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Lee SYH, Wong C. Time to Flip the Approach: Retroperitoneoscopic Adrenalectomy. J Surg Res 2024; 296:189-195. [PMID: 38277956 DOI: 10.1016/j.jss.2023.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/29/2023] [Accepted: 12/27/2023] [Indexed: 01/28/2024]
Abstract
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.
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Affiliation(s)
- Stellina Y H Lee
- Department of General Surgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia.
| | - Clement Wong
- Department of General Surgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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Шихмагомедов ШШ, Реброва ДВ, Краснов ЛМ, Фёдоров ЕА, Чинчук ИК, Черников РА, Русаков ВФ, Слепцов ИВ, Згода ЕА. [Surgical treatment of pheochromocytoma]. PROBLEMY ENDOKRINOLOGII 2023; 69:39-44. [PMID: 37968950 PMCID: PMC10680547 DOI: 10.14341/probl13283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/23/2023] [Accepted: 04/24/2023] [Indexed: 11/17/2023]
Abstract
This review article contains a summary of modern aspects of preoperative preparation, surgical treatment, and follow-up of patients with adrenal pheochromocytomas. The main component of preoperative preparation is the use of alpha-blockers. The need to prescribe them to all patients is increasingly disputed, especially for patients without severe hypertension. An increasing number of publications demonstrate positive results of treatment without the use of alpha-blockers, advocating an individual approach and the use of the drug according to certain indications. Minimally invasive endoscopic techniques of adrenalectomy have become widespread in surgical treatment. They are represented by laparoscopic and retroperitonescopic technic, including using their single-port modifications. The earliest possible intersection of the central vein in the past was considered the most important aspect of adrenalectomy for pheochromocytoma, currently, due to the development of surgical techniques and anesthesiological manuals, this has ceased to be a mandatory rule of successful surgery. Despite the significant influence of the intersection of this vessel on intraoperative hemodynamics, surgical tactics with its later intersection have their own justifications and do not lead to a deterioration in treatment results. The standard volume of surgical intervention for pheochromocytomas is total adrenalectomy, however, in the presence of hereditary syndromes, such as multiple endocrine neoplasia type 2 syndrome, neurofibomatosis type 1, von Hippel-Lindau syndrome, it is possible to perform cortical-sparing adrenalectomy.
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Affiliation(s)
- Ш. Ш. Шихмагомедов
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
| | - Д. В. Реброва
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
| | - Л. М. Краснов
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
| | - Е. А. Фёдоров
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
| | - И. К. Чинчук
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
| | - Р. А. Черников
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
| | - В. Ф. Русаков
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
| | - И. В. Слепцов
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
| | - Е. А. Згода
- Санкт-Петербургский государственный университет, Клиника высоких медицинских технологий им. Н.И. Пирогова
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Seow YT, Nyandoro MG, Poh S, Tee YC, Yew MK, Wong SL. The Impact of Obesity on Mortality and Complications in Posterior Retroperitoneoscopic Adrenalectomy. Cureus 2023; 15:e42421. [PMID: 37497309 PMCID: PMC10367120 DOI: 10.7759/cureus.42421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 07/28/2023] Open
Abstract
Background Obesity is a global epidemic. It influences surgical technique, ergonomics, safety, and outcomes. However, there is a paucity of evidence of obesity-related impact in posterior retroperitoneoscopic adrenalectomy (PRA). This study compared perioperative outcomes of obese and non-obese participants undergoing PRA. Methodology This is a multi-center retrospective cohort study of elective PRA from March 2014 to December 2022. Patient demographics, surgical techniques, clinicopathological parameters, and outcomes, including overall complication rate, were analyzed using SPSS version 27 (IBM Corp., Armonk, NY, USA). Results Seventy-five patients underwent a PRA, of which 97.3% were completed retroperitoneoscopically. The overall complication rate was (9.3%), and on subgroup analysis, the obese cohort had a lower percentage complication profile at 6.5%. Male participants comprised 52%, with a median age of 55 (IQR=19). The median BMI was 29.0 (IQR=8), of which 41% were obese, and 40% were overweight. Univariate analysis showed that being obese was not significantly associated with a higher complication rate (p=0.471). In addition, there was no significant increase in conversion (p=0.508), bleeding/transfusion (p=0.508), surgical site infection (SSI; p=1.000), incisional hernia (p=1.000), ICU or high dependency unit admission (p=0.292) and any-cause mortality (p=1.000). No sentinel deaths directly related to PRA were recorded. Procedure duration was longer in obese (117 mins) vs. non-obese participants (88.9 mins, p=0.022). However, there was no significant difference in the length-of-hospital stay (p=0.592). The cohort conversion rate was (2.7%), and tumor size was associated with a higher conversion rate (35.4 vs. 62.5mm, p=0.040). Conclusion Posterior retroperitoneoscopic adrenalectomy can be a safe procedure in obese populations, and obesity does not increase perioperative morbidity or mortality.
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Affiliation(s)
- Yi Th'ng Seow
- General and Endocrine Surgery, Royal Perth Hospital, Perth, AUS
| | - Munyaradzi G Nyandoro
- General Surgery, Fiona Stanley Hospital, Perth, AUS
- General and Endocrine Surgery, Royal Perth Hospital, Perth, AUS
| | - Shearn Poh
- General and Endocrine Surgery, Royal Perth Hospital, Perth, AUS
| | | | - Ming Khoon Yew
- General and Endocrine Surgery, Royal Perth Hospital, Perth, AUS
- General and Endocrine Surgery, St. John of God Murdoch Hospital, Murdoch, AUS
| | - Sze Ling Wong
- General and Endocrine Surgery, Royal Perth Hospital, Perth, AUS
- General and Endocrine Surgery, St. John of God Murdoch Hospital, Murdoch, AUS
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Karssemakers LHE, de Winter DCM, van der Pas SL, Nolte JW, Becking AG. The learning curve of transoral condylectomy; a retrospective analysis of 100 consecutive cases of unilateral condylar hyperplasia. J Craniomaxillofac Surg 2023:S1010-5182(23)00073-2. [PMID: 37353405 DOI: 10.1016/j.jcms.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/31/2023] [Accepted: 05/21/2023] [Indexed: 06/25/2023] Open
Abstract
In this study, 100 consecutive scheduled transoral condylectomies for unilateral condylar hyperplasia were included. The safety and surgical performances were assessed, using the operating time, conversion rate and complication rate. The conversion rate learning curve was evaluated with a learning curve cumulative summation (LC-CUSUM). The total conversion rate was 8.0%. The LC-CUSUM for conversion signaled at the 53th procedure, indicating sufficient evidence had accumulated that the surgeon had achieved competence. For procedures 54-100, the conversion rate was 4.0%. The operating time for the transoral condylectomy was 41.5 ± 15.3 min; when a conversion was necessary, the operating time was 101.4 ± 28.3 min (p < 0.05). The estimated operating time in the post-learning phase was 37 min, this was reached after approximately 47 procedures. There was 1 major complication of a permanent inferior alveolar nerve hypoesthesia. The complication rate was not significantly decreased after the learning curve. Within the limitations of the study, it seems that transoral condylectomy for UCH is a safe procedure with several advantages over the traditional preauricular approach. Surgeons starting this procedure should be aware of the potential complications and of the learning curve of approximately 53 procedures.
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Affiliation(s)
- L H E Karssemakers
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC/Emma Children's Hospital, And Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, the Netherlands; Department of Head and Neck Surgery & Oncology, Netherlands Cancer Institute, Antoni Van Leeuwenhoek, Amsterdam, the Netherlands.
| | - D C M de Winter
- Department of Oral and Maxillofacial Surgery, MKA Kennemer & Meer, Haarlem, the Netherlands
| | - S L van der Pas
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Epidemiology and Data Science, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Public Health, Methodology, Amsterdam, the Netherlands
| | - J W Nolte
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC/Emma Children's Hospital, And Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, the Netherlands
| | - A G Becking
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC/Emma Children's Hospital, And Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, the Netherlands; Department of Oral and Maxillofacial Surgery, MKA Kennemer & Meer, Haarlem, the Netherlands
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Collins RA, Wang TS, Dream S, Solórzano CC, Kiernan CM. Adoption of Robotic Adrenalectomy: A Two-Institution Study of Surgeon Learning Curve. Ann Surg Oncol 2023:10.1245/s10434-023-13406-6. [PMID: 37040047 DOI: 10.1245/s10434-023-13406-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/08/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Robotic adrenalectomy is feasible and safe, yet concerns over increased operative times and the learning curve (LC) for proficiency have limited its adoption. This study aimed to assess the LC for robotic adrenalectomy. METHODS This is a two-institution retrospective review of consecutive unilateral minimally invasive adrenalectomies performed by four high-volume adrenal surgeons between 2007 and 2022. Two surgeons transitioned from laparoscopic to robotic adrenalectomy, and two surgeons adopted the approach, with proctoring, after completion of fellowship training without robotic experience. Operative time and complications were analyzed. Multivariable regression was used to identify factors associated with operative time. The number of cases required to overcome the LC was determined using the LC-cumulative-sum (LC-CUSUM) analysis. RESULTS Of 457 adrenalectomies, 182 (40%) were laparoscopic and 275 (60%) robotic. The robotic approach was associated with shorter median operative time (106 vs 119 min; p = 0.002), fewer complications (6% vs 13%; p = 0.018), and fewer conversions to open adrenalectomy (1% vs 4%; p = 0.030), with no difference between the senior and junior surgeons. On adjusted analysis, factors associated with increased operative time were male sex (p < 0.001), BMI > 30 kg/m2 (p < 0.001), and higher gland weight (p < 0.001). The LC-CUSUM analysis showed proficiency after 8-29 procedures. Compared with the first 10 cases, there was a mean reduction in operative time of 14 min after 10-20 cases, 28 min after 20-30 cases, and 29 min after > 30 cases, regardless of surgeon experience. DISCUSSION With dedicated teams and proctoring, robotic adrenalectomy can be safely adopted at high-volume centers with a minimal LC.
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Affiliation(s)
- Reagan A Collins
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| | - Tracy S Wang
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sophie Dream
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colleen M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
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Dogrul AB, Cennet O, Dincer AH. Minimally invasive techniques in benign and malignant adrenal tumors. World J Clin Cases 2022; 10:12812-12821. [PMID: 36569018 PMCID: PMC9782958 DOI: 10.12998/wjcc.v10.i35.12812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/04/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
Minimally invasive adrenalectomy has become the main treatment modality for most adrenal lesions. Both laparoscopic transabdominal and retroperitoneoscopic approaches are safe and feasible options, each with respective advantages, including better surgical outcomes, fewer complications, and faster recovery over open adrenalectomy. While open surgery remains a valid modality in treatment of adrenocortical cancer in the presence of some findings such as invasion, robotic platforms, and minimally invasive surgery have gained popularity as technology continues to evolve. Organ preservation during adrenalectomy is feasible in some conditions to prevent adrenal insufficiency. Ablative technologies are increasingly utilized in benign and malignant tumors, including the adrenal gland, with various outcomes. A multidisciplinary team, an experienced surgeon, and a high-volume center are recommended for any surgical approaches and management of adrenal lesions. This review article evaluated recent findings and current evidence on minimally invasive adrenalectomy.
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Affiliation(s)
- Ahmet Bulent Dogrul
- Department of General Surgery, Hacettepe University Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey
| | - Omer Cennet
- Department of General Surgery, Hacettepe University Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey
| | - Anıl Hilmi Dincer
- Department of General Surgery, Hacettepe University Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey
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van Uitert A, van de Wiel ECJ, Ramjith J, Deinum J, Timmers HJLM, Witjes JA, Kool LJS, Langenhuijsen JF. Predicting surgical outcome in posterior retroperitoneoscopic adrenalectomy with the aid of a preoperative nomogram. Surg Endosc 2022; 36:6507-6515. [PMID: 35024929 PMCID: PMC9402486 DOI: 10.1007/s00464-021-09005-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/31/2021] [Indexed: 12/04/2022]
Abstract
BACKGROUND Posterior retroperitoneoscopic adrenalectomy (PRA) has several advantages over transperitoneal laparoscopic adrenalectomy (TLA) regarding operative time, blood loss, postoperative pain, and recovery. However, it can be a technically challenging procedure. To improve patient selection for PRA, we developed a preoperative nomogram to predict operative time. METHODS All consecutive patients with tumors of ≤ 7 cm and a body mass index (BMI) of < 35 kg/m2 undergoing unilateral PRA between February 2011 and March 2020 were included in the study. The primary outcome was operative time as surrogate endpoint for surgical complexity. Using ten patient variables, an optimal prediction model was created, with a best subsets regression analysis to find the best one-variable up to the best seven-variable model. RESULTS In total 215 patients were included, with a mean age of 52 years and mean tumor size of 2.4 cm. After best subsets regression analysis, a four-variable nomogram was selected and calibrated. This model included sex, pheochromocytoma, BMI, and perinephric fat, which were all individually significant predictors. This model showed an ideal balance between predictive power and applicability, with an R2 of 38.6. CONCLUSIONS A four-variable nomogram was developed to predict operative time in PRA, which can aid the surgeon to preoperatively identify suitable patients for PRA. If the nomogram predicts longer operative time and therefore a more complex operation, TLA should be considered as an alternative approach since it provides a larger working space. Also, the nomogram can be used for training purposes to select patients with favorable characteristics when learning this surgical approach.
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Affiliation(s)
- Allon van Uitert
- Department of Urology, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Elle C J van de Wiel
- Department of Urology, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Jordache Ramjith
- Department of Health Evidence, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Henri J L M Timmers
- Department of Internal Medicine, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - J Alfred Witjes
- Department of Urology, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Leo J Schultze Kool
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Johan F Langenhuijsen
- Department of Urology, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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Yeo CT, Pasieka JL, Assadzadeh GE, Harvey A. The adoption of the endoscopic retroperitoneal approach to the adrenal gland - Conversion factors and learning points. Am J Surg 2022; 224:703-709. [DOI: 10.1016/j.amjsurg.2022.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/19/2022] [Accepted: 03/31/2022] [Indexed: 11/01/2022]
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Lase I, Grönberg M, Norlén O, Stålberg P, Welin S, Janson ET. Adrenalectomy in ectopic Cushing's syndrome: A retrospective cohort study from a tertiary care centre. J Neuroendocrinol 2021; 33:e13030. [PMID: 34448524 DOI: 10.1111/jne.13030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/06/2021] [Accepted: 08/10/2021] [Indexed: 11/27/2022]
Abstract
Neuroendocrine neoplasms (NENs) causing ectopic Cushing's syndrome (ECS) are rare and challenging to treat. In this retrospective cohort study, we aimed to evaluate different approaches for bilateral adrenalectomy (BA) as a treatment option in ECS. Fifty-three patients with ECS caused by a NEN (35 females/18 men; mean ± SD age: 53 ± 15 years) were identified from medical records. Epidemiological and clinical parameters, survival, indications for surgery and timing, as well as duration of surgery, complications and surgical techniques, were collected and further analysed. The primary tumour location was thorax (n = 30), pancreas (n = 14) or unknown (n = 9). BA was performed in 37 patients. Median time from diagnosis of ECS to BA was 2 months (range 1-10 months). Thirty-two patients received different steroidogenesis inhibitors before BA to control hypercortisolaemia. ECS resolved completely after surgery in 33 patients and severe peri- or postoperative complications were detected in 12 patients. There were fewer severe complications in the endoscopic group compared to open surgery (p = .030). Posterior retroperitoneoscopic BA performed simultaneously by a two surgeon approach had the shortest operating time (p = .001). Despite the frequent use of adrenolytic treatment, BA was necessary in a majority of patients to gain control over ECS. Complication rate was high, probably as a result of the combination of metastatic disease and metabolic disorders caused by high cortisol levels. The two surgeon approach BA may be considered as the method of choice in ECS compared to other BA approaches as a result of fewer complications and a shorter operating time.
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Affiliation(s)
- Ieva Lase
- Department of Medical Sciences, Endocrine Oncology Unit, Uppsala University, Uppsala, Sweden
| | - Malin Grönberg
- Department of Medical Sciences, Endocrine Oncology Unit, Uppsala University, Uppsala, Sweden
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Staffan Welin
- Department of Medical Sciences, Endocrine Oncology Unit, Uppsala University, Uppsala, Sweden
| | - Eva Tiensuu Janson
- Department of Medical Sciences, Endocrine Oncology Unit, Uppsala University, Uppsala, Sweden
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New predictive factors for prolonged operation time of laparoscopic posterior retroperitoneal adrenalectomy; retrospective cohort study. Int J Surg 2021; 94:106113. [PMID: 34534705 DOI: 10.1016/j.ijsu.2021.106113] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/29/2021] [Accepted: 09/11/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Laparoscopic adrenalectomy is a standard surgical procedure for benign adrenal diseases. Laparoscopic posterior retroperitoneal adrenalectomy (LPRA) has many benefits. However, it is associated with factors such as prolong operation time. The aim of the study was to determine the predictive factors associated with prolonged operation time in LPRA. MATERIALS AND METHODS This study retrospectively analyzed data from 284 patients who underwent LPRA between 2014 and 2019 at Asan Medical Center. Then, we analyzed the predictive factors prolonging operation time using multivariate logistic regression analysis and classified the differences according to the learning curve using cumulative sum analysis. RESULTS In multivariate logistic regression analysis, the following were determined as factors associated with prolonged operation time: male sex (OR, 2.540; 95% CI, 1.225-5.266), pheochromocytoma (OR, 3.669; 95% CI, 1.548-8.694), right site (OR, 2.499; 95% CI, 1.086-5.748), surgeon A (OR, 3.293; 95% CI, 1.522-7.122), depth of descended adrenal tumor location to kidney (OR, 3.793; 95% CI, 1.660-8.667), large periadrenal fat volume (OR, 2.366; 95% CI, 1.120-4.996), and posterior adiposity index (PAI) (OR, 2.171; 95% CI, 1.090-4.324) (all p < 0.05). However, in the period after the learning curve, periadrenal fat volume was not a significant predictor of surgery time prolongation. CONCLUSION This study demonstrates that depth of descended adrenal tumor location to kidney is a new and important independent predictive factor for prolonged operation time in LPRA. In addition, periadrenal fat volume is a predictor of surgery time prolongation for beginner surgeons before the learning curve.
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Li KP, Duan X, Yang XS, Huang J, Wu T. Partial versus total adrenalectomy for the treatment of unilateral aldosterone-producing adenoma: a systematic review and meta-analysis. Updates Surg 2021; 73:2301-2313. [PMID: 34148213 DOI: 10.1007/s13304-021-01116-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 06/11/2021] [Indexed: 12/14/2022]
Abstract
Adrenalectomy is the first line of treatment in unilateral aldosterone-producing adenoma. Whether adrenalectomy should be performed using a cortex-sparing technique (partial adrenalectomy) or total adrenalectomy remains debatable. Therefore, this meta-analysis aims to evaluate the safety and effectiveness of partial adrenalectomy (PA) to total adrenalectomy (TA) by comparing perioperative and functional outcomes. A systematic search was performed across Pubmed, Embase, Web of Science, Cochrane Library database for RCTs and non-RCTs comparing PA and TA on unilateral aldosterone-producing adenoma. The main outcomes analyzed were the perioperative and postoperative effectiveness. In addition, weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals of continuous and dichotomous variables are presented. Two RCTs and 5 non-RCTs trials, including 834 patients were identified and included in the meta-analysis. PA was associated with statistically significant shorter hospital stay (WMD - 0.51 days, 95% CI - 0.87, - 0.14; p = 0.007), shorter operative time (WMD - 15.54 min, 95% CI - 25.12, - 5.97; p = 0.001) and lower overall complications (OR 0.52, 95% CI 0.32, 0.85; p = 0.009) compared to TA. There was no statistical significance in postoperative effectiveness, including postoperative blood pressure, potassium, hypokalemia, ARR and renin between TA and PA. PA seems to have advantages over TA. The surgical outcomes were comparable in TA and PA. The hospital stay, operative time and overall complications may be reduced. When technically feasible, PA might be considered as a better treatment for unilateral aldosterone-producing adenoma.
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Affiliation(s)
- Kun-Peng Li
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xi Duan
- Department of Dermatology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xue-Song Yang
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Jing Huang
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Tao Wu
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China.
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Billmann F, Strobel O, Billeter A, Thomusch O, Keck T, Langan EA, Pfeiffer A, Nickel F, Müller-Stich BP. Insufflation pressure above 25 mm Hg confers no additional benefit over lower pressure insufflation during posterior retroperitoneoscopic adrenalectomy: a retrospective multi-centre propensity score-matched analysis. Surg Endosc 2021; 35:891-899. [PMID: 32095951 PMCID: PMC7819942 DOI: 10.1007/s00464-020-07463-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 02/13/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Insufflation pressures of or in excess of 25 mm Hg CO2 are routinely used during posterior retroperitoneoscopic adrenalectomy (PRA) in most centres. A critical analysis of the surgical literature provides limited evidence to support this strategy. OBJECTIVE To determine whether high pressure (≥ 25 mm Hg) compared with lower pressure (< 25 mm Hg) retroperitoneoscopy reduces operating time and complications. METHODS A multi-centre retrospective cohort study was performed using data collected over a period of almost one decade (1st November 2008 until 1st February 2018) from surgical centres in Germany. A total of 1032 patients with benign adrenal tumours were identified. We compared patients undergoing PRA with insufflation pressures of < 25 mm Hg (G20 group) versus ≥ 25 mm Hg (G25 group). A propensity score matching analysis was performed using BMI, tumour size and surgeon's experience as independent variables. The main outcomes were (1) the incidence of perioperative complications and (2) the length of operating time. RESULTS The baseline patient characteristics were similar in both groups, with the exception of tumour size, BMI and surgeon's experience in PRA. After propensity score matching, perioperative outcomes, especially perioperative complications (3.7% vs. 5.5% in G20 and G25, respectively; p = 0.335) and operation duration (47 min vs. 45 min in G20 and G25, respectively; p = 0.673), did not significantly differ between the groups. CONCLUSION Neither patient safety nor operative success was compromised when PRA was performed with insufflation pressures below 25 mm Hg. Prospective studies are required to determine whether an optimal insufflation pressure exists that maximizes patient safety and minimizes the risks of post-surgical complications. Nevertheless, our results call for a careful re-evaluation of the routine use of high insufflation pressures during PRA. In the absence of prospective data, commencing PRA with lower insufflation pressures, with the option of increasing insufflation pressures to counter intraoperative bleeding or exposition difficulties, may represent a reasonable strategy.
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Affiliation(s)
- Franck Billmann
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
| | - Oliver Strobel
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Adrian Billeter
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Oliver Thomusch
- Department of Surgery, University Hospital of Freiburg Im Breisgau, Hugstetter Strasse 55, 79106, Freiburg im Breisgau, Germany
| | - Tobias Keck
- Department of Surgery, University Hospital Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Ewan Andrew Langan
- Department of Dermatology, University Hospital Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
- Department of Dermatological Science, University of Manchester, Manchester, UK
| | - Aylin Pfeiffer
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Felix Nickel
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Beat Peter Müller-Stich
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
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Billmann F, Billeter A, Thomusch O, Keck T, El Shishtawi S, Langan EA, Strobel O, Müller-Stich BP. Minimally invasive partial versus total adrenalectomy for unilateral primary hyperaldosteronism-a retrospective, multicenter matched-pair analysis using the new international consensus on outcome measures. Surgery 2020; 169:1361-1370. [PMID: 33077201 DOI: 10.1016/j.surg.2020.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/22/2020] [Accepted: 09/02/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Primary hyperaldosteronism is a recognized risk factor for myocardial infarction, stroke, and atrial fibrillation. Minimally invasive adrenalectomy is the first-line treatment for localized primary hyperaldosteronism. Whether minimally invasive adrenalectomy should be performed using a cortex-sparing technique (partial minimally invasive adrenalectomy) or not (total minimally invasive adrenalectomy) remains a subject of debate. The aim of our study was to evaluate the clinical and biochemical efficacy of both procedures and to examine the morbidity associated with partial minimally invasive adrenalectomy versus total minimally invasive adrenalectomy in a multicenter study. METHODS Using a retrospective study design, we determined the efficacy, morbidity, and mortality of partial minimally invasive adrenalectomy and total minimally invasive adrenalectomy. The Primary Aldosteronism Surgical Outcome Study classification was used to explore clinical and biochemical success. Matched-pair analysis was used in order to address possible bias. RESULTS We evaluated 234 matched patients with unilateral primary hyperaldosteronism: 78 (33.3%) underwent partial minimally invasive adrenalectomy, and 156 (66.7%) were treated with total minimally invasive adrenalectomy. Complete clinical success was achieved in 40.6%, and partial clinical success in an additional 52.6% of patients in the entire cohort. Complete biochemical success was seen in 94.0% of patients. Success rates and the incidence of perioperative complications were comparable between groups. Both postoperative hypocortisolism (11.5% vs 25.0% after partial minimally invasive adrenalectomy and total minimally invasive adrenalectomy, respectively; P < .001) and postoperative hypoglycemia (2.6% vs 7.1% after partial minimally invasive adrenalectomy and total minimally invasive adrenalectomy; P = .039) occurred more frequently after total minimally invasive adrenalectomy. CONCLUSION Our study provides evidence that patients with unilateral primary hyperaldosteronism are good surgical candidates for partial minimally invasive adrenalectomy. Not only is the surgical outcome comparable to that of total minimally invasive adrenalectomy, but also postsurgical morbidity, particularly in terms of hypocortisolism and hypoglycemia, may be reduced.
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Affiliation(s)
- Franck Billmann
- Department of Surgery, University Hospital of Heidelberg, Heidelberg, Germany.
| | - Adrian Billeter
- Department of Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Oliver Thomusch
- Department of Surgery, University Hospital of Freiburg im Breisgau, Germany
| | - Tobias Keck
- Department of Surgery, University Hospital Schleswig Holstein, Campus Lübeck, Germany
| | | | - Ewan A Langan
- Department of Dermatology, University Hospital Schleswig Holstein, Campus Lübeck, Germany; Department of Dermatological Science, University of Manchester, United Kingdom
| | - Oliver Strobel
- Department of Surgery, University Hospital of Heidelberg, Heidelberg, Germany
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Costa Almeida CE, Caroço T, Silva MA, Baião JM, Costa A, Albano MN, Louro JM, Carvalho LF. An update of posterior retroperitoneoscopic adrenalectomy - Case series. Int J Surg Case Rep 2020; 71:120-125. [PMID: 32446990 PMCID: PMC7256207 DOI: 10.1016/j.ijscr.2020.04.101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Posterior retroperitoneoscopic adrenalectomy (PRA) has advantages over transperitoneal approach. A second group of 10 patients is analyzed and compared with the first 10 procedures. Conclusions on feasibility, safety and learning curve are taken. MATERIAL AND METHODS A retrospective analysis of a second group of 10 patients submitted to PRA was conducted. All patients with functioning and non-functioning adrenal tumors <6-8 cm and without features of malignancy were included. A comparison with the previous 10 cases was conducted, and the results of all 20 cases were compared with other surgeons. RESULTS Pre-operative diagnoses: Conn's syndrome - 8 (80%); Pheochromocytoma - 1 (10%); Non-functioning tumor (≥ 4 cm) - 1 (10%). Mean size of adrenal tumors was 2,9 cm. Mean operative time for first group was 46,7 min and 31,1 min for the second (p = 0,036). Postoperative in-hospital days decreased in the second group (p = 0,01). Conversion rate was equal (10%). Morbidity and mortality were similar. DISCUSSION Comparing the evolution of operative time in both groups, a constant and faster operative time was noted for the second group and a decreasing linear tendency was noted as more cases were being performed. Postoperative in-hospital days lowered in the second group, because with experience we started discharging patients earlier. Outcomes are stable between both groups. Our results match other authors data. CONCLUSION These results are consistent with our first report and support the small learning curve for PRA, which is technically feasible and safe. Operative time and in-hospital days are influenced by surgeon's experience. More cases need to be collected so that these results can be validated.
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Affiliation(s)
- Carlos E Costa Almeida
- General Surgery, Centro Hospitalar e Universitário de Coimbra (Hospital Geral - Covões), Quinta dos vales, São Martinho do Bispo, 3041-853 Coimbra, Portugal.
| | - Teresa Caroço
- General Surgery, Instituto Português de Oncologia de Coimbra Francisco Gentil, Av. Bissaya Barreto, 2005 Coimbra, Portugal.
| | - Marta A Silva
- General Surgery, Centro Hospitalar e Universitário de Coimbra (Hospital Geral - Covões), Quinta dos vales, São Martinho do Bispo, 3041-853 Coimbra, Portugal.
| | - José M Baião
- General Surgery, Instituto Português de Oncologia de Coimbra Francisco Gentil, Av. Bissaya Barreto, 2005 Coimbra, Portugal.
| | - Ana Costa
- General Surgery, Centro Hospitalar e Universitário de Coimbra (Hospital Geral - Covões), Quinta dos vales, São Martinho do Bispo, 3041-853 Coimbra, Portugal.
| | - Miguel N Albano
- General Surgery, Centro Hospitalar e Universitário de Coimbra (Hospital Geral - Covões), Quinta dos vales, São Martinho do Bispo, 3041-853 Coimbra, Portugal.
| | - João M Louro
- General Surgery, Centro Hospitalar e Universitário de Coimbra (Hospital Geral - Covões), Quinta dos vales, São Martinho do Bispo, 3041-853 Coimbra, Portugal.
| | - Luis F Carvalho
- General Surgery, Centro Hospitalar e Universitário de Coimbra (Hospital Geral - Covões), Quinta dos vales, São Martinho do Bispo, 3041-853 Coimbra, Portugal.
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Ma T, Yang WZ, Cui Z, Zhao C. Experience in the application of laparoscopic anatomical adrenalectomy via the renal cortex surface monolayer. Pak J Med Sci 2020; 36:717-722. [PMID: 32494262 PMCID: PMC7260897 DOI: 10.12669/pjms.36.4.2102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Objective: To discuss the clinical application of laparoscopic anatomical adrenalectomy via the renal cortex surface in the operation of adrenal masses. Methods: A retrospective analysis was performed on 231 patients with adrenal masses who were received and cured in the urology department of the Affiliated Hospital of Hebei University from July 2016 to January 2019. All patients received retroperitoneal adrenalectomy by means of laparoscopic anatomical adrenalectomy via the renal cortex surface. Operation duration, bleeding volume, postoperative complications, retention time of the drainage tube were measured and analyzed, and postoperative follow-up surveys were administered. Results: All cases were successfully operated. Two cases were converted to open surgery due to the presence of large adrenal tumors, and the patients suffered no significant complications. The mean operation duration, bleeding volume and retention time of the drainage tube were 31 minutes, 20 mL and 1.2±0.6 d, respectively. In terms of the postoperative pathology of adrenal tumors, 183 cases were shown to have adenomas, 34 had pheochromocytomas, nine had schwannomas, 3 had metastases from lung cancer, and two had sarcomas. A total of 174 patients were followed up for three to 18 months. Only one case with sarcoma that relapsed within half a year of the operation. Conclusion: In the treatment of adrenal masses, laparoscopic anatomical adrenalectomy via the renal cortex surface has many advantages including the large operation space, clear view of anatomical markers, little bleeding, small trauma, few postoperative complications, simple operational procedures and short learning curves. This technique needs clinical promotion.
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Affiliation(s)
- Tao Ma
- Tao Ma, Department of Urology, Affiliated Hospital of Hebei University, Baoding, Hebei, 071000, P. R. China
| | - Wen-Zeng Yang
- Wen-zeng Yang, Department of Urology, Affiliated Hospital of Hebei University, Baoding, Hebei, 071000, P. R. China
| | - Zhenyu Cui
- Zhenyu Cui, Department of Urology, Affiliated Hospital of Hebei University, Baoding, Hebei, 071000, P. R. China
| | - Chunli Zhao
- Chunli Zhao, Department of Urology, Affiliated Hospital of Hebei University, Baoding, Hebei, 071000, P. R. China
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Oh JY, Chung HS, Yu SH, Kim MS, Yu HS, Hwang EC, Oh KJ, Kim SO, Jung SI, Kang TW, Park K, Kwon D. Comparison of surgical outcomes between lateral and posterior approaches for retroperitoneal laparoscopic adrenalectomy: A single surgeon's experience. Investig Clin Urol 2020; 61:180-187. [PMID: 32158969 PMCID: PMC7052412 DOI: 10.4111/icu.2020.61.2.180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 09/25/2019] [Indexed: 01/02/2023] Open
Abstract
Purpose To compare surgical outcomes between the lateral and the posterior approach for retroperitoneal laparoscopic adrenalectomy (RLA). Materials and Methods We retrospectively reviewed the records of 130 patients who underwent RLA for adrenal tumors by a single surgeon between January 2015 and December 2018. Patient characteristics and perioperative outcomes were analyzed and compared between two surgical groups: lateral approach (n=56) and posterior approach (n=74). Results There were no significant differences in perioperative outcomes between the two groups except for operative time (lateral approach, 105.4±41.21 minutes vs. posterior approach, 71.5±31.51 minutes; p=0.001). In the lateral approach group, two patients (3.6%) underwent open conversion, but there were no major complications in either group (Clavien-Dindo classification ≥3). Male sex was associated with an operative time of ≥90 minutes in the univariate analysis (p=0.019), but this effect did not remain significant in the multivariate analysis. In the multivariate analysis, large tumor size (>5 cm; p=0.020) and preoperative diagnosis of malignancy (p=0.043) were significantly associated with an operative time of ≥90 minutes. Conclusions Both the lateral and posterior approaches for RLA were performed safely with similar operative outcomes and are therefore comparable options for the treatment of adrenal tumors. In addition, large tumor size and preoperative diagnosis of malignancy are associated with longer operative times.
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Affiliation(s)
- Ju Yong Oh
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Ho Seok Chung
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Seong Hyeon Yu
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Myung Soo Kim
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Ho Song Yu
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Eu Chang Hwang
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Kyung Jin Oh
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Sun-Ouck Kim
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Seung Il Jung
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Taek Won Kang
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Kwangsung Park
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Dongdeuk Kwon
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
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Tuncel A, Langenhuijsen J, Erkan A, Mikhaylikov T, Arslan M, Aslan Y, Berker D, Ozgok Y, Gallyamov E, Gozen AS. Comparison of synchronous bilateral transperitoneal and posterior retroperitoneal laparoscopic adrenalectomy: results of a multicenter study. Surg Endosc 2020; 35:1101-1107. [PMID: 32152673 DOI: 10.1007/s00464-020-07474-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 02/19/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Different techniques for laparoscopic adrenalectomy have been proposed with the lateral transperitoneal approach and posterior retroperitoneal approach being the two more frequently minimally invasive surgeries in most of the clinics. There are no sufficient studies in which the results of lateral transperitoneal and posterior retroperitoneal approaches in synchronous bilateral laparoscopic adrenalectomy have been compared. In the current study, we aimed to report our multicenter results of the lateral transperitoneal and posterior retroperitoneal synchronous bilateral laparoscopic adrenalectomy experience in patients who had different bilateral adrenal pathologies and to compare the outcomes of these two different operative procedures. METHODS Between 2012 and 2018, a total of 52 patients with a mean age of 43.5 years underwent simultaneous bilateral laparoscopic adrenalectomy at 6 different centers. Twenty-seven and 25 patients underwent bilateral lateral transperitoneal and posterior retroperitoneal laparoscopic adrenalectomy, respectively. Patients' age, gender, body max index, operative indications, mass size, operation time, blood loss, length of hospitalization, intraoperative and postoperative complications and pathology reports were analyzed. RESULTS Synchronous bilateral transperitoneal group was younger than synchronous posterior retroperitoneal group (37 years vs. 50.4 years.) (p: 0.001). Posterior retroperitoneal group had significantly decreased operating time and less blood loss than transperitoneal group. No significant difference was found with regard to postoperative hospital stay, perioperative and postoperative complications between two groups. Majority of the histopathological results were adrenal hyperplasia associated with Cushing's disease (61.5%). Less frequent pathological results were adrenal adenoma and pheochromocytoma (15.4% and 13.5%, respectively). During the follow-up period, no recurrence or disease-related mortality was observed in the patients. CONCLUSION Our results shows that shorter operative time and less bleeding can be achieved with posterior retroperitoneal approach in synchronous bilateral laparoscopic adrenalectomy. In our series, intraoperative and postoperative complication rates were similar between both surgical approaches.
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Affiliation(s)
- Altug Tuncel
- Department of Urology, Ankara Numune Research and Training Hospital, University of Health Sciences, Ankara, Turkey
| | - Johan Langenhuijsen
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anil Erkan
- Department of Urology, Ankara Numune Research and Training Hospital, University of Health Sciences, Ankara, Turkey
| | - Taras Mikhaylikov
- Department of Urology, Moscow Central Aviation Hospital, Moscow, Russia
| | - Murat Arslan
- Department of Urology, Okan University, Istanbul, Turkey
| | - Yilmaz Aslan
- Department of Urology, Ankara Numune Research and Training Hospital, University of Health Sciences, Ankara, Turkey
| | - Dilek Berker
- Department Endocrinology and Metabolism Diseases, Ankara Numune Research and Training Hospital, University of Health Sciences, Ankara, Turkey
| | - Yasar Ozgok
- Department of Urology, Yuksek Ihtisas University, Ankara, Turkey
| | - Eduard Gallyamov
- Department of Urology, Moscow Central Aviation Hospital, Moscow, Russia
| | - Ali Serdar Gozen
- Department of Urology, SLK Kliniken, University of Heidelberg, Heilbronn, Germany.
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Evolution of adrenal surgery in a tertiary referral centre. Ir J Med Sci 2020; 189:1305-1310. [PMID: 32140992 DOI: 10.1007/s11845-020-02204-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 02/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic transperitoneal and retroperitoneoscopic adrenalectomy have largely replaced open adrenal surgery, particularly in benign disease. Laparoscopic surgery results in less post-operative pain, fewer surgical site complications and reduced length of hospital stay. The aim of this retrospective study was to analyse the characteristics of patients and evolution of surgical technique in adrenal surgery at Cork University Hospital over a 12-year period. METHODS All cases of adrenalectomy between January 1st, 2007 and December 31st, 2018 were retrospectively reviewed. Patient demographics, diagnosis, surgical approach, length of hospital stay, histology and complications were evaluated. Comparisons were made between open, laparoscopic transperitoneal and retroperitoneoscopic adrenalectomy cases. RESULTS There were 57 adrenalectomies performed on 55 patients over the 12-year period. Twenty-six patients (46%) were male, and the mean age was 49 years (range 14-84 years). Twenty-two (39%) right-sided adrenalectomies were performed, 33 (57%) left sided and 2 (4%) patients underwent bilateral surgery. Seventeen adrenalectomies were performed using an open transperitoneal approach, 30 via a laparoscopic transperitoneal approach and 10 using the retroperitoneoscopic technique. Adenoma and pheochromocytoma were the most common indications for surgery (42% and 40%, respectively). Seven percent were performed for malignancy and 5% for other benign indications. The complication rate for open adrenalectomy was 18% versus 10% in laparoscopic transperitoneal adrenalectomy and 0% for retroperitoneoscopic adrenalectomy. Two patients (7%) undergoing laparoscopic transperitoneal surgery required conversion to an open procedure. There were no 30-day mortalities and no disease recurrence within the study time frame. The mean length of hospital stay was 7.6 days in the open group, 5.8 days for the laparoscopic transperitoneal group and 3 days for the retroperitoneoscopic group (p = 0.03). CONCLUSIONS Adrenalectomy is a safe procedure and in our setting was primarily performed for pheochromocytoma and non-functioning adenomas. Minimally invasive adrenalectomy has become the standard of care internationally and is associated with fewer complications, shorter hospital stay and a low conversion rate.
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Pearlstein SS, Kuo JH, Chabot JA, Lee JA. Periadrenal Volume is a Better Predictor of Prolonged Operative Time in Laparoscopic Retroperitoneal Adrenalectomy than BMI. World J Surg 2019; 44:578-584. [DOI: 10.1007/s00268-019-05324-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Gimm O, Barczyński M, Mihai R, Raffaelli M. Training in endocrine surgery. Langenbecks Arch Surg 2019; 404:929-944. [PMID: 31701231 PMCID: PMC6935392 DOI: 10.1007/s00423-019-01828-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/20/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND/PURPOSE In Europe, the Division of Endocrine Surgery (DES) determines the number of operations (thyroid, neck dissection, parathyroids, adrenals, neuroendocrine tumors of the gastro-entero-pancreatic tract (GEP-NETs)) to be required for the European Board of Surgery Qualification in (neck) endocrine surgery. However, it is the national surgical boards that determine how surgical training is delivered in their respective countries. There is a lack of knowledge on the current situation concerning the training of surgical residents and fellows with regard to (neck) endocrine surgery in Europe. METHODS A survey was sent out to all 28 current national delegates of the DES. One questionnaire was addressing the training of surgical residents while the other was addressing the training of fellows in endocrine surgery. Particular focus was put on the numbers of operations considered appropriate. RESULTS For most of the operations, the overall number as defined by national surgical boards matched quite well the views of the national delegates even though differences exist between countries. In addition, the current numbers required for the EBSQ exam are well within this range for thyroid and parathyroid procedures but below for neck dissections as well as operations on the adrenals and GEP-NETs. CONCLUSIONS Training in endocrine surgery should be performed in units that perform a minimum of 100 thyroid, 50 parathyroid, 15 adrenal, and/or 10 GEP-NET operations yearly. Fellows should be expected to have been the performing surgeon of a minimum of 50 thyroid operations, 10 (central or lateral) lymph node dissections, 15 parathyroid, 5 adrenal, and 5 GEP-NET operations.
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Affiliation(s)
- Oliver Gimm
- Department of Surgery and Department of Clinical and Experimental Medicine (IKE), Linköping University, 58183 Linköping, Sweden
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of Surgery, Jagiellonian University Medical College, 37 Prądnicka Street, 31-202 Kraków, Poland
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospital NHS Foundation Trust, Oxford, OX3 7DU United Kingdom
| | - Marco Raffaelli
- U.O. Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Semeiotica Chirurgica, Università Cattolica del Sacro Cuore, Rome, Italy
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Mihai R, Donatini G, Vidal O, Brunaud L. Volume-outcome correlation in adrenal surgery-an ESES consensus statement. Langenbecks Arch Surg 2019; 404:795-806. [PMID: 31701230 PMCID: PMC6908553 DOI: 10.1007/s00423-019-01827-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/20/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Published data in the last decade showed that a majority of adrenal operations are done by surgeons performing only one such case per year and based on the distribution of personal workloads 'high-volume' surgeons are defined as those doing 4 or more cases/year. PURPOSE This paper summarises literature data identified by a working group established by the European Society of Endocrine Surgeons (ESES). The findings were discussed during ESES-2019 conference and members agreed on a consensus statement. RESULTS The annual of adrenal operations performed yearly in individual countries was reported to be 800/year in UK and over 1600/year in France. The learning curve of an individual surgeon undertaking laparoscopic, retroperitoneoscopic or robotic adrenalectomy is estimated to be 20-40 cases. Preoperative morbidity and length of stay are more favourable in high-volume centres. CONCLUSION The main recommendations are that adrenal surgery should continue only in centres performing at least 6 cases per year, surgery for adrenocortical cancer should be restricted to centres performing at least 12 adrenal operations per year, and an integrated multidisciplinary team should be established in all such centres. Clinical information regarding adrenalectomies should be recorded prospectively and contribution to the established EUROCRINE and ENSAT databases is strongly encouraged. Surgeons wishing to develop expertise in this field should seek mentorship and further training from established adrenal surgeons.
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Affiliation(s)
- Radu Mihai
- Churchill Cancer Centre, Oxford University NHS Hospitals Foundation Trust, Oxford, UK
| | - Gianluca Donatini
- Department of Surgery and INSERM U1082, CHU Poitiers, University of Poitiers, Poitiers, France
| | - Oscar Vidal
- ICMDiM, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Laurent Brunaud
- Department of Surgery and INSERM U954, CHU Nancy (Brabois), Université de Lorraine, Vandoeuvre les Nancy, France
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Teksöz S, Kılboz BB, Bükey Y. Experience of an endocrine surgeon in laparoscopic transperitoneal adrenalectomy. BMC Surg 2019; 19:134. [PMID: 31510984 PMCID: PMC6739991 DOI: 10.1186/s12893-019-0599-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 08/30/2019] [Indexed: 12/21/2022] Open
Abstract
Background Laparoscopic adrenalectomy (LA) is currently recognized as the gold standard for the treatment of most adrenal lesions, with a high safety and feasibility profile. This study aimed to present the extensive experience of a specialized endocrine surgeon in LA in a relatively large series of patients. Methods A total of 116 LAs performed from June 2009 to 2018 were evaluated in terms of adrenal pathologies, perioperative management, complications, conversions, tumor size, operative time, and learning curve. The learning curve was assessed using the cumulative sum (CUSUMOT) technique. Results Of 116 LAs, 107 (92.2%) were completed successfully, 77 (72%) of which were for Cushing’s syndrome (n = 43, 55.8%), pheochromocytoma (n = 26, 33.8%), and Conn’s syndrome (n = 8, 10.4%). Conversion was required in 9 cases (7.8%), the most common cause being limited space complicating dissection (n = 3). The mean operative time for successful LAs (unilateral 85, bilateral 22) was 74.7 min (range 40–210 min) and the mean hospital stay was 1.7 days (range 1–5 days). Gender, tumor size and body mass index were found to have no significant relationship with the operative time (p > 0.05). Postoperative normalization in hormone profiles was obtained in all patients but one. Aside from grade-I port-site infections in four patients (3.7%), no postoperative major complications and 30-day mortality were observed. On the CUSUMOT graph, the learning period covered the first 34 operations. Conclusions Laparoscopic adrenalectomy is safe and advantageous, but requires a dedicated team involving experienced endocrine surgeons who have achieved competency after completion of the learning curve.
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Affiliation(s)
- Serkan Teksöz
- Istanbul Universitesi Cerrahpasa Tip Fakultesi, General Surgery, Istanbul, Turkey.
| | | | - Yusuf Bükey
- Istanbul Universitesi Cerrahpasa Tip Fakultesi, General Surgery, Istanbul, Turkey
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23
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Seeliger B, Walz MK, Alesina PF, Agnus V, Pop R, Barberio M, Saadi A, Worreth M, Marescaux J, Diana M. Fluorescence-enabled assessment of adrenal gland localization and perfusion in posterior retroperitoneoscopic adrenal surgery in a preclinical model. Surg Endosc 2019; 34:1401-1411. [PMID: 31338664 DOI: 10.1007/s00464-019-06997-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/15/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND The posterior retroperitoneoscopic adrenal access represents a challenge in orientation and working space creation. The aim of this experimental acute study was to evaluate the impact of computer-assisted quantitative fluorescence imaging on adrenal gland identification and assessment of intraoperative remnant perfusion for adrenal resection in the posterior retroperitoneoscopic approach. METHODS Six pigs underwent simultaneous (n = 5) or sequential (n = 1) bilateral posterior retroperitoneoscopic adrenalectomy (n = 12). Fluorescence imaging was obtained via intravenous administration of 3 mL of Indocyanine Green (ICG) and by switching the camera systems to near-infrared mode (D-LIGHT P, KARL STORZ; Germany). Fluorescence-based visualization of adrenal glands before vascular division (n = 4), after the main vascular pedicle ligation (negative control, n = 1) or after adrenal resection (n = 7), was followed by completion adrenalectomy. The fluorescence signal intensity dynamics were recorded and analyzed using proprietary software. For each pixel, the slope of fluorescence signal intensity evolution over time was translated into a color-coded perfusion cartography, which was superimposed onto real-time images obtained with the corresponding left and right camera systems. Quantitative fluorescence signal analysis in the regions of interest (ROIs) served to assess adrenal remnant perfusion in divided adrenal glands. RESULTS In the retroperitoneum, the vascular anatomy was illuminated in fluorescence imaging first. The adrenal glands were promptly highlighted after primary intravenous ICG administration (n = 9) or showed a fluorescence signal intensity increase upon reinjection (n = 3). Quantitative fluorescence analysis showed a statistically significant difference between perfused and ischemic segments in divided glands (p = 0.0156). CONCLUSIONS Fluorescence imaging provides real-time guidance during minimally invasive adrenal surgery. Prior to dissection, it allows to easily discriminate the adrenal gland from surrounding retroperitoneal structures. After adrenal gland division, ICG injection associated with a computer-assisted quantitative analysis helps to distinguish between well-perfused and ischemic segments. Further studies are underway to establish the correlation between remnant perfusion and viability.
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Affiliation(s)
- Barbara Seeliger
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France. .,Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Evang. Huyssens-Stiftung/Knappschaft GmbH, Academic Teaching Hospital of the University of Duisburg-Essen, Essen, Germany. .,Institute for Research Against Cancer of the Digestive System (IRCAD), Strasbourg, France.
| | - Martin K Walz
- Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Evang. Huyssens-Stiftung/Knappschaft GmbH, Academic Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
| | - Pier F Alesina
- Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Evang. Huyssens-Stiftung/Knappschaft GmbH, Academic Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
| | - Vincent Agnus
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France
| | - Raoul Pop
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France.,Interventional Radiology Department, Strasbourg University Hospitals, Strasbourg, France
| | - Manuel Barberio
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France
| | - Alend Saadi
- Department of Surgery, Neuchâtel Hospital, Neuchâtel, Switzerland
| | - Marc Worreth
- Department of Surgery, Neuchâtel Hospital, Neuchâtel, Switzerland
| | - Jacques Marescaux
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France.,Institute for Research Against Cancer of the Digestive System (IRCAD), Strasbourg, France
| | - Michele Diana
- IHU-Strasbourg, Institute of Image-Guided Surgery, 1, Place de l'Hôpital, 67000, Strasbourg, France.,Institute for Research Against Cancer of the Digestive System (IRCAD), Strasbourg, France.,Department of Surgery, Neuchâtel Hospital, Neuchâtel, Switzerland
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24
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Quality Improvement in Laparoscopic Donor Nephrectomy by Self-Imposed Proctored Preceptorship Model. Indian J Surg 2019. [DOI: 10.1007/s12262-019-01912-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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25
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Alesina PF. Retroperitoneal adrenalectomy-learning curve, practical tips and tricks, what limits its wider uptake. Gland Surg 2019; 8:S36-S40. [PMID: 31404183 DOI: 10.21037/gs.2019.03.11] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The minimally invasive retroperitoneal approach to the adrenal surgery has been described in the early 90s following the first description of laparoscopic adrenalectomy. Although the advantages of the technique compared to laparoscopic surgery have been demonstrated in many studies, it remained for a long period confined to few centers. The operation has been standardized over the years into a safe and reproducible procedure that finally gained worldwide acceptance in the last 10 years. The present paper summarizes the surgical steps of the procedure focusing on the recent technical developments. Retroperitoneoscopic adrenalectomy should be part of the surgical armamentarium of any center dedicated to endocrine surgery.
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Affiliation(s)
- Pier Francesco Alesina
- Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Essen, Germany
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