RESUMEN
PURPOSE: This study aimed to determine the effect of adrenal mass functionality and different hormone subtypes synthesized by the adrenal masses on laparoscopic adrenalectomy (LA) outcomes. MATERIALS AND METHODS: The study included 298 patients, 154 of whom were diagnosed with nonfunctional masses. In the functional group, 33, 62, and 59 patients had Conn syndrome, Cushing's syndrome, and pheochromocytoma, respectively. The variables were analyzed between the functional and nonfunctional groups and then compared among functional masses through subgroup analysis. RESULTS: The incidence of diabetes mellitus, hypertension, and obesity, blood loss, and length of hospital stay (LOH) were significantly higher in the functional group than in the nonfunctional group. In the subgroup analysis, patients with pheochromocytoma had significantly lower body mass index but significantly higher mass size, blood loss, and LOH than the other two groups. A positive correlation was found between mass size and blood loss in patients with pheochromocytoma (p ≤ 0.001, r = 0.761). However, no significant difference in complications was found among the groups. CONCLUSIONS: In this study, patients with functional adrenal masses had higher comorbidity rates and American Society of Anesthesiologists scores. Moreover, blood loss and LOH were longer on patients with functional adrenal masses who underwent LA. Mass size, blood loss, and LOH in patients with pheochromocytoma were significantly longer than those in patients with other functional adrenal masses. Thus, mass functionality did not increase the complications.
Asunto(s)
Neoplasias de las Glándulas Suprarrenales , Adrenalectomía , Laparoscopía , Feocromocitoma , Humanos , Adrenalectomía/métodos , Adrenalectomía/efectos adversos , Femenino , Masculino , Laparoscopía/efectos adversos , Persona de Mediana Edad , Neoplasias de las Glándulas Suprarrenales/cirugía , Feocromocitoma/cirugía , Feocromocitoma/patología , Adulto , Resultado del Tratamiento , Estudios Retrospectivos , Tiempo de Internación , Síndrome de Cushing/cirugía , Hiperaldosteronismo/cirugía , Anciano , Pérdida de Sangre Quirúrgica/estadística & datos numéricosRESUMEN
BACKGROUND: Adrenalectomy for pheochromocytoma (PHEO) is challenging because of the high risk of intraoperative hemodynamic instability (HDI). This study aimed to compare the incidence and risk factors of intraoperative HDI between laparoscopic left adrenalectomy (LLA) and laparoscopic right adrenalectomy (LRA). METHODS: We retrospectively analyzed two hundred and seventy-one patients aged > 18 years with unilateral benign PHEO of any size who underwent transperitoneal laparoscopic adrenalectomy at our hospitals between September 2016 and September 2023. Patients were divided into LRA (N = 122) and LLA (N = 149) groups. Univariate and multivariate logistic regression analyses were used to predict intraoperative HDI. In multivariate analysis for the prediction of HDI, right-sided PHEO, PHEO size, preoperative comorbidities, and preoperative systolic blood pressure were included. RESULTS: Intraoperative HDI was significantly higher in the LRA group than in the LLA (27% vs. 9.4%, p < 0.001). In the multivariate regression analysis, right-sided tumours showed a higher risk of intraoperative HDI (odds ratio [OR] 5.625, 95% confidence interval [CI], 1.147-27.577, p = 0.033). The tumor size (OR 11.019, 95% CI 3.996-30.38, p < 0.001), presence of preoperative comorbidities [diabetes mellitus, hypertension, and coronary heart disease] (OR 7.918, 95% CI 1.323-47.412, p = 0.023), and preoperative systolic blood pressure (OR 1.265, 95% CI 1.07-1.495, p = 0.006) were associated with a higher risk of HDI in both LRA and LLA, with no superiority of one side over the other. CONCLUSION: LRA was associated with a significantly higher intraoperative HDI than LLA. Right-sided PHEO was a risk factor for intraoperative HDI.
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Neoplasias de las Glándulas Suprarrenales , Adrenalectomía , Hemodinámica , Complicaciones Intraoperatorias , Laparoscopía , Feocromocitoma , Humanos , Feocromocitoma/cirugía , Adrenalectomía/métodos , Adrenalectomía/efectos adversos , Laparoscopía/métodos , Laparoscopía/efectos adversos , Neoplasias de las Glándulas Suprarrenales/cirugía , Masculino , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Adulto , Complicaciones Intraoperatorias/epidemiología , Complicaciones Intraoperatorias/etiología , Factores de Riesgo , AncianoRESUMEN
Robotic adrenalectomy (RA) has gained significant popularity in the management of adrenal gland diseases. We report our experience at a single tertiary institution and evaluate the safety and surgical outcomes of RA. The data of 122 consecutive patients who underwent RA from October 2009 to December 2022 at Korea University Anam Hospital (Seoul, Korea) were reviewed. There were no perioperative complications. Clinicopathological features and surgical outcomes were retrospectively analyzed through complete chart reviews. Noteworthy findings include the influence of sex, tumor size, and body mass index on operation time, with the female and small tumor groups exhibiting shorter operation times (P = 0.018 and P = 0.009, respectively). Pheochromocytoma was identified as a significant independent risk factor for a longer operation time in the multivariate analysis [odds ratio (OR), 3.709; 95% confidence interval (CI), 1.127-12.205; P = 0.031]. A temporal analysis revealed a decreasing trend in mean operation times across consecutive groups, reflecting a learning curve associated with RA adoption. RA is a safe and effective operative technique alternative to laparoscopic adrenalectomy that has favorable surgical outcomes and enhances the convenience of the operation.
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Neoplasias de las Glándulas Suprarrenales , Adrenalectomía , Tempo Operativo , Procedimientos Quirúrgicos Robotizados , Humanos , Femenino , Adrenalectomía/métodos , Adrenalectomía/efectos adversos , Masculino , Procedimientos Quirúrgicos Robotizados/métodos , Procedimientos Quirúrgicos Robotizados/efectos adversos , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Adulto , Neoplasias de las Glándulas Suprarrenales/cirugía , Neoplasias de las Glándulas Suprarrenales/patología , Anciano , Feocromocitoma/cirugía , Feocromocitoma/patología , Factores de Riesgo , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Laparoscopía/métodos , Laparoscopía/efectos adversosRESUMEN
Purpose: Surgery is the only way to cure pheochromocytoma; however, postoperative hemodynamic instability is one of the main causes of serious complications and even death. This study's findings provide some guidance for improved clinical management. Patients and methods: This study was to investigate the factors leading to postoperative hemodynamic instability in the postoperative pathology indicated pheochromocytoma from May 2016 to May 2022. They were divided into two groups according to whether vasoactive drugs were used for a median number of days or more postoperatively. The factors affecting the postoperative hemodynamics in the perioperative period (preoperative, intraoperative, and postoperative) were then evaluated. Results: The median number of days requiring vasoactive drug support postoperatively was three in 234 patients, while 118 (50.4%) patients required vasoactive drug support for three days or more postoperatively. The results of the multivariate analysis indicated more preoperative colloid use (odds ratio [OR]=1.834, confidence interval [CI]:1.265-2.659, P=0.001), intraoperative use of vasoactive drug (OR=4.174, CI:1.882-9.258, P<0.001), and more postoperative crystalloid solution input per unit of body weight per day (ml/kg/d) (OR=1.087, CI:1.062-1.112, P<0.001) were risk factors for predicting postoperative hemodynamic instability. The optimal cutoff point of postoperative crystalloid use were 42.37 ml/kg/d. Conclusion: Hemodynamic instability is a key issue for consideration in the perioperative period of pheochromocytoma. The amount of preoperative colloid use, the need for intraoperative vasoactive drugs, and postoperative crystalloid solution are risk factors for predicting postoperative hemodynamic instability (registration number: ChiCT2300071166).
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Neoplasias de las Glándulas Suprarrenales , Hemodinámica , Feocromocitoma , Complicaciones Posoperatorias , Feocromocitoma/cirugía , Feocromocitoma/fisiopatología , Humanos , Femenino , Masculino , Neoplasias de las Glándulas Suprarrenales/cirugía , Neoplasias de las Glándulas Suprarrenales/fisiopatología , Hemodinámica/fisiología , Persona de Mediana Edad , Adulto , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Estudios de Cohortes , Adrenalectomía/efectos adversos , Estudios Retrospectivos , Factores de Riesgo , Anciano , Vasoconstrictores/uso terapéutico , Soluciones Cristaloides/administración & dosificaciónRESUMEN
BACKGROUND: Laparoscopic adrenalectomy is widely performed for a number of hormone-producing tumors and postoperative management depends on the hormones produced. In the present study, we conducted a retrospective analysis to clarify the risk factors for postoperative complications, particularly postoperative fever after laparoscopic adrenalectomy. METHODS: We analyzed 406 patients who underwent laparoscopic adrenalectomy at our hospital between 2003 and 2019. Postoperative fever was defined as a fever of 38 °C or higher within 72 h after surgery. We investigated the risk factors for postoperative fever after laparoscopic adrenalectomy. RESULTS: There were 188 males (46%) and 218 females (54%) with a median age of 52 years. Among these patients, tumor pathologies included 188 primary aldosteronism (46%), 75 Cushing syndrome (18%), and 80 pheochromocytoma (20%). Postoperative fever developed in 124 of all patients (31%), 30% of those with primary aldosteronism, 53% of those with pheochromocytoma, and 8% of those with Cushing syndrome. A multivariate logistic regression analysis identified pheochromocytoma and non-Cushing syndrome as independent predictors of postoperative fever. Postoperative fever was observed in 42 out of 80 cases of pheochromocytoma (53%), which was significantly higher than in cases of non-pheochromocytoma (82/326, 25%, p < 0.01). In contrast, postoperative fever developed in 6 out of 75 cases of Cushing syndrome (8%), which was significantly lower than in cases of non-Cushing syndrome (118/331, 35.6%, p < 0.01). CONCLUSION: Since postoperative fever after laparoscopic adrenalectomy is markedly affected by the hormone produced by pheochromocytoma and Cushing syndrome, it is important to carefully consider the need for treatment.
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Neoplasias de las Glándulas Suprarrenales , Síndrome de Cushing , Hiperaldosteronismo , Laparoscopía , Feocromocitoma , Masculino , Femenino , Humanos , Persona de Mediana Edad , Adrenalectomía/efectos adversos , Síndrome de Cushing/cirugía , Feocromocitoma/cirugía , Estudios Retrospectivos , Estudios de Casos y Controles , Laparoscopía/efectos adversos , Neoplasias de las Glándulas Suprarrenales/cirugía , Neoplasias de las Glándulas Suprarrenales/patología , Factores de Riesgo , Hiperaldosteronismo/cirugía , HormonasRESUMEN
BACKGROUND: Posterior retroperitoneoscopic adrenalectomy has several advantages over transabdominal laparoscopic adrenalectomy regarding operating time, blood loss, postoperative pain, and recovery. However, postoperatively several patients report chronic pain or hypoesthesia. We hypothesized that these symptoms may be the result of damage to the subcostal nerve, because it passes the surgical area. METHODS: A prospective single-center case series was performed in adult patients without preoperative pain or numbness of the abdominal wall who underwent unilateral posterior retroperitoneoscopic adrenalectomy. Patients received pre- and postoperative questionnaires and a high-resolution ultrasound scan of the subcostal nerve and abdominal wall muscles was performed before and directly after surgery. Clinical evaluation at 6 weeks was performed with repeat questionnaires, physical examination, and high-resolution ultrasound. Long-term recovery was evaluated with questionnaires, and photographs from the patients were examined for abdominal wall asymmetry. RESULTS: A total of 25 patients were included in the study. There were no surgical complications. Preoperative visualization of the subcostal nerve was possible in all patients. At 6 weeks, ultrasound showed nerve damage in 15 patients, with no significant association between nerve damage and postsurgical pain. However, there was a significant association between nerve damage and hypoesthesia (p = 0.01), sensory (p < 0.001), and motor (p < 0.001) dysfunction on physical examination. After a median follow-up of 18 months, 5 patients still experienced either numbness or muscle weakness, and one patient experienced chronic postsurgical pain. CONCLUSION: In this exporatory case series the incidence of postoperative damage to the subcostal nerve, both clinically and radiologically, was 60% after posterior retroperitoneoscopic adrenalectomy. There was no association with pain, and the spontaneous recovery rate was high.
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Adrenalectomía , Laparoscopía , Ultrasonografía , Humanos , Masculino , Femenino , Adrenalectomía/métodos , Adrenalectomía/efectos adversos , Estudios Prospectivos , Persona de Mediana Edad , Laparoscopía/métodos , Espacio Retroperitoneal/diagnóstico por imagen , Espacio Retroperitoneal/cirugía , Adulto , Ultrasonografía/métodos , Anciano , Dolor Postoperatorio/etiología , Nervios Intercostales/diagnóstico por imagen , Traumatismos de los Nervios Periféricos/etiologíaRESUMEN
INTRODUCTION: Adrenalectomy generally has favorable outcomes. It is unknown if patients with functional adrenal tumors experience different clinical outcomes than those with benign adrenal tumors, due to the presence of comorbid conditions secondary to the functional tumor. We investigated outcomes following open and laparoscopic adrenalectomy for benign nonfunctional (BNF) versus functional adrenal masses. METHODS: Patients undergoing adrenalectomy were identified in the 2015-2020 National Surgical Quality Improvement Program database, then categorized as BNF, hyperaldosteronism, hypercortisolism, and pheochromocytoma. The primary outcome of interest was 30-d morbidity and secondary outcomes included 30-d mortality, 30-d readmission, and postoperative length of stay (LOS). Subgroup analysis was performed based upon surgical approach. Univariate analysis was performed, followed by multivariable logistic regression for individual outcomes that differed significantly between patients with BNF and functional neoplasm, factoring in patient demographics and operative approach with statistical significance on univariate analysis. Descriptive statistics and outcomes were analyzed using Pearson's χ2 test and Mann-Whitney U-test as appropriate. RESULTS: There were 3291 patients with BNF while 484 had hyperaldosteronism, 263 hypercortisolism, and 46 pheochromocytomas. Within the laparoscopic group of 3615 (88.5%) of adrenalectomy patients, compared to BNF patients, patients with hyperaldosteronism had lower rates of postoperative morbidity (1.9% versus 5.2%, P < 0.001) and shorter LOS (1 d, interquartile range (IQR) [1-1] versus 1d IQR [1-2], P = 0.003); these persisted on multivariate analysis (OR 0.32, 95% confidence interval [CI] 0.14-0.74 and odds ratio 0.47, 95% CI 0.36-0.60, P < 0.001). Patients with hypercortisolism had higher morbidity (7.3% versus 5.2%, P < 0.001), 30-d readmission rates (5.3% versus 2.9%, P = 0.042) and longer LOS (2d, IQR [1-3] versus 1d, IQR [1-2, P < 0.001). On multivariate analysis, presence of hypercortisolism was independently associated with increased likelihood of readmission within 30 d (OR 2.20, 95% CI 1.11-2.99, P = 0.012) and longer LOS (>1 d) (OR 1.79, 95% CI 1.33-2.40, P < 0.001). Compared to BNF patients, patients with pheochromocytoma had higher rates of postoperative morbidity (6.2% versus 5.2%, P < 0.001). Within the open group of 469 (11.5% of adrenalectomy patients), there were no statistically significant differences in outcomes between patients with BNF and functional adrenal masses. CONCLUSIONS: Outcomes after adrenalectomy performed for functional neoplasms differ based on surgical indication.
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Neoplasias de las Glándulas Suprarrenales , Adrenalectomía , Laparoscopía , Tiempo de Internación , Complicaciones Posoperatorias , Humanos , Adrenalectomía/estadística & datos numéricos , Adrenalectomía/efectos adversos , Masculino , Femenino , Persona de Mediana Edad , Neoplasias de las Glándulas Suprarrenales/cirugía , Anciano , Laparoscopía/estadística & datos numéricos , Adulto , Estudios Retrospectivos , Resultado del Tratamiento , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Tiempo de Internación/estadística & datos numéricos , Feocromocitoma/cirugía , Feocromocitoma/mortalidad , Readmisión del Paciente/estadística & datos numéricos , Hiperaldosteronismo/cirugía , Hiperaldosteronismo/epidemiologíaRESUMEN
PURPOSE: To present a case series of Cushing's syndrome (CS) during pregnancy caused by adrenocortical adenomas, highlighting clinical features, hormonal assessments and outcomes. METHODS: We describe five pregnant women with CS, detailing clinical presentations and laboratory findings. RESULTS: Common clinical features included a full moon face, buffalo back and severe hypertension. Elevated blood cortisol levels with circadian rhythm disruption and suppressed adrenocorticotrophic hormone (ACTH) levels were observed. Imaging revealed unilateral adrenal tumours. Two cases underwent laparoscopic adrenalectomies during the second trimester, while three had postpartum surgery. All required hormone replacement therapy, with postoperative pathological confirmation of adrenocortical adenomas. CONCLUSION: Diagnosis of CS during pregnancy is challenging due to overlapping features with normal pregnancy: elevated blood cortisol levels and abnormal diurnal rhythm of blood cortisol, suppressed aid diagnosis. Treatment should be individualised due to a lack of explicit optimum therapeutic approaches. Laparoscopic adrenalectomy may be an optimal choice, along with multidisciplinary management including hormone replacement therapy.
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Adenoma Corticosuprarrenal , Síndrome de Cushing , Femenino , Humanos , Embarazo , Síndrome de Cushing/complicaciones , Síndrome de Cushing/diagnóstico , Adenoma Corticosuprarrenal/complicaciones , Hidrocortisona , Adrenalectomía/efectos adversosRESUMEN
This study aimed to evaluate and compare the perioperative outcomes of robot-assisted adrenalectomy (RAA) and laparoscopic adrenalectomy (LA) using propensity score matching. This retrospective study included 395 patients who underwent minimally invasive adrenalectomy: 354 who underwent LA and 41 who underwent RAA between February 2015 and March 2023. To mitigate potential confounding factors, 2:1 propensity score matching was conducted based on age, sex, body mass index, American Society of Anesthesiologists score, tumor laterality, and tumor size. Perioperative outcomes and complications were compared between the two groups, and prognostic factors for complications were analyzed. Propensity score matching analysis identified 123 patients, with 82 and 41 in the LA and RAA groups, respectively. Operative time (81.4 ± 26.6 min vs. 83.5 ± 25.9 min, P = 0.675), estimated blood loss (77.7 ± 68.3 mL vs. 83.2 ± 73.9 mL, P = 0.683), and post-operative stay (3.8 ± 1.0 days vs. 4.0 ± 0.9 days, P = 0.211) showed no significant differences between two groups. Intraoperative complications occurred in 8 patients (9.8%) in the LA group, while no patients (0%) experienced intraoperative complications in the RAA group (P = 0.051). In both groups, post-operative complications occurred in 2.4% (P = 1). The only factor contributing to complications after adrenalectomy was tumor size (OR 1.026, 95% CI 1.001-1.051, P = 0.042). RAA exhibited comparable perioperative outcomes and presented an improved intraoperative complication rate compared with LA. Tumor size was the only factor that contributed to complications after adrenalectomy.
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Laparoscopía , Neoplasias , Procedimientos Quirúrgicos Robotizados , Robótica , Humanos , Adrenalectomía/efectos adversos , Puntaje de Propensión , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/métodos , Complicaciones IntraoperatoriasRESUMEN
Background: Cushing's syndrome (CS) during pregnancy is a rare endocrine disorder characterized by hypercortisolism, which is significantly associated with maternal-fetal complications. Despite its rarity, CS during pregnancy may be related to a high risk of complications for both the mother and fetus.The aim of the present case study is to update the diagnostic approach to CS during pregnancy and the therapeutic strategies for this medical condition to minimize maternal-fetal complications. Methods: Here, we present two cases of CS in pregnant women, one of whom had twins. Typical clinical symptoms and signs of hypercortisolism developed at the beginning of pregnancy. The plasma cortisol diurnal rhythm of the pregnant patient was absent. CS was confirmed by cortisol and adrenocorticotropic hormone (ACTH) assessment, as well as imaging examination. We investigated the changes in the hypothalamic-pituitary-adrenal axis during normal pregnancy and the etiology, diagnosis and treatment of CS during pregnancy. Conclusion: Due to the associated risks of laparoscopic adrenalectomy,it is uncertain whether this treatment significantly decreases overall maternal mortality. Additional observational research and validation through randomized controlled trials (RCTs) are required. We advise that CS in pregnant women be diagnosed and treated by experienced teams in relevant departments and medical centers.
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Síndrome de Cushing , Embarazo , Femenino , Humanos , Síndrome de Cushing/diagnóstico , Hidrocortisona , Adrenalectomía/efectos adversos , Hormona Adrenocorticotrópica , FetoRESUMEN
To compare the clinical efficacy and safety of robot-assisted adrenalectomy (RA) and laparoscopic adrenalectomy (LA) for pheochromocytoma (PHEO). We conducted a comprehensive search of PubMed, the Cochrane Library, and Embase databases for studies comparing RA and LA treatment for PHEO, covering the period from database inception to January 1, 2024. Two researchers will independently screen literature and extract data, followed by meta-analysis using Review Manager 5.3 software. Six studies with 658 patients were included in the analysis. There were no significant differences in operation time [MD = -8.03, 95% CI (-25.68,9.62), P > 0.05], transfusion rate [OR = 1.10, 95% CI (0.55, 2.19) , P > 0.05], conversion rate [OR = 0.31, 95% CI (0.08, 1.12), P > 0.05], complication rate [OR = 0.93, 95% CI (0.52, 1.70), P > 0.05], Intraoperative max SBP [MD = -4.08, 95% CI (-10.13,1.97), P > 0.05], Intraoperative min SBP [MD = -2.71, 95% CI (-9.60,4.18), P > 0.05] among patients undergoing RA and LA. However, compared with patients who underwent LA, patients who underwent RA had less estimated blood loss [MD = -37.72, 95% CI (-64.11,-11.33), P < 0.05], a shorter length of hospital stay [MD = -0.43, 95% CI (-0.65,-0.21) P < 0.05]. RA has higher advantages in some aspects compared to LA. RA is a feasible, safe, and comparable treatment option for PHEO.
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Neoplasias de las Glándulas Suprarrenales , Adrenalectomía , Laparoscopía , Feocromocitoma , Procedimientos Quirúrgicos Robotizados , Humanos , Feocromocitoma/cirugía , Adrenalectomía/métodos , Adrenalectomía/efectos adversos , Procedimientos Quirúrgicos Robotizados/métodos , Procedimientos Quirúrgicos Robotizados/efectos adversos , Laparoscopía/métodos , Neoplasias de las Glándulas Suprarrenales/cirugía , Resultado del Tratamiento , Tempo Operativo , Tiempo de Internación/estadística & datos numéricos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Masculino , Femenino , Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Transfusión Sanguínea/estadística & datos numéricosRESUMEN
INTRODUCTION: The risk of adverse outcomes after adrenal metastasectomy is not well defined. Knowledge of these risks is essential to guide patient counseling. METHODS: The 2015-2020 National Surgical Quality Improvement Program datasets were combined. Patients who underwent adrenalectomy for secondary adrenal malignancy (SM) and benign nonfunctional (BNF) adrenal neoplasms were identified; BNF neoplasms were chosen as a comparison as functional neoplasms can contribute to comorbidity. Patients who had additional surgery at the time of adrenalectomy were excluded. Patient demographics, comorbidities, perioperative factors, and outcomes were compared between groups. Multivariable logistic regression analysis was performed. RESULTS: Of 3496 adrenalectomy patients, 332 had SM and 3164 had BNF neoplasms. Patients with SM were older (65 versus 54 y) and more often had chronic obstructive pulmonary disease (7.5% versus 4.4%), chronic steroid use (10.5% versus 3.8%), and bleeding disorders (4.5% versus 2.2%) than patients with BNF, respectively (P < 0.01 for all). Laparoscopic adrenalectomy was the most common operative approach for both groups (74.7% versus 88.3%). Rates of mortality, morbidity, reoperation, readmission, and nonhome discharge did not differ significantly between groups. Patients with SM had higher rates of postoperative bleeding than patients with BNF (6.3% versus 2.6%, P < 0.001). This persisted on multivariable regression analysis that adjusted for demographics, comorbidities, and operative approach (odds ratio 2.34, 95% confidence interval 1.19-4.64). CONCLUSIONS: Adrenalectomy for SM is associated with an increased risk of postoperative bleeding compared to adrenalectomy for BNF adrenal neoplasms. Patients with SM that meet criteria for adrenal metastasectomy should be counseled appropriately.
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Neoplasias de las Glándulas Suprarrenales , Laparoscopía , Humanos , Adrenalectomía/efectos adversos , Estudios Retrospectivos , Neoplasias de las Glándulas Suprarrenales/cirugía , Neoplasias de las Glándulas Suprarrenales/patología , Comorbilidad , Morbilidad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Hemorragia Posoperatoria/etiología , Laparoscopía/efectos adversosRESUMEN
INTRODUCTION: We sought to analyze temporal trends in the utilization of minimally invasive vs open adrenalectomy in the United States; to assess costs, perioperative outcomes, and the determining factors influencing these variables. METHODS: A retrospective analysis of claims data obtained from PearlDiver Mariner, a Health Insurance Portability and Accountability Act-compliant deidentified nationwide database of insurance billing records, was performed. Per-population utilization rates and trends were analyzed using negative binomial regression and trends tests respectively. Continuous and categorical variables were compared using 2-sided t tests and χ2 tests. Multivariable logistic regression analysis was conducted to identify predictors of perioperative complication. RESULTS: A total of 10,753 patients were identified (mean age 53.3 ± 16.1 years). Using the 2011 to 2014 time frame as reference, utilization of adrenalectomy decreased over time (incidence rate ratio for 2015-2018: 0.65 [95% CI 0.62-0.68, P < .001]; incidence rate ratio for 2019-2021: 0.39 [95% CI 0.37-0.41, P < .001]). Minimally invasive adrenalectomies increased significantly over time (P < .001). A greater number of adrenalectomies were performed by general surgeons compared with urologists (70.4% vs 29.5%). Complications were not significantly predicted by any surgical specialty. Significant predictors for complication rates were Charlson comorbidity index > 1 (odds ratio [OR] 1.11, 95% CI 1.09-1.13), presence of social determinants of health (OR 1.5, 95% CI 1.18-1.88) and open approach (OR 1.54, 95% CI 1.34-1.77). CONCLUSIONS: The number of adrenalectomies in the United States decreased over the past decade, with a shift towards minimally invasive approach. No difference in outcomes for general surgeons vs urologists can be observed. Social determinants of health are independent predictors of increased rate of complications.
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Especialidades Quirúrgicas , Cirujanos , Humanos , Estados Unidos/epidemiología , Adulto , Persona de Mediana Edad , Anciano , Adrenalectomía/efectos adversos , Estudios Retrospectivos , Determinantes Sociales de la SaludRESUMEN
Introduction: Obesity is associated with numerous chronic conditions and an increased risk for surgical complications. Laparoscopic and robotic adrenalectomy have proven effective in the resection of adrenal tumors. This study analyzes the outcomes of severely obese patients (body-mass index [BMI] ≥35 kg/m2) following minimally invasive adrenalectomy. Materials and Methods: A retrospective analysis of patients who underwent minimally invasive adrenalectomy at our institution between 2010 and 2023 was conducted. Two matching analyses were performed. The first analysis compared patients with BMI greater versus lower than 35 kg/m2. The second analysis compared outcomes between robotic and laparoscopic adrenalectomy in patients with a BMI ≥35 kg/m2. Results: A total of 278 patients were included in the study. The median tumor size was 29 mm. Adrenal tumors had similar laterality, and most were hormonally active (66.2%). The most common pathological diagnosis was pheochromocytoma (25.5%). No statistical difference was found in peri- and postoperative outcomes between patients with BMI ≥35 and <35 kg/m2 who underwent minimally invasive adrenalectomy. When the surgical approach was compared in severely obese patients, robotic adrenalectomy was associated with shorter hospital length of stay with similar operative time as the laparoscopic approach. Conclusions: Minimally invasive adrenalectomy is safe and feasible in patients with BMI ≥35 kg/m2. Robotic and laparoscopic approaches are both safe and efficient for the resection of adrenal tumors in severely obese patients.
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Neoplasias de las Glándulas Suprarrenales , Laparoscopía , Humanos , Adrenalectomía/efectos adversos , Índice de Masa Corporal , Estudios Retrospectivos , Neoplasias de las Glándulas Suprarrenales/cirugía , Neoplasias de las Glándulas Suprarrenales/patología , Laparoscopía/efectos adversos , Obesidad/cirugía , Tiempo de InternaciónRESUMEN
INTRODUCTION: Adrenal venous sampling (AVS) is used to distinguish unilateral from bilateral aldosterone hypersecretion as a cause of primary aldosteronism (PA). Unilateral disease is treated with adrenalectomy and bilateral hypersecretion managed medically. METHODS: We performed a single institution retrospective cohort study of adult patients undergoing adrenalectomy for PA from July 2013 to June 2022. Concordance of imaging findings with AVS was evaluated. Statistical analysis was performed with Mann-Whitney U and chi-squared Fisher's exact. Literature review performed via triple method search strategy. RESULTS: Twenty-one patients underwent AVS and adrenalectomy for PA. Two patients did not have imaging findings and 19 were localized with an adenoma. For patients with image localization, AVS was concordant in nine, discordant in four, and nondiagnostic in six. For patients with discordant findings, age range was 35.8 to 72.4 y compared with concordant patient age range of 49.8 to 71.7 y. Overall discordance between imaging results and AVS was 40%. The aldosterone level was associated with concordance with a median of 52 ng/dL compared with 26 ng/dL if discordant (P = 0.002). There was a significant reduction in antihypertensive medications for the entire cohort from a median of three medications (interquartile range 2-4) to 1 medication (interquartile range 1-2), P < 0.001. CONCLUSIONS: In this cohort, 40% of patients with selective AVS had discordant imaging and AVS results. Aldosterone level was associated with concordance. Hypertension was significantly improved with a median decrease of two antihypertensives. Our results support performance of AVS on all candidates for adrenalectomy for PA.
Asunto(s)
Glándulas Suprarrenales , Hiperaldosteronismo , Adulto , Humanos , Glándulas Suprarrenales/diagnóstico por imagen , Glándulas Suprarrenales/irrigación sanguínea , Aldosterona , Hiperaldosteronismo/diagnóstico , Hiperaldosteronismo/etiología , Hiperaldosteronismo/cirugía , Estudios de Cohortes , Estudios Retrospectivos , Adrenalectomía/efectos adversos , Tomografía Computarizada por Rayos X/efectos adversosRESUMEN
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.
Asunto(s)
Neoplasias de las Glándulas Suprarrenales , Laparoscopía , Humanos , Neoplasias de las Glándulas Suprarrenales/cirugía , Espacio Retroperitoneal/cirugía , Espacio Retroperitoneal/patología , Adrenalectomía/efectos adversos , Adrenalectomía/métodos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Estudios Retrospectivos , Tiempo de Internación , Tempo Operativo , Resultado del TratamientoRESUMEN
The laparoscopic approach represents the standard of treatment for renal and adrenal diseases, and its use is increasing even outside referral centres. Although most procedures are routinely performed, intraoperative complications do not occur, and the rate and predictive factors of these complications have not been established. The aim of this study was to evaluate the incidence and type of intraoperative complications and to identify predictive factors in patients undergoing laparoscopic renal and adrenal surgery. This was a cohort, multicentre, international retrospective study. Patients who underwent laparoscopic renal and adrenal surgeries between April 2017 and March 2022 were included in the study. Bivariate analysis was performed using contingency tables and the χ2 test for independent samples to compare qualitative variables and the T test and Mood test for continuous variables. Multivariate analysis was performed using a logistic regression model to obtain adjusted odds ratios. A total of 2374 patients were included in the study. Intraoperative complications were reported for 8.09% of patients who underwent renal surgery, with the most common complications reported being hollow viscus and vascular complications, and for 6.75% of patients who underwent adrenal surgery, with the most common complication reported being parenchymatous viscous complications. Multivariate analysis revealed that both adrenal and renal surgery radiological preoperative factors, such as invasive features during adrenalectomy and the RENAL score during nephrectomy, are predictive factors of intraoperative complications. In contrast to existing data, surgeon experience was not associated with a reduction in the incidence of perioperative complications.
Asunto(s)
Laparoscopía , Humanos , Estudios Retrospectivos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Adrenalectomía/efectos adversos , Adrenalectomía/métodos , Nefrectomía/efectos adversos , Nefrectomía/métodos , Complicaciones Intraoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Resultado del TratamientoRESUMEN
Primary aldosteronism (PA) is the most common cause of secondary arterial hypertension. For unilateral cases, surgery offers the possibility of cure, with unilateral adrenalectomy being the treatment of choice, whereas bilateral forms of PA are treated mainly with mineralocorticoid receptor antagonists (MRA). The goals of treatment for PA due to either unilateral or bilateral adrenal disease include reversal of the adverse cardiovascular effects of hyperaldosteronism, normalization of serum potassium in patients with hypokalemia, and normalization of blood pressure. The Primary Aldosteronism Surgery Outcome group (PASO) published a study defining clinical and biochemical outcomes based on blood pressure and correction of hypokalemia and aldosterone to renin ratio (ARR) levels for patients undergoing total unilateral adrenalectomy for unilateral PA. In this review, we provide several practical recommendations for the medical and surgical management and follow-up of patients with PA. (AU)
El hiperaldosteronismo primario (HAP) es la causa más frecuente de hipertensión arterial secundaria. Para los casos unilaterales, la cirugía ofrece la posibilidad de curación, siendo la adrenalectomía unilateral el tratamiento de elección, mientras que las formas bilaterales de HAP se tratan principalmente con antagonistas del receptor de mineralocorticoides (ARM). Los objetivos del tratamiento del HAP debido a enfermedad suprarrenal unilateral o bilateral incluyen la reversión de los efectos cardiovasculares adversos del hiperaldosteronismo, la normalización del potasio sérico en pacientes con hipopotasemia y la normalización de la presión arterial. El grupo Primary Aldosteronism Surgery Outcome (PASO) publicó un estudio que define los resultados clínicos y bioquímicos en función de la presión arterial y la corrección de la hipopotasemia y los niveles del cociente aldosterona/renina (ARR) para pacientes sometidos a adrenalectomía unilateral total por HAP unilateral. En esta revisión ofrecemos varias recomendaciones prácticas para el manejo y el seguimiento médico-quirúrgico de los pacientes con HAP. (AU)
Asunto(s)
Humanos , Hipertensión/terapia , Hiperaldosteronismo/terapia , Hipopotasemia/etiología , Hipertensión/complicaciones , Hiperaldosteronismo/complicaciones , Aldosterona/uso terapéutico , Estudios de Seguimiento , Adrenalectomía/efectos adversosRESUMEN
Primary aldosteronism (PA) is the most common form of secondary hypertension, with its main manifestations including hypertension and hypokalemia. Early identification of PA is extremely important as PA patients can easily develop cardiovascular complications such as atrial fibrillation, stroke, and myocardial infarction. The past decade has witnessed the rapid advances in the genetics of PA, which has shed new light on PA treatment. While surgery is the first choice for unilateral diseases, bilateral lesions can be treated with mineralocorticoid receptor antagonists (MRAs). The next-generation non-steroidal MRAs are under investigations. New medications including calcium channel blockers, macrophage antibiotics, and aldosterone synthase inhibitors have provided a new perspective for the medical treatment of PA.
Asunto(s)
Humanos , Hiperaldosteronismo/complicaciones , Adrenalectomía/efectos adversos , Aldosterona/uso terapéutico , Hipertensión/tratamiento farmacológico , Antagonistas de Receptores de Mineralocorticoides/uso terapéuticoRESUMEN
Introducción y objetivos: La cirugía laparoscópica se ha convertido en el abordaje estándar para el tratamiento de las glándulas suprarrenales. Debido a que la adrenalectomía bilateral sincrónica no se realiza con frecuencia, la evidencia sobre este procedimiento es limitada. Nuestro objetivo es reportar nuestra experiencia de 13 años con la adrenalectomía bilateral laparoscópica sincrónica, evaluando su viabilidad, seguridad y resultados perioperatorios.Pacientes y métodos: Un total de 23 pacientes consecutivos sometidos a adrenalectomía laparoscópica bilateral sincrónica entre 2007 y 2020 en un único centro académico fueron incluidos en el estudio. Las variables evaluadas fueron el tiempo quirúrgico, la pérdida media estimada de sangre, la conversión a cirugía abierta, las complicaciones postoperatorias, la mortalidad y la duración de la estancia postoperatoria.Resultados: El tiempo operatorio medio fue de 189,3±48,9min. La media de pérdida de sangre estimada fue de 163,0±201,3ml. No hubo conversiones a cirugía abierta. Cinco pacientes tuvieron complicaciones postoperatorias y 3 de estas fueron graves. Ningún paciente falleció durante el periodo perioperatorio. La mediana del tiempo de estancia postoperatoria fue de 3 días (rango 1-30). En el análisis patológico 15 pacientes tenían hiperplasia suprarrenal bilateral, 2 hiperplasia suprarrenal unilateral y un tumor benigno contralateral, uno hiperplasia suprarrenal unilateral y glándula contralateral normal, otro adenoma unilateral, 3 feocromocitomas bilaterales y uno mielolipoma bilateral.Conclusión: La adrenalectomía laparoscópica bilateral sincrónica es una técnica factible y segura. Se requiere un equipo multidisciplinar y experimentado que incluya anestesistas y endocrinólogos. (AU)
Introduction and objectives: Laparoscopic surgery is the standard approach for the treatment of adrenal glands. Bilateral synchronous adrenalectomy is rarely performed, and evidence about this procedure is limited. Our objective is to report our 13-year experience with synchronous laparoscopic bilateral adrenalectomy, evaluating its feasibility, safety, and perioperative outcomes.Patients and methods: A total of 23 consecutive patients undergoing synchronous bilateral laparoscopic adrenalectomy between 2007 and 2020 in a single academic center were included. Variables evaluated were operative time, estimated blood loss, conversion to open surgery, postoperative complications, mortality, and postoperative length of stay.Results: Mean operative time was 189.3±48.9min. Mean estimated blood loss was 163.0±201.3ml. There were no conversions to open surgery. Five patients had postoperative complications, three of those were major. No patient died in the perioperative period. Median postoperative length of stay was three days (range 1-30). At pathology analysis, 15 patients had bilateral adrenal hyperplasia, 2 unilateral adrenal hyperplasia and a contralateral benign tumor, 1 unilateral adrenal hyperplasia and a normal contralateral gland, 1 unilateral adenoma, 3 bilateral pheochromocytomas and 1 bilateral myelolipoma.Conclusion: Synchronous bilateral laparoscopic adrenalectomy is a feasible and safe technique. A multidisciplinary and experienced team involving anesthesiologists and endocrinologists is required. (AU)