Laparoscopic adrenalectomy--indications and technique

Age-related morphometrics of normal adrenal glands based on deep learning-aided segmentation

OBJECTIVE

This study aims to evaluate the morphometrics of normal adrenal glands in adult patients semiautomatically using a deep learning-based segmentation model.

MATERIALS AND METHODS

A total of 520 abdominal CT image series with normal findings, from January 1, 2016, to March 14, 2019, were retrospectively collected for the training of the adrenal segmentation model. Then, 1043 portal venous phase image series of inpatient contrast-enhanced abdominal CT examinations with normal adrenal glands were included for analysis and grouped by every 10-year gap. A 3D U-Net-based segmentation model was used to predict bilateral adrenal labels followed by manual modification of labels as appropriate. Quantitative parameters (volume, CT value, and diameters) of the bilateral adrenal glands were then analyzed.

RESULTS

In the study cohort aged 18-77 years old (554 males and 489 females), the left adrenal gland was significantly larger than the right adrenal gland [all patients, 2867.79 (2317.11-3499.89) mm³ vs. 2452.84 (1983.50-2935.18) mm³, P < 0.001]. Male patients showed a greater volume of bilateral adrenal glands than females in all age groups (all patients, left: 3237.83 ± 930.21 mm³ vs. 2646.49 ± 766.42 mm³, P < 0.001; right: 2731.69 ± 789.19 mm³ vs. 2266.18 ± 632.97 mm³, P = 0.001). Bilateral adrenal volume in male patients showed an increasing then decreasing trend as age increased that peaked at 38-47 years old (left: 3416.01 ± 886.21 mm³, right: 2855.04 ± 774.57 mm³).

CONCLUSIONS

The semiautomated measurement revealed that the adrenal volume differs as age increases. Male patients aged 38-47 years old have a peaked adrenal volume.

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.

Surgical approach to patients with primary aldosteronism

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

Lateral Transperitoneal Adrenalectomy Versus Posterior Retroperitoneoscopic Adrenalectomy for Benign Adrenal Gland Disease: Randomized Controlled Trial at a Single Tertiary Medical Center

OBJECTIVE

The aim of this study was to compare the surgical outcomes of lateral transperitoneal adrenalectomy (LTA) and posterior retroperitoneoscopic adrenalectomy (PRA) for benign adrenal tumor.

BACKGROUND

Although LTA is the standard treatment for benign adrenal gland tumor, PRA has recently gained popularity. Studies comparing the surgical outcomes of the 2 approaches have reported conflicting findings and thus it remains unclear which approach is superior.

METHODS

This trial was conducted between September 2012 and February 2016. Patients were randomized to either LTA or PRA groups in a 1:1 ratio using web-based randomization. The primary outcome was operative time, and the secondary outcomes were blood loss, intraoperative hemodynamic stability, postoperative pain, recovery of bowel movement, and complication rates. This trial was registered with ClincalTrials.gov, number NCT01676025.

RESULTS

A total of 83 patients were randomly assigned to the LTA group (n = 42) or the PRA group (n = 41). Median follow-up was 31.3 months. The mean operative times of LTA and PRA were comparable (59.7 ± 18.6 vs 67.6 ± 28.7 minutes, P = 0.139). Logistic regression analysis showed that male sex [odds ratio (OR) = 4.20] and pheochromocytoma (OR = 5.06) were associated with an operative time ≥60 minutes. There were no differences in the secondary outcomes between the groups. One patient in the PRA group required open conversion.

CONCLUSION

Both LTA and PRA were performed safely with similar operative outcomes, and thus are comparable options for the treatment of benign adrenal gland tumor.

Risk Factors Associated With Perioperative Complications and Prolonged Length of Stay After Laparoscopic Adrenalectomy

Importance

Laparoscopic adrenalectomy is the gold standard for most adrenal disorders and its frequency in the United States is increasing. While national and administrative databases can adjust for patient factors, comorbidities, and institutional variations, granular disease-specific data that may significantly influence the incidence of perioperative complications and length of stay (LOS) are lacking.

Objective

To investigate factors associated with perioperative complications and LOS after laparoscopic adrenalectomy.

Design, Setting, and Participants

This cohort study was carried out at a single academic medical center, with all patients who underwent laparoscopic adrenalectomy between 1993 and 2017 by the endocrine surgery department. Multivariable linear and logistic regression were used to obtain adjusted odds ratios (ORs).

Main Outcomes and Measures

The primary outcome was perioperative complications with a Dindo-Clavien grade of 2 or more. The secondary outcome was prolonged length of stay, defined as a stay longer than the 75th percentile of the overall cohort.

Results

We identified 640 patients who underwent 653 laparoscopic adrenalectomies, of whom 370 (56.7%) were female. The median age was 51 (range, 5-88) years. A total of 76 complications with a Dindo-Clavien grade of 2 or more occurred in 55 patients (8.4%), with postoperative mortality in 2 patients (0.3%). The median hospital length of stay was 1 day (range, 0-32 days). Factors independently associated with increased complications were American Society of Anesthesiologists class 3 or 4 (OR, 2.78 [95% CI, 1.39-5.55]; P < .01), diabetes (OR, 2.39 [95% CI, 1.14-5.01]; P = .02), conversion to hand-assisted or open surgery (OR, 5.32 [95% CI, 1.84-15.41]; P < .01), a diagnosis of pheochromocytoma (OR, 4.31 [95% CI, 1.43-13.05]; P = .01), and a tumor size of 6 cm or greater (OR, 2.47 [95% CI, 1.05-5.78]; P = .04). Prolonged length of stay was associated with age 65 years or older (OR, 2.44 [95% CI, 1.31-4.57]; P = .01), an American Society of Anesthesiologists class 3 or 4 (OR, 3.48 [95% CI, 1.88-6.41]; P < .01), any procedural conversion (OR, 63.28 [95% CI, 12.53-319.59]; P < .01), and a tumor size of 4 cm or larger (4-6 cm: OR, 2.38 [95% CI, 1.21-4.67]; P = .01; ≥6 cm: OR, 2.46 [95% CI, 1.12-5.40]; P = .03).

Conclusions and Relevance

Laparoscopic adrenalectomy remains safe for most adrenal disorders. Patient comorbidities, adrenal pathology, and tumor size are associated with the risk of complications and length of stay and should all be considered in selecting and preparing patients for surgery.

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.

A successful pregnancy in a patient with secondary hypertension caused by adrenal adenoma: a case report

Background

Secondary hypertension is a rare complication in pregnancy that causes poor outcomes, such as preeclampsia, premature delivery, intrauterine growth retardation, stillbirths, spontaneous abortion or intrauterine death. Cushing’s disease caused by an adrenal adenoma is rare during pregnancy and may be overlooked by obstetricians and physicians, but can lead to hypertension, diabetes mellitus and an increased risk of fetal and maternal morbidity. Approximately 200 cases have been reported in the literature. Here, we report the successful management of a pregnant patient with Cushing’s syndrome due to an adrenal adenoma.

Case presentation

The 35-year-old Chinese female had no individual or family medical history of hypertension, and did not exhibit chronic kidney disease, diabetes mellitus, autoimmune and common endocrine diseases. Her blood pressure was elevated from the 16th week of gestation and was not controlled by 30 mg nifedipine twice a day. Examination in our department revealed her 24 h urinary free cortisol (24 h UFC) level was 1684.3 μg/24 h (normal range: 20.26–127.55 μg/24 h) and plasma adrenocorticotropic hormone was < 1.00 ng/L in three independent measurements (normal range: 5–78 ng/L). Ultrasonography demonstrated a mass (2.9 cm × 2.8 cm) in the right side of the adrenal gland. Magnetic resonance imaging without contrast showed a 3.2 cm diameter mass in the right-side of the adrenal gland. Other medical tests were normal. Laparoscopic adrenalectomy was performed at the 26th week of gestation by a urological surgeon in the West China Hospital. Histopathology revealed an adrenocortical adenoma. After surgery, the patient accepted glucocorticoid replacement therapy. The remaining trimester continued without complication and her blood pressure was normal at the 32nd week of gestation without antihypertensive therapy. The patient gave birth to a healthy boy at the 40th week of gestation.

Conclusions

Cushing’s syndrome caused by adrenal adenoma is rare during pregnancy. This unique case suggested that analysis of the UFC level and circadian rhythm of plasma cortisol provides a suitable strategy to diagnose Cushing’s syndrome during pregnancy. Laparoscopic surgical resection in the second trimester provides a reasonable approach to treat pregnant patients exhibiting Cushing’s syndrome caused by an adrenal adenoma.

Trends in Adrenal Surgery-The Changing Nature of Tumors and Patients

BACKGROUND

The volume of adrenal surgery is increasing. There has been a concern that the widespread use of axial imaging and minimally invasive approaches has led to changing indications for adrenalectomy. We reviewed trends in adrenal surgery at a single academic institution.

MATERIALS AND METHODS

This was a retrospective analysis of all patients who underwent adrenal surgery between 1993 and 2018 by the endocrine surgery service. Patient demographics, diagnosis, operative details, and perioperative complications were evaluated. Trend analysis was performed across ordered year groups (<2000, 2000-2004, 2005-2009, 2010-2014, and 2015-2018).

RESULTS

We identified 732 patients who underwent 751 adrenal operations. Fifty-seven percent of the patients were women, and the median age was 51 y (range: 5-88). There was an increase in the number of procedures performed (P < 0.01, trend analysis). Over time, there was a higher proportion of patients with hypertension (54.7% [<2000] versus 73.6% [>2015], P < 0.01), diabetes (4.7% versus 22.1%, P = 0.01), and classified as American Society of Anesthesiology class 3/4 (15.7% versus 45.7%, P < 0.01). More patients had their adrenal lesion found incidentally (19.4% versus 39.3%, P < 0.01), and there was a larger proportion of pheochromocytomas (25% versus 36.4%, P < 0.01) and fewer nonfunctioning adenomas (7.4% versus 4.3%, P = 0.03). Median tumor size decreased from 3.5 cm to 2.9 cm (P = 0.03). Complication rates increased over time (8.3% versus 15%, P < 0.01), but the overall 30-d mortality remained low (0.3%).

CONCLUSIONS

Adrenal surgery is being performed more commonly with an increasing number of incidentalomas and pheochromocytomas. Our patients have higher comorbidities with increase in complication rates over time, although perioperative mortality remains low. This highlights the importance of a thorough preoperative evaluation to identify suitable patients who may benefit from adrenalectomy.

Laparoscopic Transperitoneal Lateral Adrenalectomy for Large Adrenal Tumors

BACKGROUND

Laparoscopic adrenalectomy is the gold standard for treatment of benign adrenal lesions. Tumor size is a factor that might influence decision-making concerning the use of laparoscopic approach. The aim of this study was to analyze the results of adrenalectomy for tumors ≥6 cm in diameter.

METHODS

Two groups of patients were analyzed: first group comprised 441 patients with tumors <6 cm in diameter and second group consisted of 89 patients with tumors ≥6 cm. Both groups were compared with regard to the duration of surgery, intraoperative blood loss, conversion and complications rate.

RESULTS

Median duration of surgery in groups 1 and 2 amounted to 86.6 and 111.9 min (p < 0.0001), respectively. Median intraoperative blood loss in groups 1 and 2 was 56.5 and 172.8 ml (p < 0.0001), respectively. There was a linear relationship between tumor size and the duration of surgery, and between tumor size and intraoperative blood loss (p < 0.0001). There were 2 (0.5%) and 6 (6.7%) conversions in groups 1 and 2, respectively. There were 41 (9.3%) and 14 (15.7%) complications in groups 1 and 2 (p = 0.0692), respectively.

CONCLUSIONS

Laparoscopic adrenalectomy of tumors ≥6 cm is more difficult, but it can be regarded safe and beneficial for patients.

The role of bilateral adrenalectomy in the treatment of refractory Cushing's disease

Cushing's syndrome (CS) results from sustained exposure to excessive levels of free glucocorticoids. One of the main causes of CS is excessive adrenocorticotropic hormone (ACTH) secretion by tumors in the pituitary gland (Cushing's disease [CD]). Cushing's disease and its associated hypercortisolism have a breadth of debilitating symptoms associated with an increased mortality rate, warranting urgent treatment. Currently, the first line of treatment for CD is transsphenoidal surgery (TSS), with excellent long-term results. Transsphenoidal resections performed by experienced surgeons have shown remission rates ranging from 70% to 90%. However, some patients do not achieve normalization of their hypercortisolemic state after TSS and continue to have persistent or recurrent CD. For these patients, various therapeutic options after failed TSS include repeat TSS, radiotherapy, medical therapy, and bilateral adrenalectomy (BLA). Bilateral adrenalectomy has been shown to be a safe and effective treatment modality for persistent or recurrent CD with an immediate and definitive cure of the hypercortisolemic state. BLA was traditionally performed through an open approach, but since the advent of laparoscopic adrenalectomy, the laparoscopic approach has become the surgical method of choice. Advances in technology, refinement in surgical skills, competency in adrenopathology, and emphasis on multidisciplinary collaborations have greatly reduced morbidity and mortality associated with adrenalectomy surgery in a high-risk patient population. In this article, the authors review the role of BLA in the treatment of refractory CD. The clinical indications, current surgical and endocrinological results reported in the literature, surgical technique (open vs laparoscopic), drawbacks, and complications of BLA are discussed.

Robot-assisted versus laparoscopic adrenalectomy: a systematic review and meta-analysis

BACKGROUND

More recently, robot-assisted adrenalectomy (RA) has emerged as an attractive alternative to laparoscopic adrenalectomy (LA), and many studies have shown the feasibility and safety of RA. However, the short- and long-term outcomes of RA versus LA have not been adequately assessed, and the advantage over the laparoscopic approach has not been demonstrated. The aim of this study was to compare the outcomes of RA versus LA by means of a systematic review and meta-analysis of the available literature in the early experience.

MATERIALS AND METHODS

A systematic search of PubMed, SCI/SSCI, CNKI, and the Cochrane Library was performed to identify prospective randomized controlled trials and retrospective observational studies that compared RA and LA and were published between January 2006 to the end of December 2012. Outcomes of interest included demographic and clinical characteristics, perioperative variables, and complications. The meta-analysis was prepared in accordance with the Quality of Reporting of Meta-analyses (QUOROM) statement.

RESULTS

Eight trials (232 cases and 297 controls) assessing RA versus LA were considered suitable for meta-analysis, including six prospective and two retrospective studies. There was a significant trend to choose patients for the performance of RA who were associated with a lower body mass index (weighted mean difference [WMD]=-2.78 kg/m(2); 95% confidence interval [CI], -3.00 to -2.55; P<.001) and higher incidence of previous surgery (odds ratio=1.59; 95% CI, 0.99-2.54; P=.05). There were no significant differences between the two groups in any other of the demographic parameters. With regard to perioperative variables, although there was a significant difference in the operating time in favor of LA (WMD=17.52 minutes; 95% CI, 3.48-31.56; P=.01), patients having RA might benefit from significantly less blood loss (WMD=-19.00 mL; 95% CI, -34.58 to -3.41; P=.02) and shorter length of hospital stay (WMD=-0.35 day; 95% CI, -0.51 to -0.19; P<.001). There were no significant differences between RA and LA with regard to conversion rates and overall complications. Sensitivity analysis performed by two methods both showed a positive reversal in the operating time with the statistical significance removed compared with the original analysis.

CONCLUSIONS

In the early experience, our data suggest that RA, compared with LA, may be a safe and feasible option associated with less blood loss and shorter hospital stay when performed by experienced surgeons in selected patients.

Surgical treatment of potentially primary malignant adrenal tumors: an unresolved issue

Although the great majority of incidentalomas are adrenocortical adenomas, a number of them, depending on the size and radiological characteristics of the lesions, will turn out to be carcinomas. These tumors may present as suspicious on initial evaluation and potentially malignant or malignant on histology. Adrenocortical carcinoma is a rare and aggressive malignancy with evolving diagnostic and therapeutic approaches. Laparoscopic surgery has become the gold standard for surgery of benign adrenal tumors. Despite the extensive experience gained in laparoscopic adrenalectomy, controversy still remains in the management of adrenal tumors with high suspicion or evidence of malignancy. The aim of this review is to update the existing information regarding the diagnostic approach and surgical management of suspicious and potentially malignant primary adrenal tumors.The interpretation of radiologic characteristics is a cornerstone in pre-operative assessment of large adrenal masses, since open surgery remains the preferred procedure when malignancy is suspected in large tumors with possible local invasion. Despite the improvement of imaging techniques, they lack sufficient accuracy to exclude primary malignancy in tumors from 4 cm to 10 cm in size. An initial laparoscopic approach can be used in this group of patients, but early conversion to open technique is mandatory if curative resection cannot be performed. Adrenal tumors >10 cm of malignant potential should be treated by the open approach from the start. Solitary adrenal metastasis from another primary malignancy is usually amenable to laparoscopic surgery. Patients with suspected adrenal cancer should be referred to tertiary centers that perform laparoscopic and open adrenal surgery with minimal morbidity and mortality.

Prognostic indices of perioperative outcome following transperitoneal laparoscopic adrenalectomy

OBJECTIVES

We sought to identify preoperative patient and tumor characteristics that may be useful prognostic indicators of postsurgical outcome in patients undergoing laparoscopic adrenalectomy (LA).

SUBJECTS AND METHODS

Data from 92 patients who underwent 93 transabdominal LA procedures between 2006-2012 were retrieved. Patients were stratified based on estimated blood loss (EBL), length of stay (LOS), and perioperative complications. Interdependencies between surgical outcome and patient demographics, tumor characteristics, comorbidities, and Charlson Comorbidity Index (CCI) were statistically analyzed. The predictive capacity of each index was assessed using receiver operating characteristic curves.

RESULTS

Neither age, gender, tumor laterality, body mass index, American Society of Anesthesiologists (ASA) score, nor CCI predicted the occurrence of perioperative complications. EBL was significantly associated with increased age, tumor size, ASA score, and CCI, whereas prolonged LOS was associated with higher ASA score. Tumor size was related, although not significantly, to LOS and perioperative complications. Tumors ≥7.5 cm in diameter were significantly associated with worse perioperative outcomes.

CONCLUSIONS

LA for adrenal lesions demonstrated reasonable complication rates and perioperative outcomes. Tumor size, CCI, and ASA score are predictive of increased EBL and LOS.

Nonfunctional adrenal lesions without loss of signal intensity on MRI: whose problem is it? The patient's? The surgeon's?

BACKGROUND

Current indications for adrenalectomy include functional adrenal tumors and potentially malignant tumors based on imaging studies. We evaluated the effectiveness of magnetic resonance imaging (MRI) in obtaining a correct preoperative diagnosis.

METHOD

Fifty-three patients with nonfunctional adrenal lesions were analyzed. Indications for adrenalectomy of nonfunctional adrenal lesions included >6 cm in size and ≤6 cm in size with atypical characteristics on MRI. Lesions with a size of >6 cm, local invasion, irregular margins, and chemical-shift imaging that demonstrated no loss of signal intensity on out-of-phase images were considered suspected of malignancy.

RESULTS

Adrenal lesions of >6 cm in size exhibited an 80-fold increased prediction of malignancy (OR: 80; 95% CI 7.8-813), whereas irregular margins and local invasion exhibited a 45-fold (OR: 45; 95% CI 6.4-312.5) and a 12-fold (OR: 12; 95% CI 4.6-30.6) increased occurrence of malignancy, respectively. The loss of signal intensity did not affect the prediction of malignancy.

CONCLUSION

The rate of unnecessary tumor resections that are <6 cm in size can be decreased by performing adrenal biopsies in selected cases or by short-term follow-up to prevent the insufficiency of imaging techniques.

Subclinical Cushing's syndrome: definition and management

Subclinical Cushing's syndrome is an ill-defined endocrine disorder that may be observed in patients bearing an incidentally found adrenal adenoma. The concept of subclinical Cushing's syndrome stands on the presence of ACTH-independent cortisol secretion by an adrenal adenoma, that is not fully restrained by pituitary feed-back. A hypercortisolemic state of usually minimal intensity may ensue and eventually cause harm to the patients in terms of metabolic and vascular diseases, and bone fractures. However, the natural history of subclinical Cushing's syndrome remains largely unknown. The present review illustrates the currently used methods to ascertain the presence of subclinical Cushing's syndrome and the surrounding controversy. The management of subclinical Cushing's syndrome, that remains a highly debated issue, is also addressed and discussed. Most of the recommendations made in this chapter reflects the view and the clinical experience of the Authors and are not based on solid evidence.

Transabdominal laparoscopic adrenalectomy of a large adrenal lipoma: A case report and review of literature

The exponential increase in use of computer tomography (CT) and magnetic resonance imaging (MRI) has lead to a significant increase in the detection of asymptomatic adrenal masses. The prevalence of adrenal "incidentalomas" is approximately 4-10%. We present a case of a 55-year-old male with a large right adrenal mass that was followed by serial computer tomography scans and multiple non-diagnostic core biopsies. Due to the large size of the mass and unknown pathology, the patient underwent laparoscopic adrenalectomy. The patient's post-operative course was uneventful. Pathology revealed a very unusual finding, a large adrenal lipoma. Adrenal lipomas are rare, benign, non-functioning tumor like lesions that occur with a relative frequency of only 0-11%. Over the past decade approximately 10 cases have been reported in literature. We review the literature of the current diagnostic and surgical treatment of adrenal lipomas (Pubmed and Cochrane from 1992-current).

Laparoscopic resection of retrocaval paraganglioma

OBJECTIVES

Definitive treatment of paraganglioma is by surgical resection. Laparoscopic resection of the paraganglioma presents a unique surgical challenge due to inherent risks associated with excessive catecholamine release during surgical manipulation and variable anatomic presentation. In this report, we present our experience with the laparoscopic resection of the retrocaval paraganglioma.

METHODS

Between October 2001 and November 2007, 2 patients underwent the laparoscopic resection of a retrocaval paraganglioma. In both cases, the tumors were located just behind the inferior vena cava (IVC) without evidence of vessel-wall invasion. The maximum diameter of the tumor was 47 and 44 mm, respectively. There was extrinsic compression of the IVC in an anterior direction by the tumor. To expose the tumor surface completely, the IVC was mobilized medially. Thereafter, we proceeded with dissection of the posterior attachment of the tumor by using a Harmonic Scalpel (Ethicon, Cincinnati, OH). Finally, the tumor and the right adrenal gland were extracted in an endobag.

RESULTS

In both cases, the tumors were successfully removed laparoscopically without the need for conversion or blood transfusion. The operative time was 440 and 195 minutes, respectively. There were no significant postoperative complications.

CONCLUSIONS

To our knowledge, this is the first report of the laparoscopic resection of a retrocaval paraganglioma. For the resection of a paraganglioma, in this location, laparoscopy has the advantage of precise visualization, which helps to resect the tumor completely. Laparoscopic resection of a paraganglioma, despite the high level of compression of the IVC, is a feasible, reproducible technique with appropriate preoperative planning.

Retroperitoneal endoscopic adrenalectomy is safe and effective

Background

The aim of this study was to review an experience with retroperitoneal endoscopic adrenalectomy (REA). This is the procedure of choice for adrenal tumours at this institution.

Methods

Between 1997 and 2008, 112 REAs were performed in a single university centre. Data were retrieved retrospectively from a prospectively collected database, including information on patient demographics, surgical procedure, complications and hospital stay.

Results

One hundred and twelve REAs were carried out successfully in 105 patients, including seven bilateral adrenalectomies. Thirty-nine patients with unilateral adrenal disease had a phaeochromocytoma, of whom 16 had multiple endocrine neoplasia syndrome type 2, 21 patients had Cushing's disease and 20 had Conn's disease. Median body mass index was 27 (interquartile range 23–29) kg/m2. The median duration of unilateral operations was 100 (90–130) min with a median blood loss of 5 ml. Median tumour size was 3·1 (2·0–4·4) cm. Conversion from REA to open surgery was needed in two patients. Seven patients experienced postoperative complications (2 major, 5 minor). One patient needed a reoperation. The median postoperative hospital stay was 3 days. A learning curve with a significant decrease in operating time was observed over the years.

Conclusion

REA appears to be a safe and effective surgical technique for adrenal gland tumours up to 6 cm in diameter, with a minimal complication rate.

Evolution of laparoscopy in pediatric urology

The use of laparoscopy has evolved over the last 30 years, particularly in the last decade, from merely extirpative or diagnostic procedures to intricate reconstructive procedures on the major genitourinary organs. The development of laparoscopy as a method of treating urological problems has progressed more slowly in children compared with adults; perhaps due to the availability of miniaturized technology, the steep learning curve and the high success of traditional open surgery. This article seeks to provide a comprehensive review of the evolution of laparoscopy from its inception to its present-day applications in the field of pediatric urology, including the current indications and results of various laparoscopic procedures.

Laparoscopic adrenalectomy: Norwegian single-center experience of 242 procedures

BACKGROUND

The last 15 years have been characterized by a rapid expansion of minimally invasive surgery as treatment for adrenal diseases. During these years, both indications and surgical techniques have shown improvements. This study analyzed an 11-year single-center experience with laparoscopic adrenalectomy.

MATERIALS AND METHODS

Between January 1997 and April 2008, 242 laparoscopic adrenalectomies were performed in 220 patients at Rikshospitalet University Hospital. Of these, 192 patients were operated on for benign lesions, 23 for malignant lesions, and in 5 cases "en bloc" adrenalectomies were performed. Benign lesions included 136 hormonally active lesions (41 pheochromocytomas, 48 Conn adenomas, 25 Cushing adenomas, and 18 patients with Cushing's disease) and 56 with hormonally inactive lesions (among them, 47 nonfunctional adenomas). Malignant lesions included 16 adrenal metastases and 7 adrenocortical carcinomas.

RESULTS

All adrenalectomies were completed laparoscopically. The median time of unilatateral adrenalectomy was 85 (range, 35-325) minutes. The median blood loss was 0 (range, 0-1100) mL. There were 6 intraoperative and 7 postoperative minor complications. The number of complications did not differ between the types of adrenal pathology. Only 19% of the patients required opioids postoperatively. Per- and postoperative parameters were homogeneous among patients with different adrenal lesions. The patients with adrenocortical carcinoma had a distinctive intraoperative course with an evidently longer operative time and higher blood loss. The median postoperative hospital stay was 2 (range, 1-15) days. Hospital stay was the only postoperative parameter where a difference was found between patients with different adrenal lesions. The patients with carcinoma, pheochromocytoma, and Cushing's disease had the longest median postoperative stay, respectively, 5 (range, 2-6), 3 (range, 1-15), and 3 (range, 2-6) days.

CONCLUSIONS

Laparoscopic adrenalectomy is a safe, effective procedure providing improved fast and uncomplicated patient recovery independent of the type of adrenal lesion. Laparoscopic adrenalectomy can be easily introduced and may soon replace traditional open surgery in specialized centers.

Laparoscopic bilateral simultaneous adrenalectomy: results of 11 operations

BACKGROUND

This study was undertaken to evaluate the outcomes of the simultaneous bilateral laparoscopic adrenalectomy.

MATERIALS AND METHODS

This was a retrospective study, including 11 patients with bilateral adrenal lesions, affected by Cushing's syndrome (n=2), Cushing's disease (n=6), pheochromocytoma (n=2), and 1 adrenocorticotrophin-hormone-dependent hypercortisolism of unknown origin.

RESULTS

Elevan bilateral adrenalectomies were carried out by the laparoscopic approach with no conversions. The operations were performed in 7 cases by the lateral transperitoneal adrenalectomy (LTLA), in 3 by the posterior approach (PRA), and in 1 by the combined approach. The mean size of the masses was 5 cm. (range, 4-13). The average operating time was 245 minutes for LTLA and 218 minutes for PRA (P<0.05). The estimated mean blood loss was 87+/-36 mL (range, 20-150). No patients required transfusions. The mean hospital stay was 5+/-1.8 days (range, 4-7). The mean follow-up was 34 months (range, 2-96).

CONCLUSIONS

Our study confirms that the bilateral adrenalectomy by the minimally invasive technique is safe and effective, affording acceptable blood loss and morbidity with a short hospital stay.

Surgery for Cushing's syndrome: an historical review and recent ten-year experience

BACKGROUND

Cushing's syndrome (CS), due to multiple etiologies, is a disorder associated with the ravages of cortisol excess. The purpose of this review article is to provide a historical synopsis of surgery for CS, review a recent 10-year period of operative management at a tertiary care facility, and to outline a practical approach to diagnosis and management.

MATERIALS AND METHODS

From 1996 to 2005, 298 patients underwent 322 operative procedures for CS at Mayo Clinic, Rochester, Minnesota. A retrospective chart review was carried out. Data was gathered regarding demographics, preoperative assessment, procedures performed, and outcomes. Data are presented as counts and percentages. Five-year survival rates were calculated where applicable by the Kaplan-Meier method. Statistical analysis was carried out with SAS, version 9 (SAS Institute, Inc., Cary, NC).

RESULTS

Two-hundred thirty-one patients (78%) had ACTH-dependent CS and 67 patients (22%) had ACTH-independent CS. One-hundred ninety-six patients (66%) had pituitary-dependent CS and 35 patients (12%) had ectopic ACTH syndrome. Fifty-four patients (18%) had cortisol-secreting adenomas, 10 patients (3%) had cortisol-producing adrenocortical carcinomas, and 1% had other causes. Cure rates for first time pituitary operations (transsphenoidal, sublabial, and endonasal) were 80% and 55% for reoperations. Most benign adrenal processes could be managed laparoscopically. Five-year survival rates (all causes) were 90%, 51%, and 23% for adrenocortical adenomas, ectopic ACTH syndrome, and adrenocortical carcinomas, respectively.

CONCLUSIONS

Surgery for CS is highly successful for pituitary-dependent CS and most ACTH-independent adrenal causes. Bilateral total adrenalectomy can also provide effective palliation from the ravages of hypercortisolism in patients with ectopic ACTH syndrome and for those who have failed transsphenoidal surgery. Unfortunately, to date, adrenocortical carcinomas are rarely cured. Future successes with this disease will likely depend on a better understanding of tumor biology, more effective adjuvant therapies and earlier detection. Clearly, IPSS, advances in cross-sectional imaging, along with developments in transsphenoidal and laparoscopic surgery, have had the greatest impact on today's management of the complex patient with CS.

Open and laparoscopic adrenalectomy: analysis of the National Surgical Quality Improvement Program

BACKGROUND

Numerous series demonstrate the benefits of laparoscopic versus open adrenalectomy, but fail to adjust for confounding factors. This study uses the Veterans Affairs National Surgical Quality Improvement Program database to compare these two approaches, adjusting for baseline differences.

STUDY DESIGN

Laparoscopic (n=358) and open (n=311) adrenalectomy data were collected at 123 Department of Veterans Affairs and 14 university hospitals from October 1, 2001 to September 30, 2004. Preoperative characteristics, operative data, and 30-day outcomes were compared using the chi-square or Fisher's exact test for categorical variables and the t-test for continuous variables. Unadjusted odds ratio (OR) and 95% confidence interval (CI) were computed for the effect of operative approach on postoperative morbidity. Adjusted odds ratios and 95% CI were computed for this same effect, adjusting for variables that were predictive of outcomes or imbalanced at baseline. Data are reported as means +/-SD, unless otherwise indicated.

RESULTS

Patients undergoing open adrenalectomy were more likely to be older (57.8+/-11.9 years versus 53.5+/-13.2 years, p < 0.0001), harbor malignancy (44.5% versus 13.5%, p < 0.0001), have higher American Society of Anesthesiologists classifications (p=0.0037), smoke (35.4% versus 22.6%, p=0.0003), and have lower serum albumin levels (3.9+/-0.5 g/dL versus 4.0+/-0.5 g/dL, p=0.0241). Open procedures had increased operative times (3.9+/-1.8 hours versus 2.9+/-1.3 hours, p < 0.0001), transfusion requirements (0.7+/-1.8 U versus 0.1+/-0.5 U, p<0.0001), reoperations (4.8% versus 1.4%, p=0.0094), length of stay (9.4+/-11.0 days versus 4.1+/-4.7 days, p < 0.0001) and 30-day morbidity rates (17.4% versus 3.6%, p < 0.0001) with unadjusted and adjusted odds ratio (95% CI) of 5.52 (2.94, 10.33), and 3.97 (1.92, 8.22), respectively. Open procedures resulted in more pneumonia, unplanned intubation, unsuccessful ventilator wean, systemic sepsis, cardiac arrest, renal insufficiency, and wound infections.

CONCLUSIONS

Even after adjustment for confounding factors, 30-day morbidity was much higher for patients having open adrenalectomy.

Outcomes of laparoscopic adrenalectomy. Clinical experience with 68 patients

The aim of this study was to analyze feasibility and outcomes of laparoscopic adrenalectomy (LA). Pathology, size and bilateral site of lesions were considered. Between December 1998 and May 2007 in our institution a total of 68 patients of mean age of 53 years underwent unilateral (n=57) or bilateral (n=11) LA. Adrenal masses averaged 5.4cm in size (range 1.2-13cm) and 56.7g in weight (range 10-265) including 71 benign and 8 malignant lesions. A total of 79 adrenal glands were resected, 44 right sided and 35 left sided. Removal was complete in 77 cases and partial (sparing adrenalectomy) in 1 patient affected by bilateral pheochomocytoma. Three left adrenalectomies for pheochromocytoma were robot-assisted. The transperitoneal lateral approach was preferred and the posterior retroperitoneal approach was adopted in 5 patients. The mean duration of surgery for each LA was 138+/-90min and 3.8 trocar were used on average (range 3-6). Conversion was needed in 3 cases owing to difficult dissection of large masses. Estimated mean blood loss for each LA was 95+/-30ml and it was greater for bilateral LA. Mortality was nil and morbidity was 5.8%. The average length of hospital stay (LOS) in surgical unit was 4+/-2.4 days (range 2-8). Patients affected by hormone secreting or bilateral lesions, by unilateral or bilateral pheochromocytoma and by bilateral Cushing's disease were transferred to the endocrinological ward so that their overall hospital stay was prolonged to 9+/-2.8 days on average (range 7-17). Mean duration of follow-up of patients was 38 months (range 2-100) and demonstrated acceptable endocrine results. Three primary cortical carcinomas were discovered as chance findings on histologic examination. While long-term results after LA for cortical carcinomas were poor and LA is not recommended in such cases, long-term results after LA for adrenal metastases were encouraging.

Incidence of pheochromocytoma in trauma patients during the management of unrelated illness: A retrospective review

BACKGROUND

Over the last two decades the rate of detection of asymptomatic adrenal masses has increased as a result of the widespread use of abdominal imaging modalities. Incidental pheochromocytoma discovered during the management of an unrelated illness is a rare presentation of these tumors. They can occur in patients treated for multiple trauma with no history of prior arterial hypertension.

METHODS

From January 1995 to December 2005 a total of 45 patients underwent adrenalectomy for incidentaloma. Of these, a pheochromocytoma was detected in 13 patients (29%) seen for an unrelated condition, 3 were in trauma patients. Nine men and 4 women with a mean age 44.5 years (range 21-67) underwent adrenalectomy for incidental pheochromocytoma.

RESULTS

Less than half (6 patients, 46%), and one of the trauma patients had a history of arterial hypertension. Preoperative hormonal studies revealed a pheochromocytoma in 11 patients with incidentalomas. One patient had normal preoperative catecholamines levels. Laparoscopic transabdominal adrenalectomy was attempted in 10 patients with one conversion to open surgery in the case of paraganglioma and one for injury to the left renal vein. Three patients underwent open adrenalectomy. Mean surgery time of trauma patients was 167 (range, 130-235) min. Intraoperative instability (systolic pressure >200 mmHg) requiring nitroprusside and/or labetalol, was observed in 7 patients (54%). There was no postoperative morbidity or mortality. Over the last 10 years, 23% of the pheochromocytomas found incidentally were in trauma patients.

CONCLUSION

Incidentally discovered adrenal masses need to be investigated for pheochromocytoma. This holds specially true for trauma patients who may be put in serious jeopardy should they need surgery for their injuries.

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.

Incidentally discovered tumors of the endocrine glands

Clinically inapparent masses, or ‘incidentalomas’ of the endocrine glands are increasingly common owing to continued advancements in medical imaging. Incidentalomas of the adrenal glandS have received substantial attention in the literature, whereas lesions of the thyroid and endocrine pancreas, though frequently encountered in the clinic, have received relatively little attention. We review the detection and subsequent management of incidentalomas of the thyroid, adrenal and pancreas, with specific attention paid to the mode of detection and risk stratification of lesions.

Adrenalectomy in Hong Kong: a critical review of adoption of laparoscopic approach

BACKGROUND

A population-based study on adrenal surgery for treatment of adrenal diseases is still lacking. The aim of the present study is to evaluate the practice and the adoption of laparoscopic adrenalectomy (LA) in a stable population, as well as the potential impact of case volume on outcomes.

METHODS

Patients undergoing elective adrenalectomy (n = 486) from 15 Hong Kong public hospitals over a 6-year period were reviewed. Patients undergoing LA (n = 353) were compared to those undergoing open adrenalectomy (n = 133).

RESULTS

The overall number of adrenalectomies and the number and proportion of laparoscopic approach increased progressively during this period. The median operating time was similar but the median blood loss (50 mL vs 300 mL, P < .01) was less and the mean hospital stay (4.4 days vs 9.4 days) was shorter for LA. Smaller lesions tended to be selected for LA. There was no correlation between postoperative outcome with respect to length of stay and case volume for LA.

CONCLUSIONS

The adoption of LA in Hong Kong hospitals was propagating progressively. Patients selected for LA had improved outcome although there seemed to be no significant correlation between postoperative outcome and case volume.

Retroperitoneoscopic adrenalectomy: an early institutional experience

OBJECTIVE

To review our initial experience with the retroperitoneoscopic approach, which is rapidly becoming the procedure of choice for paediatric adrenalectomy. Swift access to the vascular pedicle makes this approach ideal for adrenal surgery where haemodynamic instability is a common feature.

METHOD

Patients were placed in a fully prone position and the locations of the 12th rib, iliac crest and paravertebral muscles were marked. A 10-mm incision was made lateral to the para-vertebral muscle, halfway between the iliac crest and costal margin. A retroperitoneal working space was created around the kidney using a homemade balloon. A 10-mm Hasson port was then inserted. A 5-mm working port was placed lateral to the tip of the 12th rib and, if necessary, a second was inserted medial to the camera port. Dissection was performed with diathermy and/or Harmonic Scalpeltrade mark and the adrenal vessels were divided between clips. The specimen was retrieved in an endopouch through the 10-mm port.

RESULTS

Over 16 months, six adrenalectomies were performed in five patients (three boys and two girls); two right, two left and one bilateral. Median age at surgery was 8 years. Presentation was with hypertension (n=2), Cushing's syndrome (n=2) and abdominal pain (n=1). Median operative time was 154 min. A single-instrument port adrenalectomy was performed in three patients. Histopathological diagnosis included adrenal cyst (n=1), cystic phaeochromocytoma (n=1), adrenal cortical tumour (n=2) and central Cushing's disease (n=1). All were completely resected. All patients remain symptom free with a median follow up of 17 months.

CONCLUSION

These cases represent our initial institutional experience with retroperitoneoscopic adrenalectomy. The senior reporting surgeons have already surmounted the general learning curve for laparoscopy, and this experience has proved vital to expand our repertoire with encouraging early results. This is our technique of choice as it provides a superior view of the adrenal gland and vessels, with good intraoperative haemodynamic stability.

Large idiopathic unilateral adrenal hematoma in a young woman

This is a case report on a young woman with a large idiopathic unilateral adrenal hematoma (AH). Only few cases of AH which were not associated with any trauma, previous surgery, coagulative or any other systemic disorders have been described. The mass was discovered by abdominal ultrasound which was performed for a recent flank pain. Magnetic resonance imaging (MRI) confirmed the presence of a 13-cm sized lesion in the right hemi-abdomen; T1 and T2 weighed imaging was compatible with subacute-to-chronic adrenal hematoma. The lesion dislocated the liver and right kidney. Positron emission tomography (PET) did not show any significant radiotracer uptake by the mass. Serum cortisol, aldosterone, renin activity and DHEA-S were normal. Urinary catecholamines and free cortisol excretion were within the normal range too. The lesion was removed by transabdominal laparoscopic adrenalectomy without any complication. The histological exam confirmed a large subacute- to-chronic organized AH. In conclusion, in the absence of known risk factors, differential diagnosis of a large AH may not be easy. The possibility of an underlying pheochromocytoma, malignant adrenal or metastatic tumor must always be considered. In our patient, computed tomography (CT) scan and MRI suggested the presence of a large subacute-to-chronic AH, and PET excluded metabolic activity of the mass. Laparoscopic adrenalectomy can be the surgical treatment of choice in organized symptomatic AH. The correct diagnosis, early recognition and treatment of complications including adrenal insufficiency may decrease patient morbidity and mortality.

Laparoscopic transperitoneal adrenalectomy using the LigaSure vessel sealing system

BACKGROUND

Laparoscopic adrenalectomy is being performed with increasing frequency in the surgical treatment of adrenal tumors. Among laparoscopic approaches to the adrenal glands, the transperitoneal access is preferred. Along with advances in technology, different energy systems have been utilized. Laparoscopic adrenalectomy has become easier with the use of the LigaSure vessel sealing system (Valleylab, Boulder, Colorado).

MATERIALS AND METHODS

Between January 2002 and August 2004, 23 laparoscopic transperitoneal adrenalectomies were performed in 22 patients using the LigaSure vessel sealing system: 16 of the patients were female, 6 were male and the mean age was 44 years (range, 17-70 years). Indications for surgery were non-functioning adenoma (n = 10), pheochromocytoma (n = 4), Cushing's syndrome (n = 5), Conn's syndrome (n = 2), and lymphoma (n = 1). The mean diameter of lesions was 4 cm (range, 1-7 cm). The distribution was 12 left, 9 right, and 1 bilateral adrenalectomies.

RESULTS

The mean operative time for unilateral adrenalectomies was 57 minutes (range, 30-75 minutes). The operative time for the patient with Cushing's disease in whom a bilateral adrenalectomy was performed was 180 minutes. All operations were completed laparoscopically. A nonsteroidal anti-inflammatory drug (Lornoxicam) was sufficient for postoperative analgesia. Oral feeding was started 6 hours postoperatively. When used, drains were removed on postoperative day 1. The mean postoperative hospital stay was 1.5 days (range, 1-3 days). Wound infections developed in two patients with Cushing's syndrome. There was no mortality. Histopathologic examination of specimens revealed a cortex adenoma in 16 cases (10 of which was nonfunctional), a pheochromocytoma in 4 cases, a bilateral cortical hyperplasia in 1 case, and a lymphoma in 1 case.

CONCLUSION

Laparoscopic adrenalectomy is an established method in the treatment of adrenal masses. Laparoscopic adrenalectomy as well as other laparoscopic procedures has become easier with the introduction of new energy systems. Vascular control and dissection of the gland by Liga- Sure is feasible. It makes the procedure easier and eventually shortens the operation time.

Risk Assessment in 457 Adrenal Cortical Carcinomas: How Much Does Tumor Size Predict the Likelihood of Malignancy?

BACKGROUND

Laparoscopic adrenalectomy for tumors > 6 cm is controversial because of the risk of malignancy, but data to support this position are mostly from small series. The recent NIH consensus conference did not make a definitive recommendation about management of 4- to 6-cm nonfunctioning incidentalomas.

STUDY DESIGN

Adrenocortical carcinomas (ACC) recorded in the Surveillance, Epidemiology, and End Results (SEER) database (1988 to 2000) were compared with benign functional or nonfunctional adrenal cortical adenomas (excluding aldosteronomas) operated on at our institution between January 1, 1993, and July 1, 2003. Data were compared using t-tests, chi-square tests, likelihood ratios, and receiver operating characteristic (ROC) curves.

RESULTS

We identified 457 patients with ACC and 47 patients with adrenal cortical adenomas; 376 and 44 neoplasms, respectively, had tumor size data available. Tumor size was larger in ACC (12.0 +/- 5.6 versus 4.2 +/- 1.9 cm, mean +/- SD, p < 0.05). For ACC presenting with local disease, the sensitivity, specificity, and likelihood ratios of tumor size to predict malignancy were 96%, 52%, and 2.0, respectively, for tumors > or = 4 cm; 90%, 80%, and 4.4 for tumors > or = 6 cm; 77%, 95%, and 16.9 for tumors > or = 8 cm; and 55%, 98%, and 24.4 for tumors > or = 10 cm. Assuming a pretest probability of malignancy of 5%, the likelihood ratios derived from this study yield a posttest probability of 10%, 19%, and 47% for cancer in adrenal cortical tumors > or = 4 cm, > or = 6 cm, and > or = 8 cm, respectively.

CONCLUSIONS

These data suggest that size is useful for predicting malignancy, and that at a size threshold of > or = 4 cm, the likelihood of malignancy doubles (to 10%) and it is more than ninefold higher for tumors > or = 8 cm (47%).

Laparoscopic surgery for melanoma metastases to the adrenal gland

The probability of developing cutaneous melanoma is now predicted to be one in 55 for males and one in 88 for females. Although melanoma is relatively uncommon compared with other malignancies such as breast (one in seven) or prostate cancer (one in six), the incidence is growing at an alarming rate. The development of novel strategies for the management of advanced disease will become even more urgent and require continued and controlled investigations over the next 10 years. Surgery is effective for the palliation of isolated resectable metastases. However, most patients with Stage IV melanoma have widespread disease and are not cured by metastasectomy. For the few individuals with isolated adrenal metastases from melanoma, complete resection appears to confer a survival advantage. New data are emerging about the efficacy and outcome of laparoscopic adrenalectomy for malignant lesions. However, the natural history of laparoscopic surgery for these lesions is still unknown. The indications for and limitations of laparoscopic adrenalectomy for metastatic melanoma are discussed.

Cushing's syndrome during pregnancy secondary to adrenal adenoma: metyrapone treatment and laparoscopic adrenalectomy

Cushing's syndrome during pregnancy is a rare and difficult to diagnose disorder. We describe the case of a 30-yr-old woman presenting with symptoms and signs of mild hypercortisolism, in which ACTH-independent Cushing's syndrome was diagnosed. Urinary cortisol excretion was elevated and circadian rhythm of cortisol was absent. ACTH levels were low. In addition, plasma cortisol failed to suppress after a high dexamethasone dose. An abdominal computed tomography scan confirmed a left adrenal mass. While diagnosis work-up was still in progress, the patient became pregnant and wanted to carry her pregnancy to full-term. Hypercortisolism was successfully controlled with metyrapone, which was started at 8 weeks of gestation. At 16 weeks of gestation, a laparoscopic left adrenalectomy was performed. Pathologic examination of the gland showed a benign adrenocortical adenoma. The patient developed secondary adrenal insufficiency and was discharged on 20 mg hydrocortisone daily dose. At 30 weeks of gestation, the patient had a pre-term rupture of membranes and underwent spontaneous vaginal delivery. The newborn was a normal virilized male who weighed 1280 g. No apparent metyrapone-induced teratogenic effects were observed and there was no clinical or biochemical suppression of adrenocortical function. In conclusion, in adrenal Cushing's syndrome during pregnancy, medical treatment with metyrapone as soon as the diagnosis is made, in combination with laparoscopic surgery during the second trimester, are useful in preventing complications secondary to hypercortisolism and safe both for the mother and infant.

Évolution de la prise en charge de la pathologie surrénalienne depuis l'avènement de la laparoscopie. Une étude rétrospective de 220 patients

OBJECTIVE

Soon after its introduction in 1992, laparoscopic adrenalectomy became the gold standard in the surgical management of most adrenal tumors. The aim of this study was to assess the influence of laparoscopy on surgical indications.

PATIENTS AND METHODS

Between 1994 and 2003, 220 adrenalectomies were performed, 179 among them by a laparoscopic approach. There were 137 females and 83 males. The mean age was 53 years (range 15-83 years).

RESULTS

The indications of adrenalectomy were: Cushing syndrome 18%, pheochromocytoma 31%, Conn syndrome 16%, incidentaloma 21%, and malignant tumours 13%. Laparoscopic approach was performed in 81% of the cases and the conversion rate was 11%. There were 3 postoperative deaths (2 after laparoscopy). The mean hospital stay was 7.6 days in the laparoscopic group, and 13.6 days in the open surgery group.

CONCLUSIONS

This study is consistent with the findings of the literature supporting that there are no indications for the open procedure in case of small benign lesions. The video-asisted adrenalectomy had not changed the management of the adrenal incidentaloma. Today, the laparoscopic approach seems to be adapted also for malignant disease.

Laparoscopic Appreciation of the Adrenal Artery: Fact or Fiction?

BACKGROUND

It is well accepted that identification and control of the adrenal vein is a critical step in laparoscopic adrenalectomy. The surgical and anatomic literature propagates the notion of a dominant or multiple dominant adrenal arteries that should likewise be controlled during surgical extirpation.

MATERIALS AND METHODS

We assessed the frequency of adrenal-artery identification and the need for formal ligation in an extensive series of laparoscopic adrenalectomies.

RESULTS

In our experience, even using a magnified laparoscopic view, we found it possible to identify and necessary to formally ligate an adrenal artery in only 3 of 265 cases (1.1%). Further, in this series, only the inferior adrenal artery was ever seen definitively to require formal clip ligation, while a discrete middle or superior adrenal artery was almost never seen, and the vasculature in these areas could be controlled with electrocautery or ultrasonic energy alone during routine dissection.

CONCLUSIONS

The need to search for and ligate the arterial supply during laparoscopic adrenalectomy is not as clinically significant as once thought, and formal control appears unnecessary unless the vessels are serendipitously encountered during the routine dissection.

Reasons for conversion from laparoscopic to open or hand-assisted adrenalectomy: review of 261 laparoscopic adrenalectomies from 1993 to 2003

Over the past decade, laparoscopic adrenalectomy has become the operation of choice for resecting adrenal tumors. However, few reported data exist regarding the reasons for conversion from laparoscopic to open or hand-assisted adrenalectomy. We retrospectively reviewed the records of 261 consecutive laparoscopic adrenalectomies performed by one surgeon between 1993 and 2003. Laparoscopic adrenalectomy could not be completed in 8 of the 261 patients (3%); four of the operations were converted to hand-assisted laparoscopic adrenalectomy and four to open adrenalectomy. The reasons for the conversion were as follows: In three patients the tumor was too adherent to surrounding structures to be resected laparoscopically; in three patients the tumor was found to have malignant features during laparoscopy, and the operation was converted to achieve proper resection margins; in two patients the tumors were too large (15 and 16 cm, respectively) to be safely removed laparoscopically. The eight resected tumors included three pheochromocytomas, one myelolipoma, one angiomyolipoma, one solitary fibrous tumor, one liposarcoma, and one metastatic hepatocellular carcinoma. There were no cases in which conversion was required emergently for bleeding or other intraoperative catastrophes. All eight of the tumors removed were at least 5 cm in size (range 5-16 cm). The mean length of hospitalization was 4.4 days (range 3-8 days).

Recent developments in the therapy of phaeochromocytoma

The basic principles of treatment for phaeochromocytomas and paragangliomas are to block the effects of high catecholamines and make the patient safe for surgical removal of the tumour. The traditional preoperative medical preparation uses the non-selective alpha-adrenoceptor blocker phenoxybenzamine and a beta-adrenoceptor blocker, propranolol. Other agents have been used effectively, including selective alpha-adrenoceptor blockers, doxazosin and prazosin, and calcium channel antagonists. There have been no trial comparing regimens and there is some controversy as to the best regimen. Major advances have been made in laparoscopic and laparoscopic-assisted surgery. Cortical-sparing adrenalectomy has been used in some centres for familial phaeochromocytomas. High-dose [(131)I]-metaiodobenzylguanidine therapy and combined [(131)I]-metaiodobenzylguanidine and chemotherapy are promising new developments for the malignant disease. All patients should be followed indefinitely because the recurrence or malignancy rate is >or= 10% over a prolonged follow up.