Results

Following the demonstration of the feasibility of laparoscopic partial adrenalectomy (6), several authors have reported on short-to-medium term follow-up results of small series of patients with aldosterone adenoma. Al-Sobhi et al. deemed transperitoneal laparo-scopic partial adrenalectomy in seven patients with aldosterone-producing adenomas as effective and safe—six patients had normalization of blood pressure and no recurrence at a median follow-up of 12 months (43). Jeschke et al., who employed a transperitoneal approach in 13 patients with aldosterone-producing adenoma, were able to remove the tumor (mean tumor size, 2.1 cm) with negative margins. The mean operative time was 99 minutes, and blood loss was 78 mL. Mean hospital stay was 4.3 days (range, 2-6 days). Normal blood pressure, serum electrolytes, and aldosterone and no local recurrence were observed at a median follow-up of 39 months (44). The same transperitoneal approach was used by Ishikawa et al. in 11 patients with benign adrenal tumors. Operative time for laparoscopic partial adrenalectomy was shorter compared to total adrenalectomy (92 vs. 154 minutes, respectively) (45). Kok and Yapp prospectively reviewed eight patients who underwent laparoscopic partial adrenalectomy for aldos-terone-producing adenomaaldosterone-producing adenoma (seven by enucleation and one by vascular stapler). At a mean follow-up of 25 months, hypertension was cured in seven patients and medication requirement significantly reduced in one patient (46). Ikeda's experience in seven patients with aldosterone-producing adenomas and three patients with pheochromocytoma showed no correlation between adrenal vein preservation and the functional status of the adrenal gland, as assessed by postoperative 131I adosterol scintigram (42). At a mean follow-up of 24 months for aldosterone-producing adenoma patients and 33 months for pheochromocytoma patients, the hormone levels returned to normal. Munver et al. employed this technique successfully in two patients and reviewed worldwide experience (47). Imai et al. effectively used vascular staplers during laparoscopic partial adrenalectomy in five patients with lesions located at the adrenal poles (48). Meria et al. reported a large series of laparoscopic management of primary hyperaldosteronism in 212 consecutive patients, including 20 cases of transperitoneal laparoscopic partial adrenalectomy (49). At a mean follow-up of 44 months, the longest reported to date, hypokalemia was cured in all patients and hypertension was cured or significantly improved with reduction of medication requirements.

The safety and efficacy of laparoscopic partial adrenalectomy for hereditary pheochromocytoma was shown by Janetschek et al. (7). Six patients, two with bilateral disease, successfully underwent laparoscopic partial adrenalectomy. The feasibility of laparoscopic partial adrenalectomy in the presence of more than one tumor in the gland, tackling both adrenal glands, and managing the extra-adrenal pheochromocytoma at the same time was assessed. Blood pressure and urine catecholamines returned to normal and none of the patients required steroid supplementation. After a mean follow-up of

13.5 months (range, 3-18 months), no recurrence was noted. Walther et al. used silk suture ligation and harmonic scalpel in three patients, among whom one had bilateral disease, and removed seven tumors by laparoscopic partial adrenalectomy. During short follow-up, there was no need for steroid supplementation and no tumor recurrence.

Sasagawa et al. (26) performed partial adrenalectomy by the posterior retroperito-neoscopic approach in 13 patients with aldosterone-producing adenoma, 10 with Cushing's adenoma, three with pheochromocytoma, two with myelolipoma, one with ganglioneuroma, and 18 with a nonfunctioning tumor larger 3 cm (total, n = 47). Mean operative time was 198 minutes, blood loss 40.8 mL, and open conversion rate 2.1%. Due to the impact of the learning curve, significant operative time reduction was noted in the 26 most recent cases compared to initial cases. Walz et al. reported their experience with laparoscopic management of pheochromocytomas and paraganglionoma, including partial adrenalectomy in 19 patients (50). A retroperitoneal approach was predominantly used and a combination of electrocoagualtion, harmonic scalpel, and clips was employed as needed. In seven patients with bilateral disease, partial adrenalectomy was performed, at least unilaterally. All patients had normalization of their biochemical profiles and had no recurrence after a mean follow-up of 34 months. Only one patient in the bilateral group needed cortisol replacement (10 mg hydrocortisone). Interestingly, the main adrenal vein could not be spared in any of these seven patients because of tumor location. Neumann et al. meticulously evaluated the functional result of laparoscopic partial adrenalectomy in four patients with pheochromocytoma (51). Two to 24 months following surgery, all patients were normotensive, had normal sodium, glucose, aldos-terone, rennin, and serum cortisol concentrations, and a normal 24-hour excretion of norepinephrine, epinephrine, and vanillylmandelic acid. Imaging failed to disclose any recurrence. adreno corticotrophic hormone stimulation test showed normal cortisol responses.

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