Minimally Invasive Adrenalectomy Research Articles

Outpatient surgery benchmarks and practice variation patterns: Case controlled study.

Despite numerous potential benefits of outpatient surgery, there is currently a lack of national benchmarking data available for hospitals and surgeons to compare their own outcomes as they transition toward outpatient surgery. Patients who underwent 14 common general surgery operations from 2016-2020 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Operations were selected based on frequency and the ability to be performed both in- and outpatient. Postoperative complications and readmissions were compared between patients who underwent inpatient vs outpatient surgery. After adjusting for patient comorbidities, multivariable models assessed the effect of patient characteristics on the odds of experiencing postoperative complications. A separate multiinstitutional study of 21 affiliated hospitals assessed practice variation. In 13 of the 14 studied procedures, complications were lower for patients who were selected for outpatient surgery (all P<0.01); minimally invasive (MIS) adrenalectomy showed no difference (P=0.61). Multivariable analysis confirmed these findings; the odds of experiencing any adverse events were lower following outpatient surgery in all operations but MIS adrenalectomy (OR 0.97; 95% CI 0.47-2.02). Analysis of institutional practices demonstrated variation in the rate of outpatient surgery in certain breast, endocrine, and hernia repair operations. Institutional practice patterns may explain the national variation in the rate of outpatient surgery. While the present data does not support the adoption of outpatient surgery to less optimal candidates, addressing unexplained practice variations could result in improved utilization of outpatient surgery.

Same day discharge after minimally invasive adrenalectomy: a national study.

Same day discharge (SDD) may be considered in some patients undergoing minimally invasive adrenalectomy (MIA). Recent studies have demonstrated similar outcomes between SDD and admitted patients; however, most excluded pheochromocytoma and adrenal metastases. This study evaluates 30-day complications and hospital readmission in a large cohort of patients undergoing MIA. Adult patients undergoing MIA (2010-2020) for benign adrenal disorders, pheochromocytoma, and adrenal metastases were identified within the ACS-NSQIP database. Comparisons between patients having SDD versus admission were performed. Factors associated with 30-day complications and unplanned readmission were evaluated by multivariable regression modeling. Of 7316 patients who underwent MIA, 254 had SDD. Baseline characteristics were similar between groups, although SDD patients had lower ASA class (p < 0.001) and were more likely to undergo MIA for nonfunctioning adenoma or primary aldosteronism (p = 0.001). After adjusting for covariates, higher ASA class and presence of medical comorbidities were associated with increased complications (p < 0.001; p < 0.05) and unplanned readmission (p < 0.001; p < 0.05). Additionally, prolonged operative time was associated with 30-day complications (p < 0.001). Notably, SDD was not associated with increased complications (OR 0.78, 95% CI 0.38-1.61, p = 0.502) or unplanned readmission (OR 0.76, 95% CI 0.35-1.64, p = 0.490). The rate of SDD for MIA increased from 1.48% in 2017 to 10.81% in 2020. Not all patients undergoing MIA should have SDD; however, the current analysis demonstrates a trend toward SDD and supports its safety in select patients with adrenal metastases and benign adrenal disorders including pheochromocytoma.

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

The deep anatomy of the adrenal gland, surrounded by abundant blood vessels and organs, makes it vulnerable to serious complications due to injury in the operation. Preventing complications is an ongoing goal of the surgeon. Currently, larger adrenal tumors (≥5 cm) are one of the most challenging procedures in urological surgery, with the incidence from 8.6 to 38.6% of adrenal tumors. In the last decade, urologists have become increasingly interested in minimally invasive adrenalectomy (MIA), such as laparoscopic adrenalectomy and robot-assisted adrenalectomy. With the addition of experience and the development of state-of-the-art techniques, a mountain of evidence suggests that MIA is safe and feasible in carefully selected patients and converted to open if the local invasion is identified during the laparoscopic procedure1–3. Therefore, some centers propose MIA as an alternative treatment. However, there is still some controversy about the advantages of MIA over open adrenalectomy in recent urology surgery. Recently, we read with great enthusiasm the article published by Gan et al4. We sincerely congratulate the authors for publishing an excellent systematic review and meta-analysis (using PRISMA guidelines) about the safety and effectiveness of MIA versus open adrenalectomy in patients with large adrenal tumors (≥5 cm). Based on 10 studies (five retrospective and five prospective), including 898 patients, the authors concluded that MIA offers advantages over open adrenalectomy in the management of patients. MIA is associated with shorter length of stay, drainage time, fasting time, and reduced blood transfusion, while operative time and complications are similar. The authors should be acknowledged for conducting a meta-analysis on this controversial topic to present interesting results which are relevant to clinical practice and learning of junior surgeons. Since the introduction of laparoscopic adrenalectomy in 1992 by Gagner et al5, this has become a standard procedure for performing adrenalectomy. However, for large adrenal tumors, laparoscopic surgery is still quite difficult and complications are relatively high. Robotic systems with articulation, three-dimensional views, and stable surgical platforms overcome the limitations of laparoscopy6. Here, we would like to offer some humble suggestions and experiences about MIA. (1) Experience with laparoscopic adrenal surgery and skill in robotic procedures are mandatory for preventing complications. Causes of conversion to laparoscopic or open adrenalectomy from robotic surgery have been reported to be due to visceral injury, difficulty in hemostasis, malposition of robotic trocars, and prolonged operation time. (2) The risk of surgery is either damage to the surrounding organs or bleeding. Therefore, the surrounding organs should be well protected during surgery and not actively combined with organ removal. (3) Specimens need to be removed through a large incision, which traditionally requires dissection of the lumbar muscles, resulting in significant postoperative pain for the patient. We can bag the specimen and place it into the pelvis and take it out through an incision in the lower midsection. This not only does not require dissection of the muscle tissue but the incision in that area can be sufficiently stretched. Alternatively, if the preoperative diagnosis is an adrenal medullary lipoma, the specimen can be bagged and then mashed with an aspirator before being taken out. (4) Transperitoneal has a better vision and clearer anatomical signs, which facilitates the rapid separation of the tumor, thereby avoiding damage to the surrounding organs and rendering the operation less complex, which makes it a safe and effective treatment for large adrenal tumors. (5) As the adrenal gland is fragile, it is essential not to clamp the gland or tumor directly throughout the separation procedure. (6) For large functional adrenal tumors, blood pressure fluctuates considerably in the perioperative period and hemodynamic stability is critical to the success of the procedure. Overall, we thank Gan and colleagues from the bottom of our hearts for their concerted efforts in investigating the therapeutic efficiency of MIA in larger adrenal tumors. They have made a meaningful step forward on this important topic. MIA is an efficient and safe procedure that can provide an alternative to the open procedure. However, more prospective studies and/or high-quality case-matched comparative studies are needed in the future to further clarify the advantages and disadvantages of MIA. Ethical approval None. Sources of funding None. Authors’ contribution Z.T.: writing. S.F. and H.W.: data collection and data analysis. J.W.: study design. Conflicts of interest disclosure The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantor Jiansong Wang and Haifeng Wang. Provenance and peer review Commentary, internally reviewed.

Pathological and clinical outcomes of adrenalectomy: A multi-center experience in Saudi Arabia

ObjectiveTo determine the nature of adrenal pathology in patients undergoing adrenalectomy in Saudi Arabia over the last decade and compare it with the literature. We compared perioperative outcomes between minimally invasive adrenalectomy (MIA) and open adrenalectomy (OA). MethodsThis retrospective study included patients who underwent adrenalectomy at five tertiary care centers in Saudi Arabia from 2010 to 2020. We collected patients’ baseline and perioperative characteristics and detailed hormonal evaluation of adrenal masses. ResultsAmong 160 patients (mean age 44 ± 14.5 years; mean BMI 29.17 ± 5.96 kg/m2), 84 (51.5 %) were men and 51.5 % had left-sided adrenal masses. The mean tumor size was 6.1 ± 4.2 (1.0–19.5) cm, including 60 (37.5 %) incidentalomas and 65 (40.6 %) functioning masses. Histopathology revealed 74 (46.2 %) adenomas and 24 (15 %) cancers or metastases from other primary organs; 20 %, 8.8 %, and 2.5 % of patients had pheochromocytoma, myelolipoma, and 2.5 % ganglioneuroblastoma, respectively. MIA and OA were performed in 135 (84.4 %) and 21 (15.6 %) patients, respectively. Adrenalectomy was increasingly performed over three equal periods in the last decade (17.5 % vs 34.4 % vs 48.1 %), with increasing numbers of MIAs to replace OAs. OA patients had larger tumors and needed blood transfusion more frequently (47.6 % vs 10.8 %, p< 0.001). MIA was significantly associated with shorter operative time, shorter length of stay, and less blood loss. Postoperative complications occurred in 10 (6.2 %) patients and were significantly higher for OA (24 % vs 3.0 %, p< 0.001). ConclusionsThe majority of adrenal masses are benign. Herein, the observed functional and perioperative outcomes were comparable to those of available meta-analyses.

Association Between Surgical Indication and Outcomes for Outpatient Adrenalectomy

IntroductionDespite a favorable risk-benefit profile, inpatient admission postoperatively for minimally invasive adrenalectomy (MIA) has remained common. Prior studies have shown that outpatient MIA was not associated with an increased 30-day complications or readmission. However, this has not been explored in-depth by adrenalectomy indication. We aimed to examine whether the safety profile of outpatient MIA varies by adrenal indication. Materials and MethodsClinicopathologic parameters were examined for all MIAs entered into an adrenal database at our institution from 2012 to 2021. Predictor variables included patient demographics, surgical indication, and operative time. Outcomes were 30-day emergency department visit, readmission, and complication rates between surgical indications, comparing outpatient and inpatient groups. Statistical analyses were performed using Kruskal–Wallis, Wilcoxon, Mann-Whitney, and Chi-squared tests, as appropriate. ResultsA total of 185 MIA patients were included. Outpatient MIA was performed in 53 patients (28.6%). Outpatient discharge post-MIA was related to both surgical indication and operative time. Pheochromocytoma (PC) patients were less likely to be discharged as an outpatient postoperatively when compared to all other indications (13.0% versus 33.8%, P = 0.007). Among all patients with operations 2-3 h in length, PC patients were less likely to be discharged home as an outpatient (10% versus 33.3%, P = 0.040). No significant differences were identified between outpatient and inpatient MIA groups for complications, emergency department visits, or readmission (P > 0.05 for all). Only six outpatient MIA patients had any complication (11.3%) and six were readmitted (11.3%). ConclusionsOutpatient MIA was demonstrated to be associated with similar, low complication and readmission rates compared to inpatient MIA, although it was used less often for patients with PC or prolonged operative times. Our study highlights potential evidence that outpatient MIA can be safely used in selected patients across all indications for adrenal surgery.

Association of Surgical Approach With Treatment Burden, Oncological Effectiveness, and Perioperative Morbidity in Adrenocortical Carcinoma.

In the National Cancer Database (NCDB), patients treated with minimally invasive adrenalectomy (MIA) for adrenocortical carcinoma (ACC) had similar oncological outcomes and cumulative treatment burden with less morbidity compared with open adrenalectomy (OA). Although OA remains the standard of care for adrenal lesions concerninge for malignancy, MIA in appropriately selected patients may offer equivalent oncological outcomes. We investigated the cumulative treatment burden, oncological effectiveness, and perioperative morbidity in patients undergoing MIA compared with (OA) for patients with ACC. We reviewed the NCDB for patients undergoing surgical resection (MIA vs. OA) for ACC from 2010 to 2017. Inverse probability of treatment weighted logistic regression, negative binomial, and Cox proportional hazards models were fit to assess for an association of surgical approach with cumulative treatment burden (any adjuvant therapy, radiation therapy [RT], and systemic therapy), oncological effectiveness (positive surgical margins [PSM], lymph node yield [LNY], and overall survival [OS]), and perioperative morbidity (length of stay [LOS] and readmission) as appropriate. We identified 776 patients that underwent adrenalectomy for ACC, of which 307 underwent MIA. We noted patients with larger tumors (OR 0.82, 95% CI 0.78-0.86, P < .001) were less likely to have MIA prior to IPTW. We did not appreciate a significant association of MIA with cumulative treatment burden or the use of any adjuvant therapy (OR 0.85, 95% CI 0.60-1.21, P=.375), adjuvant RT (OR 0.94, 95% CI 0.59-1.50, P=.801), or adjuvant systemic therapy (OR 0.84, 95% CI 0.58-1.21, P=.352). Patients undergoing MIA had similar oncological effectiveness of surgery and OS when compared with patients which underwent OA. Patients that underwent MIA had a significantly shorter LOS (IRR: 0.74, 95% CI 0.62-0.88, P=.001) and lower odds of readmission (OR 0.46, 95% CI 0.23-0.91, P=.026). Although the standard of care for adrenal lesions suspicious for ACC remains OA, in appropriately selected patients, MIA may offer similar oncological effectiveness and cumulative treatment burden, with less morbidity, than OA.

Association of tumor size and surgical approach with oncological outcomes and overall survival in patients with adrenocortical carcinoma.

To investigate the association of surgical approach with outcomes in patients with adrenocortical carcinomas smaller and larger than 6 cm in size. We reviewed the national cancer database for patients undergoing minimally invasive adrenalectomy (MIA) and open adrenalectomy (OA) from 2010 to 2017. To adjust for differences between patients undergoing MIA and OA, we performed propensity score matching within each size strata of ≤6 cm, 6.1 to 10 cm, and 10.1 to 20 cm. We fit generalized estmiating equations with a logit link function to assess for the association of surgical approach with positive surgical margins and a Cox proportional hazards model to assess for the association of surgical approach with overall survival. We identified 364 patients that underwent MIA (182) and OA (182) in the matched cohort. We noted 21% and 18% of patients undergoing MIA and OA had a positive surgical margin, respectively. We did not identify a significant association between surgical approach and positive surgical margins in the cohort as a whole or within each of strata. Furthermore, we did not appreciate a significant association between surgical approach and overall survival in the cohort as a whole or within each size strata. In the National Cancer Database, patients undergoing MIA had similar positive surgical margins and overall survival compared with OA for masses ≤6 cm, 6.1 to 10cm, and >10 cm in size. Patients undergoing MIA should be carefully selected with surgical oncologic integrity being the primary determinants of surgical approach.

Surgical Management of Adrenocortical Carcinoma: A Literature Review.

Background: Adrenocortical carcinoma (ACC) is a rare malignant tumor with a poor prognosis. Radical surgical resection with negative margins represents the only opportunity for a potential cure. This review provides a critical assessment of the existing studies regarding the surgical approaches for the treatment of ACC. Methods: This review was performed according to criteria reported in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The research was carried out using the PubMed electronic library. This review is limited to comparative studies evaluating minimally invasive adrenalectomy (MIA) and open adrenalectomy (OA) in adult patients affected by ACC. Results: A total of 14 studies were selected for the review, reporting that 2574 patients underwent adrenal surgery for ACC: 1779 (69.1%) by means of OA and 795 (30.8%) by means of MIA. Six studies considered OA to be superior to MIA, whereas eight studies reported that MIA is as effective as OA in highly selected cases. All studies were retrospective with a heterogenous selection of patients. Conclusions: Data regarding the management of MIA are scarce, heterogenous, and mainly based on retrospective studies. OA remains the gold standard approach for the management of ACC; however, MIA may play a role in selected cases treated in high volume institutions with experienced surgeons.

Outcomes after Surgical Treatment of Metastatic Disease in the Adrenal Gland; Valuable for the Patient?

Simple SummaryAdrenal glands are common dissemination sites for metastases of various solid tumors. The rapid development of new treatment strategies, such as targeted therapy and immunotherapy for different cancer types, has led to increased metastatic adrenalectomies. Therefore, clear communication between oncologists and adrenal gland specialists has become increasingly important to outweigh surgical risks versus oncological advantages of adrenalectomies in these patients. This study assesses trends in diagnosis, type of surgery, and short-term and long-term surgical outcomes of patients who underwent metastatic adrenalectomy. We included a total of 95 patients with an adrenal metastasis of non-adrenal primary tumors, most often colorectal or lung cancer, who underwent (minimal invasive) adrenalectomy. 37.9% of the patients experienced one or more complications after adrenalectomy. Within our patient cohort, an increased demand for metastatic adrenalectomy was observed over the past years, which might be associated with the rise of targeted- and immunotherapy. Our data aims to assist multidisciplinary teams with weighing the pros and cons of resection of the metastasized adrenal gland of cancer patients.The adrenal glands are common dissemination sites for metastasis of various solid tumors. Surgical treatment is often recommended because targeted therapies and immunotherapy are frequently ineffective for adrenal metastasis. We report the experience with short-term and long-term surgical outcomes of patients undergoing surgery for adrenal metastasis in two hospitals. A retrospective, multicenter study was performed to analyze patient characteristics, tumor-related data, perioperative outcomes, and oncological outcomes. Postoperative complications that occurred within 30 days were scored according to the Clavien Dindo classification. Metastatic adrenalectomy was performed in 95 patients. We observed an increase from an average of 3 metastatic adrenalectomies per year between 2001–2005 to 10 between 2015–2019. The most frequent underlying malignancies were colorectal and lung cancer. In 55.8%, minimal invasive adrenalectomy was performed, including six conversions to open surgery. A total of 37.9% of patients had postoperative complications, of which ileus or gastroparesis, wound problems, pneumonia, and heart arrhythmias were the most occurring complications. Improved cancer care has led to an increased demand for metastatic adrenalectomy over the past years. Complication rates of 37.9% are significant and cannot be neglected. Therefore, multidisciplinary teams should weigh the decision to perform metastatic adrenalectomy for each patient individually, taking into account the drawbacks of the described morbidity versus the potential benefits.

Open versus minimally invasive surgery for suspected adrenocortical carcinoma.

Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis. Although laparoscopy has been widely adopted for management of benign adrenal tumors, minimally invasive surgery for ACC remains controversial. Retrospective analyses, frequently with fewer than one hundred participants, comprise the majority of the literature. High-quality data regarding the optimal surgical approach for ACC are lacking due to the rarity of the disease and the fact that determination of tumor type (e.g., adenoma or carcinoma) is determined after adrenalectomy, since adrenal tumors are generally not biopsied. While the benefits of minimally invasive surgery including lower intra-operative blood loss and decreased hospital length-of-stay have been consistently demonstrated, clinical equipoise for long-term survival and recurrence outcomes between open and minimally invasive adrenalectomy (MIA) remains. This review examines retrospective studies that directly compare patients with ACC who underwent either open or laparoscopic adrenalectomy, and considers these findings in the context of current guideline recommendations for surgical management of ACC.

Reassessing the impact of tumor size on operative approach in adrenocortical carcinoma.

Adrenocortical carcinoma (ACC) is often a contraindication to minimally invasive adrenalectomy (MIA). We used an administrative data set to analyze postoperative outcomes. We hypothesized that small tumors would have better short- and long-term outcomes, independent of the operative approach. The National Cancer Database (2010-2016) identified patients with ACC who underwent adrenalectomy. Tumors were grouped:<5 cm (n = 125), 5-10 cm (n = 431), and>10 cm (n = 443). The primary and secondary outcomes were margin positivity and overall survival, respectively. Nine hundred and ninety-ninepatients were analyzed: 37% MIA and 63% open adrenalectomy (OA). As the size increased, the rate of attempted MIA decreased. Larger tumors were associated with conversion to open. Althoughtumors with local invasion and those which required conversion to open were associated with an increased likelihood of a positive margin, tumor size was not. Although "complete" MIA (vs. OA) and tumor size were not associated with differences in survival, conversion (HR = 1.83, p = .02), positive margins (HR = 1.54, p = .01), and local invasion (HR = 1.84, p < .001) were associated with poor survival. Positive margins are associated with poor survival in ACC. Tumors ≥ 5 cm were associated with an increased conversion rate and subsequent increase in margin positivity. MIA may be considered for select patients with small tumors but adequate oncologic resection is critical.

Implications of Conversion during Attempted Minimally Invasive Adrenalectomy for Adrenocortical Carcinoma.

Although advocated by some, minimally invasive adrenalectomy (MIA) for adrenocortical carcinoma (ACC) is controversial. Moreover, the oncologic implications for patients requiring conversion to an open procedure during attempted MIA for ACC are not extensively reported. The National Cancer Database was queried for patients undergoing resection for ACC. Overall survival (OS) for patients undergoing successful MIA was compared with those requiring conversion, and additionally evaluated with a multivariable Cox regression analysis including other factors associated with OS. After propensity matching, those experiencing conversion were further compared with patients who underwent planned open resection. Among 196 patients undergoing attempted MIA for ACC, 38 (19.4%) required conversion. Independent of 90-day postoperative mortality, conversion was associated with significantly reduced OS compared with successful MIA (median 27.9months versus not reached, p = 0.002). Even for tumors confined to the adrenal, conversion was associated with worse median OS compared with successful MIA (median 34.2months versus not reached, p = 0.003). After propensity matching for clinicopathologic covariates to establish well-balanced cohorts (N = 38 per group), patients requiring conversion during MIA had significantly worse OS than those having planned open resection (27.9months versus 50.5months, p = 0.020). On multivariable analysis for predictors of OS, conversion during MIA (HR 2.32, p = 0.003) was independently associated with mortality. ACC is a rare tumor for which adequate oncologic resection is the only chance for cure. Given the relatively high rate of conversion and its associated inferior survival, open resection should be considered standard of care for known or suspected ACC.

Minimally invasive adrenalectomy results in equivalent perioperative outcomes versus open adrenalectomy for adrenal mass larger than 6 cm: A retrospective propensity score-matched study

IntroductionThe indication for choosing the minimally invasive approach for large adrenal mass remains controversial. This study is to assess perioperative outcomes after minimally invasive adrenalectomy (MIA) versus open adrenalectomy (OA) for adrenal mass ≥ 6 cm. Materials and methodsA cohort of 173 patients underwent adrenalectomy for adrenal mass ≥ 6 cm in our urology center between May 2005 and April 2018 was included. MIA was performed in 96 patients, whereas 77 patients underwent OA. We performed a retrospective propensity score-matched study to compare MIA versus OA. ResultsAfter propensity score-matched, 58 matched pairs of patients identified from each group. There were no significant differences between the groups in postoperative morbidity (p = 0.146), operative time (p = 0.163), intraoperative hypertension (p = 0.248) and drainage time (p = 0.188). Estimated blood loss, the rate of blood transfusions postoperative hospital stay was less in MIA group (p < 0.0001; p = 0.007; p < 0.0001). Total expense was significantly more in the MIA group [49379.28 (38496.69, 68008.69) CNY vs 39951.48 (30666.33, 50292.03) CNY, p = 0.001]. ConclusionsMIA results in equivalent perioperative outcomes compared with OA and is an effective and safe surgical method for patients with an adrenal mass more than 6 cm in diameter.

Adrenal tumours: open surgery versus minimally invasive surgery.

The aim of this article is to focus on state-of-the-art minimally invasive adrenalectomy (MIA) and the most recent role of open adrenalectomy for adrenal tumours, respect to MIA and open adrenalectomy for adrenocortical cancer (ACC). The laparoscopic (both transperitoneal and retroperitoneal) approach is the first-choice treatment in cases of small-to-medium benign adrenal tumours. This approach is feasible and well tolerated even for larger lesions without radiological signs of malignancy. Robotic adrenalectomy has recently increased in popularity, although the results appear to be fully comparable with those of laparoscopy. Open approach is the keystone of ACC surgery, especially when neighbour tissues, organs, or vessels are involved. Recent evidence suggests caution in treating localized ACC with laparoscopy, because of the higher rate of local or peritoneal recurrence, and shorter recurrence-free survival rates with respect to open adrenalectomy. MIA has progressively replaced the traditional open approach and plays a complementary role in the treatment of adrenal tumour. It is the first option for benign lesions, whereas open adrenalectomy is a cornerstone treatment for ACC. The overlap of indications for laparoscopic adrenalectomy and open adrenalectomy is today confined to the treatment of organ-confined adrenal cancer, in which the role of laparoscopic surgery is far from being clearly defined.

Minimal Invasive Surgery of Adrenal Tumors

Minimal invasive surgical methods are gold standard at the resection of adrenal tumors. Special medical care units provide laparoscopical and retroperitoneoscopical techniques. This review gives an overview about indication of minimal invasive adrenalectomy, technical implementation, perioperative management and generic surgery-associated complications.

MP12-20 PREDICTORS OF 30-DAY COMPLICATIONS AND HOSPITAL READMISSIONS FOLLOWING ADRENALECTOMY.

INTRODUCTION AND OBJECTIVES: Minimally invasive adrenalectomy (laparoscopic and robot-assisted) may offer lower postoperative morbidity and mortality. The purpose of this study is to analyze postoperative complications, readmission rates, and predictors of readmission in minimally invasive adrenalectomy (MIA) using a national outcomes database. METHODS: American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was used to analyze patients who underwent MIA in 2011 and 2012. Perioperative variables and Clavien complications were analyzed using multivariate regression analysis. P<0.05 was considered statistically significant. RESULTS: Of the total (N 1⁄4 1,294) patients that were included in the analysis, N1⁄41,093 (84%) were performed via MIA, N1⁄4555 (43%) were male, and N1⁄4124 (10%) were performed by urologists. A total of N1⁄4138 (10.6%) patients had at least one complication. Complications based on Clavien were as follows: Clavien I N1⁄418 (13%); Clavien II N1⁄475 (54.3%); Clavien III N1⁄414 (10.1%); Clavien IV N1⁄428 (20.2); and Clavien V N1⁄43 (2.2%). On multivariate analysis, predictors for Clavien III-V included higher ASA score (p1⁄40.01), open surgical approach (p1⁄40.02), and lower preoperative albumin level (p1⁄40.01). Readmission rates within 30-days because of a complication remain low (N1⁄477, 6%). On multivariate analysis, predictors for readmission included higher ASA score (p1⁄40.02), and history of diabetes mellitus (p1⁄40.03). CONCLUSIONS: Minimally invasive adrenalectomy complications rates and readmission rates are low, and but can have high Clavien grade (Clavien III-V) when they happen. Predictors for highgrade Clavien complications include higher ASA score, open surgical approach, and lower preoperative albumin. Predictors for readmission included higher ASA score, and history of diabetes mellitus.

MP12-19 NATIONAL TRENDS AND PREDICTORS IN 30-DAY POSTOPERATIVE COMPLICATIONS AND READMISSION RATES FOLLOWING MINIMALLY INVASIVE ADRENALECTOMY

INTRODUCTION AND OBJECTIVES: Minimally invasive adrenalectomy (laparoscopic and robot-assisted) may offer lower postoperative morbidity and mortality. The purpose of this study is to analyze postoperative complications, readmission rates, and predictors of readmission in minimally invasive adrenalectomy (MIA) using a national outcomes database. METHODS: American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was used to analyze patients who underwent MIA in 2011 and 2012. Perioperative variables and Clavien complications were analyzed using multivariate regression analysis. P<0.05 was considered statistically significant. RESULTS: Of the total (N 1⁄4 1,294) patients that were included in the analysis, N1⁄41,093 (84%) were performed via MIA, N1⁄4555 (43%) were male, and N1⁄4124 (10%) were performed by urologists. A total of N1⁄4138 (10.6%) patients had at least one complication. Complications based on Clavien were as follows: Clavien I N1⁄418 (13%); Clavien II N1⁄475 (54.3%); Clavien III N1⁄414 (10.1%); Clavien IV N1⁄428 (20.2); and Clavien V N1⁄43 (2.2%). On multivariate analysis, predictors for Clavien III-V included higher ASA score (p1⁄40.01), open surgical approach (p1⁄40.02), and lower preoperative albumin level (p1⁄40.01). Readmission rates within 30-days because of a complication remain low (N1⁄477, 6%). On multivariate analysis, predictors for readmission included higher ASA score (p1⁄40.02), and history of diabetes mellitus (p1⁄40.03). CONCLUSIONS: Minimally invasive adrenalectomy complications rates and readmission rates are low, and but can have high Clavien grade (Clavien III-V) when they happen. Predictors for highgrade Clavien complications include higher ASA score, open surgical approach, and lower preoperative albumin. Predictors for readmission included higher ASA score, and history of diabetes mellitus.

Long-term outcomes of laparoscopic adrenalectomy for Cushing disease

IntroductionIn the surgical management of the patients with Cushing syndrome (CS), minimal invasive adrenalectomy (MA) has become the procedure of choice to treat adrenal tumors with a benign appearance ≤6 cm in diameter. Authors evaluated medium- and long-term outcomes of laparoscopic adrenalectomy (LA) for CS or subclinical CS (sCS), performed for ten years in an endocrine surgery unit. MethodsWe retrospectively reviewed 21 consecutive patients undergone LA for CS or sCS from 2003 to 2013. Postoperative clinical and cardiovascular status modifications and surgical medium and long-term outcomes were analyzed. ResultsIn each patient surgery determined a normalization of the hormonal profile. There was no mortality neither major post-operative complications. Mean operative time was higher during the learning curve, there was no conversion, and morbidity rate was 6.3%. Regression of the main clinical symptoms occurred slowly in twelve months. ConclusionsLA is a safe, effective and well-tolerated procedure for the treatment of CS and sCS reducing arterial blood pressure, body weight and fasting glucose levels. Following the learning curve a morbidity rate similar to that reported in the MA series for other adrenal diseases is observed.

Laparoscopic adrenal surgery: ten-year experience in a single institution

BackgroundMinimal invasive adrenalectomy has become the procedure of choice to treat adrenal tumors with a benign appearance, ≤ 6 cm in diameter and weighing < 100 g. Authors evaluated medium- and long-term outcomes of laparoscopic adrenalectomy (LA), performed for ten years in a single endocrine surgery unit.MethodsWe retrospectively reviewed 88 consecutive patients undergone LA for lesions of adrenal glands from 2003 to 2013. The first 30 operations were considered part of the learning curve. Doxazosin was preoperatively administered in case of pheochromocytoma (PCC), while spironolactone and potassium were employed to treat Conn's disease. Perioperative cardiovascular status modifications and surgical and medium- and long-term results were analyzed.ResultsForty nine (55.68%) functioning tumors, and one (1.13%) bilateral adrenal disease were identified. In 2 patients (2.27%) a supposed adrenal metastasis was postoperatively confirmed, while in no patients a diagnosis of incidental primitive malignancy was performed. There was no mortality or major post operative complication. The mean operative time was higher during the learning curve. Conversion and morbidity rates were respectively 1.13% and 5.7%. Intraoperative hypertensive crises (≥180/90 mmHg) were observed in 23.5% (4/17) of PCC patients and were treated pharmacologically with no aftermath. There was no influence of age, size and operative time on the occurrence of PCC intraoperative hypertensive episodes. Surgery determined a normalization of the endocrine profile. One single PCC persistence was observed, while in a Conn's patient, just undergone right LA, a left sparing adrenalectomy was performed for a contralateral metachronous aldosteronoma.ConclusionsLA, a safe, effective and well tolerated procedure for the treatment of adrenal neoplasms ≤ 6 cm, is feasible for larger lesions, with a similar low morbidity rate. Operative time has improved along with the increase of the experience and of the technological development. Preoperative adrenergic blockade did not prevent PCC intraoperative hypertensive crises, but facilitated the control of the hemodynamic stability.

Minimally Invasive Adrenalectomy: A Multicenter Comparison of Transperitoneal and Retroperitoneal Approaches

Minimally invasive adrenalectomy (MIA) is both feasible and safe with either transperitoneal or retroperitoneal entry. However, only a few studies have rigorously compared these two techniques. The aim of the current study is to compare transperitoneal and retroperitoneal adrenalectomy to detect significant differences in patient selection and perioperative outcomes. Between 1995 and 2009, 171 patients underwent MIA through transperitoneal (n = 127) or retroperitoneal access (n = 44). The respective cohorts were then examined retrospectively through matched and unmatched comparisons. Multivariate analyses of intraoperative blood loss, postoperative morbidity, and length of hospital stay were performed. Surgical indications were benign lesions (70.2%), malignant tumors (11.1%), and pheochromocytomas (18.7%). The postoperative morbidity rate was 15.8 per cent, but mortality was null. The rate of conversion to open surgery was 5.3 per cent. Blood loss and operative time were significantly lower with the transperitoneal approach, whereas time to oral intake was shorter for the retroperitoneal group. Tumor size less than 4.5 cm was associated with less blood loss, shorter hospital stay, and lower postoperative morbidity. Laparoscopic and retroperitoneal routes are both effective and safe for excising adrenal lesions. In the present study, however, laparoscopic adrenalectomy demonstrated shorter operative times with less blood loss. Regardless of this, we remain cautious in recommending one procedure preferentially. Other important measures of clinical outcome such as required pain control, ease of patient recovery, and cost considerations were not included in this analysis. Further randomized trials, with large patient numbers, are therefore desirable for defining an optimal surgical method.