between the 2 groups was performed considering patients characteristics, operative times, blood losses, intraoperative and post-operative complications, analgesic consumption, post-operative hospital stay and recovery. Open surgery was performed in 10 patients and laparoscopy in 13 patients. No significant difference was recorded between the two groups as to patients' characteristics and complications. Mean operative time was significantly increased in Group B, while post-operative hospital stay was significantly longer in Group A. Laparoscopic bilateral adrenalectomy can be safely and effectively employed to treat Cushing's syndrome. However, long operatives times may represent a limitation especially in high risk patients.