Challenging risk factors for right and left laparoscopic adrenalectomy: A single centre experience with 272 cases

ABSTRACT Purpose This study aimed to compare perioperative and postoperative results of right and left laparoscopic adrenalectomy (LA), and to evaluate the impact of challenging factors on these outcomes. Materials and Methods A total of 272 patient's medical records that underwent single side LA between October 2006 and September 2017 were retrospectively reviewed. The patients were divided into 2 groups according to operation side. Moreover, pheochromocytoma, metastatic masses and adrenal lesions >5cm in size were considered to be difficult adrenalectomy cases and the outcomes of these cases were compared between two groups. Results 135 patients (49.6%) underwent right LA and 137 patients (50.4%) underwent left LA. Operation time, estimated blood loss (EBL) and hospitalization time were similar between the groups (p=0.415, p=0.242, p=0.741, respectively). Although EBL was higher on the right side than the left (p=0.038) in the first 20 cases, after this learning period has been completed, there was no significant difference between the groups. In patients with pheochromocytoma, metastatic mass and a mass >5cm in size, despite bleeding complications were clinically higher on the right side, this difference was not statistically significant. Conclusions During the learning period of LA, EBL is higher on the right side. Due to the greater risk of bleeding complications on the right side even on the hands of experienced surgeons, extra care and preoperative planning are required in patients with pheochromocytoma, metastatic masses and masses >5cm in size.

Long-term Results after CT-Guided Percutaneous Ethanol Ablation for the Treatment of Hyperfunctioning Adrenal Disorders

OBJECTIVES: To evaluate the safety and long-term efficacy of computed tomography-guided percutaneous ethanol ablation for benign primary and secondary hyperfunctioning adrenal disorders. METHOD: We retrospectively evaluated the long-term results of nine patients treated with computed tomography-guided percutaneous ethanol ablation: eight subjects who presented with primary adrenal disorders, such as pheochromocytoma, primary macronodular adrenal hyperplasia and aldosterone-producing adenoma, and one subject with Cushing disease refractory to conventional treatment. Eleven sessions were performed for the nine patients. The patient data were reviewed for the clinical outcome and procedure-related complications over ten years. RESULTS: Patients with aldosterone-producing adenoma had clinical improvement: symptoms recurred in one case 96 months after ethanol ablation, and the other patient was still in remission 110 months later. All patients with pheochromocytoma had clinical improvement but were eventually submitted to surgery for complete remission. No significant clinical improvement was seen in patients with hypercortisolism due to primary macronodular adrenal hyperplasia or Cushing disease. Major complications were seen in five of the eleven procedures and included cardiovascular instability and myocardial infarction. Minor complications attributed to sedation were seen in two patients. CONCLUSION: Computed tomography-guided ethanol ablation does not appear to be suitable for the long-term treatment of hyperfunctioning adrenal disorders and is not without risks.

Adrenalectomía laparoscópica en patología benigna / Laparoscopic adrenalectomy in benign disease

Introduction: Nowadays the laparoscopic approach is the procedure of choice in adrenal diseases, except malignant adrenal tumors. Methods: A descriptive and retrospective study of the first 55 cases of laparoscopic adrenalectomy performed in our hospital between 1998 and 2011, we reviewed the short and long term results. Results: We had one case of conversion to open surgery in a patient with accidental section of the right renal vein. One case of reoperation due to hepatic injury. One case of postoperative mortality in a 71 year old woman with high anesthetic risk operated for Cushing's syndrome. Other complications were a case of hydropneumothorax and three cases of abdominal wall hematoma in site of laparoscopic trocar. In the follow up at 45 months all the patients remain asymptomatic, except one with ectopic Cushing's syndrome due to bronchial carcinoid. Conclusions: Laparoscopic adrenalectomy has good results and is an easily reproducible procedure, but must be performed by expert laparoscopic surgeons with a good knowledge of adrenal anatomy and experience in open surgery which allow them to solve the complications that may arise during the laparoscopic procedure.

Introducción: Al día de hoy el abordaje laparoscópico es el procedimiento de elección en la mayoría de lesiones que asientan sobre la glándula suprarrenal, a excepción del tumor maligno suprarrenal. Material y Métodos: Estudio descriptivo y retrospectivo de los 55 primeros casos de adrenalectomía laparoscópica realizados en nuestro centro en el período comprendido entre 1998 y 2011, evaluando los resultados a corto y largo plazo. Resultados: Hubo un caso de conversión a cirugía abierta (1,8 por ciento) en un paciente con sección accidental de la vena renal derecha. Un caso de reintervención por laceración hepática que pasó inadvertida durante la cirugía. Un caso de mortalidad en el postoperatorio inmediato por parada cardiorrespiratoria en una paciente de 71 años con riesgo anestésico ASAIII, intervenida por síndrome de Cushing. Otras complicaciones menores fueron un caso de hidroneumotórax y 3 casos de hematoma parietal en el trayecto del trocar. Se consiguió el control de la enfermedad de base después de un seguimiento medio de 45 meses en todos los casos menos en un paciente con síndrome de Cushing ectópico por un carcinoide bronquial. Conclusiones: La adrenalectomía laparoscópica es una técnica con buenos resultados y fácilmente reproducible, pero ha de ser realizada por cirujanos laparoscopistas expertos con un buen conocimiento de la anatomía de las glándulas suprarrenales y con experiencia en la cirugía abierta que les permita resolver las complicaciones que puedan surgir durante el procedimiento laparoscópico.

Risk of catecholamine crisis in patients undergoing resection of unsuspected pheochromocytoma

PURPOSE: To report the risk of catecholamine crisis in patients undergoing resection of unsuspected pheochromocytoma. MATERIALS AND METHODS: Over a four-year period, we retrospectively identified four patients who underwent resection of adrenal pheochromocytoma in whom the diagnosis was unsuspected based on preoperative clinical, biochemical, and imaging evaluation. RESULTS: None of the patients exhibited preoperative clinical features of catecholamine excess. Preoperative biochemical screening in two patients was normal. CT scan performed in all patients demonstrated a nonspecific enhancing adrenal mass. During surgical resection of the adrenal mass, hemodynamic instability was observed in two of four patients, and one of these two patients also suffered a myocardial infarct. CONCLUSION: Both surgeons and radiologists should maintain a high index of suspicion for pheochromocytoma, as the tumor can be asymptomatic, biochemically negative, and have nonspecific imaging features. Resection of such unsuspected pheochromocytomas carries a substantial risk of intraoperative hemodynamic instability.

Pheochromocytoma: a long-term follow-up of 24 patients undergoing laparoscopic adrenalectomy

Purpose: Pheochromocytomas are tumors derived from chromaffin cells that often secrete catecholamines and cause hypertension. The clinical diagnosis of pheochromocytoma depends on the presence of excessive production of catecholamines. Conventional imaging modalities that have been used in the preoperative evaluation include CT, MRI, and 131I-MIBG scintigraphy. Surgical resection is the definitive treatment for patients with pheochromocytoma. The goal of this study was to evaluate the long-term follow-up of 24 patients undergoing laparoscopic adrenalectomy for pheochromocytoma. Materials and Methods: From January 1995 to September 2006, 24 patients underwent laparoscopic adrenalectomy for adrenal pheochromocytoma. Twenty (83.3 percent) patients had arterial hypertension. The inclusion criteria of patients in this retrospective study were laparoscopic approach, unilateral or bilateral adrenal tumor, pathological diagnosis of pheochromocytoma and a minimum follow-up of 18 months. Results: Intra-operative complications occurred in 4 (16.7 percent) patients. Two (8.3 percent) patients had postoperative complications. Two patients (8.3 percent) had blood transfusion. The mean postoperative hospital stay was 3.8 days (range 1 to 11). Eighteen (90 percent) of the twenty patients who had symptomatic hypertension, returned to normal blood pressure immediately after surgery, during the hospital stay. In one patient, the high blood pressure levels remained unchanged. Another patient persisted with mild hypertension, well controlled by a single antihypertensive drug. Conclusions: Our results confirmed that laparoscopic adrenalectomy for pheochromocytoma is a safe and effective procedure, providing the benefits of a minimally invasive approach. In our study, the initial positive results obtained in the treatment of 24 patients were confirmed after a mean follow-up of 74 months.