Laparoscopic adrenalectomy in the elderly

Impact of frailty on complications and length of stay after minimally invasive adrenalectomy surgery

BACKGROUND

Adrenal disease requiring surgery incidence increases with age, and minimally invasive adrenalectomy procedures have improved the safety of adrenal surgery. This study evaluates the perioperative outcomes of elective adrenalectomies when performed in older patients and how frailty affects such outcomes.

METHODS

Patients undergoing elective minimally invasive adrenalectomy were identified using the American College of Surgeon's National Surgical Quality Improvement Program Participant Use Targeted File years 2005 to 2020. The surgical indication was categorized as a benign disease, an endocrine disorder, or a malignant disease. Frailty was defined using the 5-item modified frailty index. Multivariable regressions were used to model the relationship of age and frailty with surgical outcomes.

RESULTS

In 8,693 minimally invasive adrenalectomy patients, 5,281 (61%) were female, 5,026 (58%) were White, and 1,924 (22%) were aged 65 years or older. Surgical indications were benign disease 5,487 (63%), endocrinopathy 2,850 (33%), and malignancy 356 (4%). Patients aged <65 years (compared to those aged ≥65) were more likely to have a 5-item modified frailty index = 0 (26% vs 14%, respectively) and less likely to have a 5-item modified frailty index = ≥3 (2% vs 4%, respectively; P < .001).

OUTCOMES

30-day mortality 20 (0.2%), complications 459 (5%), return to operating room 73 (0.8%), and median length of stay 2 days. Thirty-day mortality was associated with a 5-item modified frailty index ≥3 (P = .009) and endocrine disease (P = .005) but not with age. Complications were associated with a 5-item modified frailty index ≥2 (≤P < .001) and malignant disease (P = .002), but not with age.

CONCLUSION

Minimally invasive adrenalectomy has low 30-day mortality and complication rates that increase with frailty and not age. Frailty is a better predictor than the age of most adverse outcomes after elective minimally invasive adrenalectomy.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Predictive factors for open conversion of laparoscopic adrenalectomy: a 13-year review of 456 cases

BACKGROUND AND PURPOSE

Laparoscopic adrenalectomy has largely replaced open adrenalectomy for the treatment of adrenal tumor. However, certain cases still require conversion to open procedures. Identifying the risk of conversion remains difficult. This study identified risk factors that may predict conversion from a laparoscopic to an open procedure.

PATIENTS AND METHODS

From January 1993 to September 2006, a total of 456 laparoscopic adrenalectomies were performed at two urologic centers. A retrospective analysis of parameters, including tumor size, patient age, American Society of Anesthesiology classification, body mass index (BMI), sex, laparoscopic approach, previous abdominal surgery, laterality, type of tumor, laparoscopist experience, and surgeon, was performed. Multivariate logistic regression was used to identify those variables predicting conversion.

RESULTS

A total of 25 (5.5%) laparoscopic adrenalectomies required conversion. Significant predictors of conversion according to univariate analysis were tumor size > or =5 cm, BMI > or =24 kg/m(2), and pheochromocytoma. Multivariate analysis showed that the significant independent predictive factors for conversion were tumor size > or =5 cm (8.884 greater odds ratio [OR] of conversion; 95% confidence interval 3.543, 22.277; P < 0.001), BMI > or = 24 kg/m(2) (OR 3.632; 95% confidence interval 1.367, 9.648; P = 0.010), and pheochromocytoma (OR 3.068; 95% confidence interval 1.175, 8.007; P = 0.022).

CONCLUSIONS

Knowledge of tumor size, BMI, and tumor type can help in counseling patients undergoing laparoscopic adrenalectomy with regard to the probability of conversion. The size of the tumor was found to be the most important predictor.

Retroperitoneoscopic adrenal surgery with reusable instruments

BACKGROUND AND PURPOSE

Retroperitoneoscopic surgery has proven advantages over open surgery in terms of cosmesis, reduced postoperative pain, hospital stay, and early return to work. This is particularly true for surgery of the adrenal gland that otherwise entails a large surgical incision. One of the drawbacks of this surgery is the additional cost attributable to the disposable instruments. We present our cost-reductive retroperitoneoscopic techniques to tackle a variety of adrenal pathologies.

PATIENTS AND METHODS

Beginning March 1995, 17 patients underwent cost-reductive retroperitoneoscopic adrenal surgery for various indications including 12 pheochromocytomas, 3 myelolipomas, 2 adrenal cortical adenomas, and two adrenal cysts. Two patients underwent simultaneous bilateral procedures for pheochromocytoma. A cost-reductive technique using minimal disposable equipment was employed.

RESULTS

The procedure was completed in 18 of 19 cases (94%). One patient undergoing an adrenalectomy for pheochromocytoma was converted to open surgery because of nonprogress of the dissection. The largest tumor removed measured 10 cm. The mean operative time was 133 minutes, the average blood loss 169 mL, NSAID doses 3.56, and hospital stay 4.6 days. There were two major and two minor complications with no deaths.

CONCLUSIONS

Cost-reductive retroperitoneoscopy is a feasible option for the management of a variety of adrenal pathologies. It should be considered a difficult procedure and be undertaken only by surgeons proficient in laparoscopy.