Outcome

Since its advent in 1992, laparoscopic adrenalectomy has gained worldwide acceptance, with a rapidly increasing numbers of reports being published in recent years. In a search of the literature, we were able to retrieve more than 500 articles dealing with laparoscopic adrenalectomy. Table 74-1 summarizes the reported results of selected large series of laparoscopic adrenalectomies performed with different laparoscopic techniques. Although no prospective, randomized series exist, numerous studies have compared laparoscopic with open adrenalectomy (either retrospectively or nonrandomized prospectively), documenting the safety, decreased analgesic postoperative requirements, enhanced recovery, shorter hospital stay, and cost-effectiveness of the laparoscopic approach.4"8-24,30"39 No differences in patient population, indications for surgery, or mean size of lesions were noticed. Our own experience, presented here, with 100 procedures in 88 patients,3 further supports the superiority of this procedure.

Table 74-2 lists the indications and pathology for our procedures. The overall mean age was 46 years (range, 17 to 84 years), and the ratio of female to male was slightly higher than 2:1. Fifty-two of the adrenalectomies were performed in the left, and 10 were performed bilaterally. The mean operating time was 132 minutes (range, 80 to 360 minutes). In our initial experience, a right-sided procedure required an average of 138 minutes compared with 102 minutes for a left-sided procedure. However, review of the last 30 cases showed the time required for both sides is essentially equal. The time required for bilateral adrenalectomy averaged approximately 45 minutes longer than the combined averages for the unilateral procedure alone. The indications for bilateral adrenalectomy are listed in Table 74-3. The average length of stay was 2.4 days (range, 1 to 6 days), and the average size of the lesions was 4.95 cm (range, 0.7 to 12 cm). The estimated intraoperative blood loss was approximately 70 mL, and the mean number of postoperative narcotic injections was 5.5.

Complications

Conversion to open surgery was necessary in three patients (3%). These conversions occurred in our first attempt at laparoscopic adrenalectomy in a patient with a 15-cm right adrenal angiomyolipoma, in a second patient with a locally invasive retroperitoneal sarcoma, and in a third patient with adrenal adenocarcinoma invading into the inferior vena cava.

More than half of our patient population (55%) had undergone previous abdominal surgery. We have not viewed this as a contraindication for laparoscopic approach, and no conversions occurred because of adhesions. We performed one procedure 6 weeks after a laparotomy that failed to find the adenoma. In addition, 20 of the 88 patients underwent other associated laparoscopic procedures at the time of their adrenalectomy. These are listed in Table 74-4.

Of the 100 procedures, 12% had postoperative complications, which are listed in Table 74-5.

Reoperation within 30 days of surgery was required on two occasions (2%) for evacuation of a retroperitoneal

TABLE 74-1 Summary of Outcome of Selected Series with Laparoscopic Adrenalectomy

Study, Year,

Operative

Blood

Conversion

Complication

Length of

Mortality

Reference No.

No. of Procedures

Time (min)*

Loss |mL)

Rate (%)

Rate (%)

Stay (days)

(%)

Gagner et al,

100

123

70

3

12

2.4

0

19973

Gill et al, 199976

110

188

125

NR

16

1.9

0

Guazzoni et al,

161

160

NR

2.5

5.1

2.8

0

2001s'

Salomon et al,

115

118

77

0.8

Î5.5

4

0

200180

Terachi et al,

100

240

77

3

12

NR

0

199796

Mancini et al,

172

132

NR

7

8.7

5.8

1.2

199997

Thompson et al,

50

167

NR

4.5

6

3.1

0

1997«

Suzuki et al,

118

166

92

5

12,7

4.6

0

2001le

Lezoche et al,

216

100

NR

1.9

2.3

3

0.05

2002"

Bonjer et al,

111

114

65

4.5

11

2

0.9

200078

Henry et al,

169

129

NR

5

7.5

5.4

0

200041

Brunt et al,

72

176

107

2.8

19

3

0

200152

Kebebew et al,

176

168

NR

0

5,1

1.7

0

20019a

Miccoli et al,

137

111

NR

4.3

3.9

3.8

0

2002s3

•Of unilateral procedures. NR = not recorded.

•Of unilateral procedures. NR = not recorded.

hematoma in a patient who had been anticoagulated for mitral valve prosthesis and for postoperative acute cholecystitis in the second case. These procedures were accomplished laparo-scopically with uneventful recovery thereafter. There have been no wound complications, and there was no mortality.

Additional reported complications may result from injury to structures in the area of dissection, adjacent to the adrenals, including the kidney, colon, tail of the pancreas, and the stomach on the left side. On the right side, the liver and the duodenum are at risk.

Because both adrenals are located in close proximity to major blood vessels (the hilum of kidneys and the vena cava), massive bleeding is a potentially disastrous complication.

Furthermore, dissection high in the abdomen could result in diaphragmatic injury, leading to potential tension pneumothorax. A multi-institutional study by Terachi and associates from Japan evaluated 370 patients who underwent laparoscopic adrenalectomy.40 There was no mortality. Overall complications developed in 57 patients (15%), intraoperative in 33 patients (9%) and postoperative in 24 patients (6%). Conversion to open surgery was necessary in 13 cases (3.5%). The 33 intraoperative complications involved vascular injury in 22 patients (5.9%) and visceral injury in 11 patients (3%). The 22 vascular injuries involved injuries to the vena cava in 2 patients, renal vein in 2 patients, adrenal vein in 4 patients, other adrenal vessels in 11 patients, and other vessels in an additional 3 patients. The 11 visceral injuries included the liver in 4 patients, spleen in 3,

TABLE 74-2 Indications for 100 Laparoscopic

Adrenal Procedures

Indication

No.

Pheochromocytoma

25

Conn's syndrome

21

Nonfunctional adenoma

20

Cushing's adenoma

13

Cushing's disease

8

Carcinoma

3

Angiomyolipoma

2

Paraneoplastic hypercortisolism

2

Macronodular hyperplasia

2

Androgen-producing adenoma

2

Others

2

TABLE 74-3. Indications for Bilateral

Laparoscopic Adrenalectomy

Indication

No. of Patients

Benign pheochromocytoma

2

Cushing's disease

4

Bilateral adenoma

2

Bilateral macronodular hyperplasia

2

TABLE 74-4. Additional Procedures Performed

during Laparoscopic Adrenalectomy

Procedure

No. of Patients

Liver biopsy

8

Cholecystectomy

6

Periaortic node dissection

2

Ventral hernia repair

1

CBD exploration

1

Colorectal reanastomosis

1

Left ovarian cystectomy

1

CBD = common bile duct.

pancreas in 2, gallbladder in 1, and adrenal gland in 1. The 24 postoperative complications involved bleeding in 6 patients, wound infection in 4, atelectasis in 3, ileus in 2, pneumothorax in 1, and other in 8. Most complications were minor and were treated laparoscopically. Henry and coworkers reported the complications of laparoscopic adrenalectomy in 169 consecutive procedures.41 There was no mortality. Twelve patients (7.5%) had significant complications: three peritoneal hematomas requiring (in two cases) laparotomy, and (in one case) transfusion; one parietal hematoma; three intraoperative bleeding episodes without need for transfusion; one partial infarction of the spleen; one pneumothorax; one tumor disruption; and two venous thromboses. Another large multi-institutional study from France42 reported a similar complication rate of 7.7% occurring in 10 patients out of 130 cases of laparoscopic adrenalectomy. Neither this study, nor others,40,43-45 has found significant differences between transperitoneal and retroperitoneal approaches, except for the risk of the intraperitoneal visceral injury.

PHEOCHROMOCYTOMA

Pheochromocytoma constituted 25% of the pathologies in our series. These tumors were larger than in patients with other diseases (6.3 vs. 3.9 cm [P < 0.05]). In addition, operative time was longer (2.5 vs. 1.8 hours [P < 0.05]). During the removal of these tumors, hypertension occurred in 56% of patients and hypotension in 52%. Moreover, 7 of 12 (=60%) of our postoperative complications were observed in this subset. Associated MEN 2A syndrome was identified in six patients and MEN 2B was found in two patients. Several studies have addressed the issue of hemodynamic changes

TABLE 74-5. Complications Occurring in

100 Laparoscopic Procedures

Type of Complication

No.

Deep venous thrombosis

3

Hematomas

2

Anemia

2

Subdural hematoma

Urinary tract infection

Colonic pseudo-obstruction

Pulmonary edema

Acute cholecystitis

during laparoscopic adrenalectomy for pheochromocytoma compared to open surgery.46"48 The laparoscopic approach has resulted in less48 or comparable46,47 hemodynamic changes compared to the traditional open surgery, although patients who underwent laparoscopy had a more rapid postoperative recovery. The retroperitoneal approach seems to offer no advantage over the intraperitoneal approach,49 and carbon dioxide pneumoperitoneum is well tolerated in this subset of patients.47 In a literature review of large series of more than 300 laparoscopic adrenalectomies exclusively for pheochromocytoma, no mortality has been reported to date.28,48,50"61 These cases included familial multiple endocrine hyperplasia syndromes, bilateral pheochromocytoma, and extra-adrenal pheochromocytoma. Both transperitoneal and extraperitoneal approaches were used. Although earlier experience was associated with more blood loss, longer operative time, and more complication rate compared to other pathologies,50,51 the more recent large series demonstrated no significant difference. The occurrence of hypertension postoperatively is rare, and hypertension was cured in almost all patients.

OTHER HORMONE-SECRETING TUMORS

With regard to the functional outcome in other hormonally active tumors, during our follow-up period (range, 1 to 44 months), patients appear to have responded well to laparoscopic adrenalectomy. Two were found to have renovascular hypertension, and none had hormonal recurrence. The renal arteriograms showed no stenosis and, in addition, excluded the possibility of superior arteriolar renal occlusions by metal clips. One patient operated on for Cushing's disease who had a partial response to ACTH stimulation, however, still had serum cortisone levels below the normal range by the end of the follow-up period. Other authors52,62 65 have uniformly reported excellent results comparable with those of open surgery. The Mayo Clinic group reported bilateral laparoscopic adrenalectomy in 19 patients with ACTH-dependent Cushing's syndrome in whom the ACTH-secreting neoplasm could not be removed.62 All patients experienced resolution of the signs and symptoms of Cushing's syndrome as well as weight loss, improved glucose tolerance, and improved control of blood pressure. No residual cortisone secretion was detected. Similar success rates were reported by others in more than 100 cases with Cushing's disease and syndrome.21,22,25 Rossi and associates63 reported the effectiveness of laparoscopic adrenalectomy in 30 patients with primary hyperaldosteronism. Twenty-nine of 30 patients (95%) were rendered normokalemic, and persisting hypertension was present in 10 of 30 patients (33%). In these patients, the hypertension was easily controlled medically. Duration of the hypertension before surgery was a significant risk factor for persistent hypertension. Several other articles specifically focusing on laparoscopic adrenalectomy for aldosteronoma revealed that hypertension was cured or significantly improved in greater than 90% of patients.64,66,67 In a recent study by Brunt and colleagues52 involving 72 patients with hormonally active adrenal tumors, laparoscopic adrenalectomy resulted in an excellent clinical outcome. Resolution of clinical and biochemical signs was accomplished in 34 of 34 patients with pheochromocytoma, 25 of 26 patients with aldosteronomas, 5 of 5 patients with cortisol-producing adenomas, and 3 of 3 patients with ACTH-dependent Cushing's syndrome. Two patients with MEN 2 had contralateral pheochromocytomas removed 4 and 5 years after the initial surgery. Surprisingly, persistent hypertension necessitating medications was present in 72% of patients with aldosteronomas, although 92% of these patients had significantly improved blood pressure control after surgery. Recurrent hypokalemia developed in 1 patient (4%) with a cortical nodule in the contralateral adrenal. The authors concluded52 that the clinical and biochemical cure rates are comparable with those of open adrenalectomy during long-term follow-up.

Outcome for Malignancy

Concerning the outcome of laparoscopic adrenalectomy in the setting of malignancy, 8 of our patients had malignant diseases. Six had primary adrenal cancer (3 pheochromocytomas and 3 nonfunctioning tumors that showed microscopic features of carcinoma), and 2 had metastatic adrenal secondaries. None had evidence of local recurrence during follow-up (range, 1 to 44 months). Laparoscopic adrenalectomy for solitary adrenal metastasis or cancer has also been investigated at few centers, and to date, very few references are available in the literature. The experience from the Cleveland Clinic in 11 patients was reported by Heniford and coworkers.68 All of the tumors except one were due to metastatic cancer. The metastatic sources included renal cell cancer, lung cancer, colon cancer, and melanoma. The mean size of the tumors was 5.9 cm (range, 1.9 to 12 cm). One patient required conversion to open surgery due to local invasion of the tumor into the vena cava. At a mean follow-up of 8.3 months, there were no port site or local recurrences. One patient developed a new hepatic nodule, 10 of the 11 patients were alive by the time of the report, and 1 died of extensive brain metastasis from melanoma. Valeri and associates12 addressed the same issue of adrenal masses in 8 patients with primary lung cancer (7 patients) and renal cancer (1 patient). The adrenal lesions appeared during follow-up evaluation or at the time of diagnosis of the primary malignancy. All patients underwent laparoscopic adrenalectomy with complete removal of the lesions. Histology confirmed the metastatic origin in 6 patients, and 2 lesions proved to be nonfunctioning adenomas. Three patients died later of brain metastasis, accounting for a 3-year survival rate of 63%. The authors claimed that laparoscopic adrenalectomy allows for a much more aggressive approach to adrenal masses demonstrated at follow-up evaluation in patients with primary lung or kidney cancer with no evidence of masses at other locations. Two other reports on laparoscopic adrenalectomy for large (>6 cm) and potentially malignant tumors were recently published and documented favorable outcome.69,70 In the study by Henry and associates,69 out of 6 patients with adrenocortical carcinoma, only 1 patient developed liver metastasis and died 6 months after surgery. The other 5 patients were disease free during a follow-up period ranging from 8 to 83 months. The largest series with the longest follow-up to date was recently published by Kebebew and colleagues.71 It included 23 patients who had a laparoscopic approach for suspected and unsuspected malignant adrenal tumors. Six of the patients had primary adrenal cancers, 13 had adrenal metastasis, 2 had lymphomas, and 2 cases had no evidence of cancer. The tumor resection margin was negative in all adrenalectomies. There were three locoregional recurrences in the 6 patients with primary adrenal cancer and no port site recurrences. There were four distant recurrences in 13 patients with metastatic adrenal tumors. The disease-free survival was 65% at a mean follow-up period of 3.3 years (range, 1 to 7 years). These results were comparable with the known results for conventional surgery.72 In all these studies, no major complications occurred. Conversions were required only in patients with intraoperative evidence of tumor invasion. The laparoscopic removal achieved tumor-free resection margins in all patients, and no port site metastasis was reported.

10 Ways To Fight Off Cancer

10 Ways To Fight Off Cancer

Learning About 10 Ways Fight Off Cancer Can Have Amazing Benefits For Your Life The Best Tips On How To Keep This Killer At Bay Discovering that you or a loved one has cancer can be utterly terrifying. All the same, once you comprehend the causes of cancer and learn how to reverse those causes, you or your loved one may have more than a fighting chance of beating out cancer.

Get My Free Ebook


Post a comment