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Acta Medica Okayama Jun 2021The management of blood pressure is a significant concern for surgeons and anesthesiologists performing adrenalectomy for pheochromocytoma. We evaluated clinical factors...
The management of blood pressure is a significant concern for surgeons and anesthesiologists performing adrenalectomy for pheochromocytoma. We evaluated clinical factors in pheochromocytoma patients to identify the predictors of postoperative hypotension. The medical records of patients who underwent adrenalectomy for pheochromocytoma between 2001 and 2017 were retrospectively reviewed and clinical and biochemical data were evaluated. Of 29 patients, 13 patients needed catecholamine support in the perisurgical period while 16 patients did not. There were significant differences in median age, tumor size, and blood pressure drop (maxmin) between the 2 groups (68 vs 53 years old, p=0.045; 50 vs 32 mm diameter, p=0.022; 110 vs 71 mmHg, p=0.015 respectively). In univariate logistic analysis, age > 65.5 years, tumor size > 34.5 mm, urine metanephrine > 0.205 mg/day and urine normetanephrine > 0.665 mg/day were significant predictors of prolonged hypotension requiring postoperative catecholamine support. Tumor size and urine metanephrine and urine normetanephrine levels were correlated with postoperative hypotension. These predictors may help in the safe perioperative management of pheochromocytoma patients treated with adrenalectomy.
Topics: Adrenal Gland Neoplasms; Adrenalectomy; Adult; Aged; Biomarkers; Humans; Hypotension; Japan; Metanephrine; Middle Aged; Normetanephrine; Pheochromocytoma; Preoperative Period; ROC Curve; Retrospective Studies
PubMed: 34176938
DOI: 10.18926/AMO/62229 -
Urology Journal Mar 2020Laparoscopic adrenalectomy (LAD) is considered the gold standard surgical method for resecting adrenal tumors. To date, only few small studies have investigated the...
PURPOSE
Laparoscopic adrenalectomy (LAD) is considered the gold standard surgical method for resecting adrenal tumors. To date, only few small studies have investigated the safety of clipless laparoscopic adrenalectomy in which the adrenal vessels were controlled by the LigaSure system or bipolar coagulation. The aim of the present study was to evaluate the safety and feasibility of sutureless and clipless laparoscopic adrenalectomy operations performed in our center.
MATERIALS AND METHODS
All patients with functional adrenal tumors, nonfunctional adrenal tumors larger than 5 cm and secondary adrenal metastases from the kidneys, lungs or breasts who had underwent an LAD procedure between 2012 to 2019 were included in our study. In all of the cases, complete coagulation of adrenal veins was achieved through bipolar cautery and no vascular staplers, clips or other energy sources were used for controlling the adrenal vessels whatsoever. Outcomes of interest included operation time, length of hospital stay, changes of serum hemoglobin level, and occurrence of major complications.
RESULTS
Of a total 251 patients, unilateral right and left-side adrenalectomy was performed in 168 and 67 cases, respectively, and 16 cases had underwent bilateral adrenal resection. The mean age (SD) of patients was 40.7 (13.6) years old at the time of operation and the mean size (SD) of the adrenal lesions was 5.2 (3.1) cm as measured by the greatest diameter. Histological examination showed that the most common pathology of the resected adrenal glands was pheochromocytoma (n=78). None of the laparoscopic operations required a conversion to open surgery. Also, major bleeding or other serious complications did not occur in any of the cases either intraoperatively or postoperatively.
CONCLUSION
Clipless and sutureless laparoscopic adrenalectomy seems to be feasible and safe for removing adrenal tumors. Moreover, bipolar cautery is associated with an acceptable outcome for vessel closure.
Topics: Adrenal Gland Neoplasms; Adrenal Glands; Adrenalectomy; Blood Loss, Surgical; Electrocoagulation; Female; Hemostasis, Surgical; Humans; Laparoscopy; Male; Middle Aged; Neoplasm Metastasis; Outcome and Process Assessment, Health Care; Pheochromocytoma; Postoperative Complications
PubMed: 31460666
DOI: 10.22037/uj.v0i0.5493 -
BJS Open Nov 2023Bilateral pheochromocytomas are rare and often heritable. Total adrenalectomy leads to a definitive oncological cure, with subsequent definitive hypocortisolism.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Bilateral pheochromocytomas are rare and often heritable. Total adrenalectomy leads to a definitive oncological cure, with subsequent definitive hypocortisolism. Subtotal adrenalectomy is a possible alternative. The aim of this study was to assess the effects of total adrenalectomy and subtotal adrenalectomy on bilateral pheochromocytoma in terms of post-surgical rate of recurrence, metastatic disease, and steroid dependence.
METHODS
Systematic searches in the bibliographic databases PubMed, Embase, and Europe PMC were performed for 1945 to 1 June 2023. PRISMA guidelines were followed and the PICO strategy was applied to English-language studies comparing subtotal adrenalectomy with total adrenalectomy. A random-effects model was used to assess the different outcomes for studies with high heterogeneity. The Newcastle-Ottawa scale and the Risk Of Bias In Non-randomized Studies of Interventions ('ROBINS-I') tool were used to assess quality and risk of bias.
RESULTS
From a total of 12 909 studies, 1202 patients (from 10 retrospective studies) were eligible for the meta-analysis. In six studies, including 1176 patients, the recurrence rate after subtotal adrenalectomy and total adrenalectomy was 14.1 versus 2.6 per cent respectively (OR 4.91, 95 per cent c.i. 1.30 to 18.54; P = 0.020; I2 72 per cent). In nine studies, including 1124 patients, the rate of post-surgical steroid dependence was 93.3 versus 11.6 per cent after total adrenalectomy and subtotal adrenalectomy respectively (OR 0.003, 95 per cent c.i. 0.0003 to 0.03; P < 0.00001; I2 66 per cent). Based on two studies, including 719 patients, no differences were evident regarding the occurrence of post-surgery metastatic disease.
CONCLUSION
Subtotal adrenalectomy leads to less post-surgical primary adrenal insufficiency, but leads to a higher postoperative recurrence rate. Future prospective randomized studies, with clear eligibility criteria, are needed to confirm these results.
Topics: Humans; Pheochromocytoma; Adrenalectomy; Retrospective Studies; Adrenal Gland Neoplasms; Steroids
PubMed: 37945270
DOI: 10.1093/bjsopen/zrad109 -
International Journal of Surgery... Feb 2017The benefit of robotic adrenalectomy (RA) compared to laparoscopic adrenalectomy (LA) is still debatable. The purpose of this paper was to systematically review and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The benefit of robotic adrenalectomy (RA) compared to laparoscopic adrenalectomy (LA) is still debatable. The purpose of this paper was to systematically review and synthesize all available evidence comparing RA to LA so as to evaluate which procedure provides superior clinical outcomes.
METHODS
A systematic literature search of PubMed and Scopus databases was performed with respect to the PRISMA statement (end-of-search date: January 31, 2016). Data on perioperative variables were extracted by three independent reviewers. Data were pooled using a random-effects model.
RESULTS
Twenty-seven studies were included in this review (13 comparative and 14 non-comparative). Overall, 1162 patients underwent adrenalectomy (747 treated with RA and 415 with LA). There was no significant difference between the robotic and the laparoscopic groups for intraoperative complications (OR: 1.20; 95%CI, 0.33-4.38), postoperative complications (OR: 0.69; 95% CI, 0.36-1.31), mortality (OR: 0.42; 95%CI, 0.07-2.72), conversion to laparotomy (OR: 0.51; 95%CI, 0.21-1.23), conversion to laparotomy or laparoscopy (OR: 0.73; 95%CI, 0.32-1.69) and blood loss (WMD: -9.78; 95%, -22.10 to 2.53). For patients treated with RA, there was a significantly shorter hospital stay (WMD: -0.40; 95% CI, -0.64 to -0.17) and a significantly longer operating time (WMD: 15.60; 95%CI, 2.12 to 29.08).
CONCLUSIONS
Robotic adrenalectomy is a safe and feasible procedure with similar clinical outcomes as the laparoscopic approach in selected patient populations. High quality RCTs as well as uniform and detailed reporting of outcomes are needed to determine the role and cost-effectiveness of robotic adrenal surgery in the years to come.
Topics: Adrenalectomy; Humans; Intraoperative Complications; Laparoscopy; Length of Stay; Operative Time; Postoperative Complications; Robotics
PubMed: 28043926
DOI: 10.1016/j.ijsu.2016.12.118 -
Surgery Aug 2022Neuroendocrine tumors can cause ectopic Cushing syndrome, and most patients have metastatic disease at diagnosis. We identified risk factors for outcome, evaluated...
BACKGROUND
Neuroendocrine tumors can cause ectopic Cushing syndrome, and most patients have metastatic disease at diagnosis. We identified risk factors for outcome, evaluated ectopic Cushing syndrome management, and explored the role of bilateral adrenalectomy in this population.
METHODS
This was a retrospective study including patients with diagnosis of ectopic Cushing Syndrome secondary to neuroendocrine tumors with adrenocorticotropic hormone secretion treated at our quaternary referral center over a 40-year period (1980-2020).
RESULTS
Seventy-six patients were included. Mean age at diagnosis was 46.3 ± 15.8 years. Most patients (N = 61, 80%) had metastases at ectopic Cushing syndrome diagnosis. Average follow-up was 2.9 ± 3.7 years (range, 4 months-17.2 years). Patients with neuroendocrine tumors before ectopic Cushing syndrome had more frequent metastatic disease and resistant ectopic Cushing syndrome. Patients with de novo hyperglycemia, poor neuroendocrine tumor differentiation, and metastatic disease had worse survival. Of those with nonmetastatic disease, 8 (53%) had ectopic Cushing syndrome resolution after neuroendocrine tumor resection, 3 (20%) were medically controlled, and 4 (27%) underwent bilateral adrenalectomy. In patients with metastatic neuroendocrine tumors, hypercortisolism was initially medically managed in 92%, 3% underwent immediate bilateral adrenalectomy, 2% had control after primary neuroendocrine tumor debulking, and 2% were lost to follow-up. Medical treatment resulted in hormonal control in 7 (13%) patients. Of the 49 patients with metastatic disease and medically resistant ectopic Cushing syndrome, 23 ultimately had bilateral adrenalectomy with ectopic Cushing syndrome cure in all.
CONCLUSION
Patients with neuroendocrine tumors before ectopic Cushing syndrome development were more likely metastatic and had worse survival. De novo hyperglycemia and poor neuroendocrine tumor differentiation were predictive of worse prognosis. Medical control of hypercortisolism is difficult to achieve in patients with neuroendocrine tumors-ectopic Cushing syndrome. Well-selected patients may benefit from bilateral adrenalectomy early in the treatment algorithm, and multidisciplinary management is essential in this complex disease.
Topics: ACTH Syndrome, Ectopic; Adrenalectomy; Adrenocorticotropic Hormone; Cushing Syndrome; Humans; Hyperglycemia; Neuroendocrine Tumors; Retrospective Studies
PubMed: 35437162
DOI: 10.1016/j.surg.2022.03.014 -
The Journal of Surgical Research Jan 2022Same-day surgery in the carefully selected patient decreases costs, improves inpatient capacity, and decreases patient exposure to hospital-acquired conditions....
INTRODUCTION
Same-day surgery in the carefully selected patient decreases costs, improves inpatient capacity, and decreases patient exposure to hospital-acquired conditions. Outpatient adrenalectomy has been shown to be safe and effective, but patients' perspectives have yet to be addressed. This study compares patient satisfaction following inpatient and outpatient adrenalectomy.
METHODS
An institutional database was queried for minimally-invasive adrenalectomies performed from 2017 to 2020. Patients were contacted up to two times to participate in a phone survey consisting of 25 questions modeled after the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems Survey (OAS CAHPS) assessing preparation for surgery, discharge experience, post-operative course, and overall satisfaction. Statistical analysis was performed using Kruskal Wallis, Wilcoxon-Mann Whitney, and Chi-square tests, as appropriate.
RESULTS
One hundred five adrenalectomy patients were identified, of which 98 were contacted and 58 responded (59%). Two surgeons contributed patients, with no difference in the percentage of patients in the outpatient group (51.7% versus 62.1%, P = 0.423). Outpatient adrenalectomy patients had slightly higher overall experience scores, but this difference was not statistically significant (9.12 ± 1.36 versus 8.93 ± 1.51, P = 0.367). Patients undergoing outpatient adrenalectomy were more likely to have their discharge plan discussed pre-operatively (94% versus 62%, P = 0.005), but no significant differences were noted between inpatient and outpatient groups regarding preparation for surgery, readiness for discharge, night of surgery experiences, or self-reported pain or complications (P > 0.05 for all). Significantly higher overall experience scores were reported by patients counseled about their discharge plan (9.27 versus 7.9, P = 0.036), felt prepared for recovery (9.39 versus 5.5, P < 0.001), received information about pain control (9.13 versus 7.00, P = 0.031), felt prepared at time of discharge (9.33 versus 5.80, P < 0.001), and received information about potential complications (9.29 versus 7.00, P = 0.001). Although not statistically significant, there was a trend towards outpatients being more likely to choose the same approach if they were to undergo surgery again (97% versus 84%, P = 0.081).
CONCLUSIONS
Patient satisfaction following adrenalectomy is significantly associated with patients' self-reported degree of preparation for surgery and discharge, with no significant difference in patient satisfaction between inpatient and outpatient groups. Patients undergoing outpatient adrenalectomy would be likely to choose the same approach compared to inpatients. Targeted pre-operative counseling can contribute to enhanced patient outcomes for all patients undergoing adrenalectomy.
Topics: Adrenalectomy; Ambulatory Surgical Procedures; Humans; Inpatients; Outpatients; Patient Satisfaction
PubMed: 34601371
DOI: 10.1016/j.jss.2021.08.019 -
The Journal of Urology Jul 2010Many patients with small adrenal masses undergo total adrenalectomy. We evaluated partial adrenalectomy outcomes by performing a comprehensive literature review. (Review)
Review
PURPOSE
Many patients with small adrenal masses undergo total adrenalectomy. We evaluated partial adrenalectomy outcomes by performing a comprehensive literature review.
MATERIALS AND METHODS
We performed a PubMed search of the English language literature using the queries partial adrenalectomy and adrenal sparing surgery, and identified 317 and 155 articles, respectively. We excluded case reports or series with fewer than 5 patients, articles not focused on surgical management and those that did not indicate perioperative outcomes. The remaining articles were cross-referenced by author and institution to eliminate studies with redundant cases. Demographics, diagnosis, tumor characteristics, perioperative and functional outcomes, and recurrence data were collected when available.
RESULTS
A total of 22 articles from a total of 22 first authors met our inclusion criteria, describing outcomes in a total of 417 patients. There has been an increasing trend toward partial adrenalectomy worldwide in the last 20 years. Partial adrenalectomy is most commonly done for Conn's syndrome, followed by pheochromocytoma. Most procedures are laparoscopic with minimal morbidity. The recurrence rate is only 3% and more than 90% of patients remain steroid independent.
CONCLUSIONS
Partial adrenalectomy surgical outcomes and perioperative complications are similar to those reported for total adrenalectomy. When partial adrenalectomy is done for small adrenal lesions, the malignancy rate is negligible, the recurrence rate is low and most patients remain steroid-free at long-term followup. These data strongly support the acceptance of partial adrenalectomy as first line treatment for small adrenal masses.
Topics: Adrenal Gland Neoplasms; Adrenalectomy; Humans; Recurrence
PubMed: 20546805
DOI: 10.1016/j.juro.2010.03.052 -
JSLS : Journal of the Society of... 2022Laparoscopic adrenalectomy is now the preferred approach for most adrenal tumors. As minimally invasive surgery departments gain familiarity with the robotic platform,...
BACKGROUND AND OBJECTIVE
Laparoscopic adrenalectomy is now the preferred approach for most adrenal tumors. As minimally invasive surgery departments gain familiarity with the robotic platform, the safety profiles and efficacy of robotic adrenalectomy has been an area of continued discussion. The objective of this study is to outline our experience with transitioning to the robotic platform and determining the effectiveness and safety of transperitoneal robotic adrenalectomy.
METHODS
We performed a single-center, retrospective review of 37 patients who underwent transperitoneal robotic adrenalectomy between August 1, 2010 and August 31, 2020. Outcomes included patient morbidity, hospital length of stay, operative time, estimated blood loss, gland volume, pathology, and postoperative complications.
RESULTS
Sixty-five percent of the total robotic adrenalectomies were of the left adrenal gland. The average operating room time was 213 minutes. The average gland volume was 71 cm, estimated blood loss was 74 mL and length of stay was 1.4 days. There were no significant differences in outcomes between the right and left total robotic adrenalectomies. Approximately one-third of our cohort had an adrenal cortical adenoma, while only one patient had adrenal cortical carcinoma. Four patients experienced postoperative complications that resulted in unplanned hospital readmissions and there was one mortality.
CONCLUSIONS
Although the standard of care for most adrenal tumors is laparoscopic resection, our 10-year experience has shown that robotic adrenalectomy is highly effective and can be a valuable tool in the community and academic setting.
Topics: Adrenal Gland Neoplasms; Adrenalectomy; Hospitals; Humans; Laparoscopy; Length of Stay; Postoperative Complications; Retrospective Studies; Robotic Surgical Procedures
PubMed: 35444401
DOI: 10.4293/JSLS.2021.00083 -
The Journal of Surgical Research Apr 2024Retroperitoneoscopic adrenalectomy (RPA) has gained increasing popularity with its excellent perioperative outcomes and direct surgical access compared to other... (Review)
Review
INTRODUCTION
Retroperitoneoscopic adrenalectomy (RPA) has gained increasing popularity with its excellent perioperative outcomes and direct surgical access compared to other adrenalectomy approaches. We review perioperative outcomes of RPA by a specialized endocrine surgeon before and after expert intensive trainings (EITs), and to that of other laparoscopic adrenalectomy approaches at our center over a 9-year period, aiming to ascertain if RPA is worth the steep learning curve.
MATERIAL AND METHODS
One hundred twenty one adrenalectomies were performed between January 2014 to June 2022. Patient demographic, tumor characteristics, and perioperative outcomes were retrospectively reviewed. The primary endpoints included procedure duration, complications, and length of stay. Part I of the study examined the effect of EITs on RPA's learning curve, and part II compared these outcomes with that of the alternative approach, transabdominal lateral adrenalectomy (TLA).
RESULTS
Both procedure duration and days in hospital markedly decreased after the two EITs for RPA. RPA resulted in a shorter procedure duration and hospital stay compared to TLA, and had lesser and milder intraoperative and postoperative complications compared to TLA.
CONCLUSIONS
RPA results in safe and excellent outcomes, and offers additional benefit of direct surgical access, feasibility in patients with previous abdominal surgery, high body mass index, and multiple comorbidities. The steep learning curve can be overcome and shortened by EITs, motivating centers with specialized endocrine surgery to integrate RPA training into its curriculum, given its foreseeable rewarding outcomes.
Topics: Humans; Adrenal Gland Neoplasms; Retroperitoneal Space; Adrenalectomy; Laparoscopy; Retrospective Studies; Length of Stay; Operative Time; Treatment Outcome
PubMed: 38277956
DOI: 10.1016/j.jss.2023.12.032 -
Clinics (Sao Paulo, Brazil) 2012Since the first laparoscopic adrenalectomy, the technique has evolved and it has become the standard of care for many adrenal diseases, including pheochromocytoma. Two... (Review)
Review
Since the first laparoscopic adrenalectomy, the technique has evolved and it has become the standard of care for many adrenal diseases, including pheochromocytoma. Two laparoscopic accesses to the adrenal have been developed: transperitoneal and retroperitoneal. Retroperitoneoscopic adrenalectomy may be recommended for the treatment of pheochromocytoma with the same peri-operative outcomes of the transperitoneal approach because it allows direct access to the adrenal glands without increasing the operative risks. Although technically more demanding than the transperitoneal approach, retroperitoneoscopy can shorten the mean operative time, which is critical for cases with pheochromocytoma where minimizing the potential for intra-operative hemodynamic changes is essential. Blood loss and the convalescence time can be also shortened by this approach. There is no absolute indication for either the transperitoneal or retroperitoneal approach; however, the latter procedure may be the best option for patients who have undergone previous abdominal surgery and obese patients. Also, retroperitoneoscopic adrenalectomy is a good alternative for treating cases with inherited pheochromocytomas, such as multiple endocrine neoplasia type 2A, in which the pheochromocytoma is highly prevalent and frequently occurs bilaterally.
Topics: Adrenal Gland Neoplasms; Adrenalectomy; Follow-Up Studies; Humans; Laparoscopy; Pheochromocytoma; Retroperitoneal Space
PubMed: 22584723
DOI: 10.6061/clinics/2012(sup01)27