Safety of outpatient adrenalectomy across 3 minimally invasive approaches at 2 academic medical centers

Adrenalectomy Outcome Variations Across Different Functional Adrenal Tumors

INTRODUCTION

Adrenalectomy generally has favorable outcomes. It is unknown if patients with functional adrenal tumors experience different clinical outcomes than those with benign adrenal tumors, due to the presence of comorbid conditions secondary to the functional tumor. We investigated outcomes following open and laparoscopic adrenalectomy for benign nonfunctional (BNF) versus functional adrenal masses.

METHODS

Patients undergoing adrenalectomy were identified in the 2015-2020 National Surgical Quality Improvement Program database, then categorized as BNF, hyperaldosteronism, hypercortisolism, and pheochromocytoma. The primary outcome of interest was 30-d morbidity and secondary outcomes included 30-d mortality, 30-d readmission, and postoperative length of stay (LOS). Subgroup analysis was performed based upon surgical approach. Univariate analysis was performed, followed by multivariable logistic regression for individual outcomes that differed significantly between patients with BNF and functional neoplasm, factoring in patient demographics and operative approach with statistical significance on univariate analysis. Descriptive statistics and outcomes were analyzed using Pearson's χ2 test and Mann-Whitney U-test as appropriate.

RESULTS

There were 3291 patients with BNF while 484 had hyperaldosteronism, 263 hypercortisolism, and 46 pheochromocytomas. Within the laparoscopic group of 3615 (88.5%) of adrenalectomy patients, compared to BNF patients, patients with hyperaldosteronism had lower rates of postoperative morbidity (1.9% versus 5.2%, P < 0.001) and shorter LOS (1 d, interquartile range (IQR) [1-1] versus 1d IQR [1-2], P = 0.003); these persisted on multivariate analysis (OR 0.32, 95% confidence interval [CI] 0.14-0.74 and odds ratio 0.47, 95% CI 0.36-0.60, P < 0.001). Patients with hypercortisolism had higher morbidity (7.3% versus 5.2%, P < 0.001), 30-d readmission rates (5.3% versus 2.9%, P = 0.042) and longer LOS (2d, IQR [1-3] versus 1d, IQR [1-2, P < 0.001). On multivariate analysis, presence of hypercortisolism was independently associated with increased likelihood of readmission within 30 d (OR 2.20, 95% CI 1.11-2.99, P = 0.012) and longer LOS (>1 d) (OR 1.79, 95% CI 1.33-2.40, P < 0.001). Compared to BNF patients, patients with pheochromocytoma had higher rates of postoperative morbidity (6.2% versus 5.2%, P < 0.001). Within the open group of 469 (11.5% of adrenalectomy patients), there were no statistically significant differences in outcomes between patients with BNF and functional adrenal masses.

CONCLUSIONS

Outcomes after adrenalectomy performed for functional neoplasms differ based on surgical indication.

Perioperative Outcomes After Adrenalectomy for Secondary Adrenal Malignancy

INTRODUCTION

The risk of adverse outcomes after adrenal metastasectomy is not well defined. Knowledge of these risks is essential to guide patient counseling.

METHODS

The 2015-2020 National Surgical Quality Improvement Program datasets were combined. Patients who underwent adrenalectomy for secondary adrenal malignancy (SM) and benign nonfunctional (BNF) adrenal neoplasms were identified; BNF neoplasms were chosen as a comparison as functional neoplasms can contribute to comorbidity. Patients who had additional surgery at the time of adrenalectomy were excluded. Patient demographics, comorbidities, perioperative factors, and outcomes were compared between groups. Multivariable logistic regression analysis was performed.

RESULTS

Of 3496 adrenalectomy patients, 332 had SM and 3164 had BNF neoplasms. Patients with SM were older (65 versus 54 y) and more often had chronic obstructive pulmonary disease (7.5% versus 4.4%), chronic steroid use (10.5% versus 3.8%), and bleeding disorders (4.5% versus 2.2%) than patients with BNF, respectively (P < 0.01 for all). Laparoscopic adrenalectomy was the most common operative approach for both groups (74.7% versus 88.3%). Rates of mortality, morbidity, reoperation, readmission, and nonhome discharge did not differ significantly between groups. Patients with SM had higher rates of postoperative bleeding than patients with BNF (6.3% versus 2.6%, P < 0.001). This persisted on multivariable regression analysis that adjusted for demographics, comorbidities, and operative approach (odds ratio 2.34, 95% confidence interval 1.19-4.64).

CONCLUSIONS

Adrenalectomy for SM is associated with an increased risk of postoperative bleeding compared to adrenalectomy for BNF adrenal neoplasms. Patients with SM that meet criteria for adrenal metastasectomy should be counseled appropriately.

Effects of the COVID-19 pandemic on endocrine operations in the United States

BACKGROUND

The COVID-19 pandemic disrupted the United States (US) healthcare system. Endocrine operations are predominantly elective and were likely affected. Therefore, our aim was to determine the effect of the pandemic on endocrine operations.

STUDY DESIGN

The Vizient Clinical Data Base® was examined for cases from 1/2019-12/2022 using ICD10 and CPT codes for thyroid, parathyroid, and adrenal operations. Control chart analysis identified trends in operative volume. Negative binomial regression was utilized to analyze demographic trends.

RESULTS

Monthly volumes for all operations from 515 hospitals decreased at the beginning of 2020, except for operations for adrenal malignancy. Inpatient operations (Thyroid -17.1%, Parathyroid -20.9%, p ​< ​0.001 for both) experienced more significant and longer lasting disruptions than outpatient operations (Thyroid -2.6%, p ​= ​0.883, Parathyroid -9.1%, p ​= ​0.098).

CONCLUSIONS

The COVID-19 pandemic disrupted endocrine operations across the US. While all adrenal operations and outpatient thyroid and parathyroid operations have returned to pre-pandemic levels, inpatient operations for thyroid and parathyroid remain decreased.

Patient satisfaction analysis of robot-assisted minimally invasive adrenalectomy: a single-center retrospective study

The objective of this study is to compare the satisfaction of patients undergoing robot-assisted retroperitoneal laparoscopy adrenalectomy under the ambulatory mode and conventional mode. Basic information and clinical data of patients who underwent robotic-assisted posterior laparoscopic adrenalectomy between June 2020 and June 2023 were queried from our case system. The Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems Survey (OAS CAHPS®) was used to investigate patient satisfaction with preoperative preparation, discharge counseling, postoperative instructions, postoperative pain, and satisfaction with nursing work. The stats R package was used to select the appropriate statistic for the statistics based on the characteristics of the data. A total of 311 patients who underwent robot-assisted posterior laparoscopic adrenalectomy were enrolled in our case system. There were no statistical differences between the two groups in gender, age, body mass index, ASA classification, laterality, maximum tumor diameter, type of resection, hormonal activity, disease type, pathological classification, duration of surgery, estimated intraoperative bleeding, postoperative complications and follow-up period that were compared between the two groups of patients. There were no significant differences in preoperative preparation score, discharge counseling score, postoperative guidance score and nursing care satisfaction score (P > 0.05). Postoperative hospitalization, peristalsis time, defecation time, time to first postoperative mobilization, duration of indwelling drain and hospitalization costs in patients in the ambulatory model group were significantly less than patients in the conventional model group (P < 0.001). Patients in the ambulatory model group had significantly higher postoperative pain relief scores than patients in the conventional model group. In conclusion, our data suggest that patient satisfaction is equal between the conventional and ambulatory mode of performing robotic-assisted adrenalectomy. Patient satisfaction was probably associated with shorter hospitalization days, adequate preoperative preparation and standardized, high-quality post-discharge information and guidance.

Same day discharge after minimally invasive adrenalectomy: a national study

BACKGROUND

Same day discharge (SDD) may be considered in some patients undergoing minimally invasive adrenalectomy (MIA). Recent studies have demonstrated similar outcomes between SDD and admitted patients; however, most excluded pheochromocytoma and adrenal metastases. This study evaluates 30-day complications and hospital readmission in a large cohort of patients undergoing MIA.

METHODS

Adult patients undergoing MIA (2010-2020) for benign adrenal disorders, pheochromocytoma, and adrenal metastases were identified within the ACS-NSQIP database. Comparisons between patients having SDD versus admission were performed. Factors associated with 30-day complications and unplanned readmission were evaluated by multivariable regression modeling.

RESULTS

Of 7316 patients who underwent MIA, 254 had SDD. Baseline characteristics were similar between groups, although SDD patients had lower ASA class (p < 0.001) and were more likely to undergo MIA for nonfunctioning adenoma or primary aldosteronism (p = 0.001). After adjusting for covariates, higher ASA class and presence of medical comorbidities were associated with increased complications (p < 0.001; p < 0.05) and unplanned readmission (p < 0.001; p < 0.05). Additionally, prolonged operative time was associated with 30-day complications (p < 0.001). Notably, SDD was not associated with increased complications (OR 0.78, 95% CI 0.38-1.61, p = 0.502) or unplanned readmission (OR 0.76, 95% CI 0.35-1.64, p = 0.490). The rate of SDD for MIA increased from 1.48% in 2017 to 10.81% in 2020.

CONCLUSIONS

Not all patients undergoing MIA should have SDD; however, the current analysis demonstrates a trend toward SDD and supports its safety in select patients with adrenal metastases and benign adrenal disorders including pheochromocytoma.

Older age impacts outcomes after adrenalectomy

BACKGROUND

Adrenalectomy is well tolerated with low complication rates. It is unclear if these excellent outcomes are consistent across all age groups.

METHODS

The 2015-2020 American College of Surgeons National Surgical Quality Improvement Program datasets were used. Patients who underwent adrenalectomy were identified and grouped based on age: ≤60, 61 to 70, 71 to 80, and >80 years. Patient characteristics, surgical indications, operative characteristics, and postoperative outcomes were compared between age groups. Primary outcome measures were mortality, morbidity, postoperative length of stay, non-home discharge, and unplanned readmission. Multivariable logistic regression analysis was performed.

RESULTS

Adrenalectomy was performed on 6,114 patients. Younger patients more frequently had surgery for non-functional benign neoplasms compared with older (55.7% vs 52.8% vs 45.9% vs 45.3%, for patients ≤60, 61 to 70, 71 to 80, and >80 years, respectively, P < .001), and less frequently had surgery for malignancy (8.8% vs 14.4% vs 22.5% vs 24.5%, P < .001). The median length of stay for patients ≤60 was 1 day compared with 2 days for patients 61-70, 71-80, and >80 (P < .001). The overall mortality rate was <1% and did not differ based on age (P = .18). Morbidity occurred less frequently in the younger age groups (7.3% vs 8.9% vs 11.2% vs 16.0%, P < .001) compared with older. Similar trends were seen for non-home discharge (1.4% vs 2.5% vs 4.8% vs 17.0%, P < .001). On multivariable analysis, patients aged >80 had a 2-fold increased likelihood of morbidity and a 9-fold increased likelihood of non-home discharge compared to patients aged ≤60.

CONCLUSION

Older age is associated with morbidity and non-home discharge after adrenalectomy. Knowledge of these risks is critical when counseling an aging surgical population.

Association Between Surgical Indication and Outcomes for Outpatient Adrenalectomy

INTRODUCTION

Despite a favorable risk-benefit profile, inpatient admission postoperatively for minimally invasive adrenalectomy (MIA) has remained common. Prior studies have shown that outpatient MIA was not associated with an increased 30-day complications or readmission. However, this has not been explored in-depth by adrenalectomy indication. We aimed to examine whether the safety profile of outpatient MIA varies by adrenal indication.

MATERIALS AND METHODS

Clinicopathologic parameters were examined for all MIAs entered into an adrenal database at our institution from 2012 to 2021. Predictor variables included patient demographics, surgical indication, and operative time. Outcomes were 30-day emergency department visit, readmission, and complication rates between surgical indications, comparing outpatient and inpatient groups. Statistical analyses were performed using Kruskal-Wallis, Wilcoxon, Mann-Whitney, and Chi-squared tests, as appropriate.

RESULTS

A total of 185 MIA patients were included. Outpatient MIA was performed in 53 patients (28.6%). Outpatient discharge post-MIA was related to both surgical indication and operative time. Pheochromocytoma (PC) patients were less likely to be discharged as an outpatient postoperatively when compared to all other indications (13.0% versus 33.8%, P = 0.007). Among all patients with operations 2-3 h in length, PC patients were less likely to be discharged home as an outpatient (10% versus 33.3%, P = 0.040). No significant differences were identified between outpatient and inpatient MIA groups for complications, emergency department visits, or readmission (P > 0.05 for all). Only six outpatient MIA patients had any complication (11.3%) and six were readmitted (11.3%).

CONCLUSIONS

Outpatient MIA was demonstrated to be associated with similar, low complication and readmission rates compared to inpatient MIA, although it was used less often for patients with PC or prolonged operative times. Our study highlights potential evidence that outpatient MIA can be safely used in selected patients across all indications for adrenal surgery.

Pathological and clinical outcomes of adrenalectomy: A multi-center experience in Saudi Arabia

Objective

To determine the nature of adrenal pathology in patients undergoing adrenalectomy in Saudi Arabia over the last decade and compare it with the literature. We compared perioperative outcomes between minimally invasive adrenalectomy (MIA) and open adrenalectomy (OA).

Methods

This retrospective study included patients who underwent adrenalectomy at five tertiary care centers in Saudi Arabia from 2010 to 2020. We collected patients' baseline and perioperative characteristics and detailed hormonal evaluation of adrenal masses.

Results

Among 160 patients (mean age 44 ± 14.5 years; mean BMI 29.17 ± 5.96 kg/m²), 84 (51.5 %) were men and 51.5 % had left-sided adrenal masses. The mean tumor size was 6.1 ± 4.2 (1.0-19.5) cm, including 60 (37.5 %) incidentalomas and 65 (40.6 %) functioning masses. Histopathology revealed 74 (46.2 %) adenomas and 24 (15 %) cancers or metastases from other primary organs; 20 %, 8.8 %, and 2.5 % of patients had pheochromocytoma, myelolipoma, and 2.5 % ganglioneuroblastoma, respectively. MIA and OA were performed in 135 (84.4 %) and 21 (15.6 %) patients, respectively. Adrenalectomy was increasingly performed over three equal periods in the last decade (17.5 % vs 34.4 % vs 48.1 %), with increasing numbers of MIAs to replace OAs. OA patients had larger tumors and needed blood transfusion more frequently (47.6 % vs 10.8 %, p< 0.001). MIA was significantly associated with shorter operative time, shorter length of stay, and less blood loss. Postoperative complications occurred in 10 (6.2 %) patients and were significantly higher for OA (24 % vs 3.0 %, p< 0.001).

Conclusions

The majority of adrenal masses are benign. Herein, the observed functional and perioperative outcomes were comparable to those of available meta-analyses.

Patient Satisfaction is Equivalent for Inpatient and Outpatient Minimally-Invasive Adrenalectomy

INTRODUCTION

Same-day surgery in the carefully selected patient decreases costs, improves inpatient capacity, and decreases patient exposure to hospital-acquired conditions. Outpatient adrenalectomy has been shown to be safe and effective, but patients' perspectives have yet to be addressed. This study compares patient satisfaction following inpatient and outpatient adrenalectomy.

METHODS

An institutional database was queried for minimally-invasive adrenalectomies performed from 2017 to 2020. Patients were contacted up to two times to participate in a phone survey consisting of 25 questions modeled after the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems Survey (OAS CAHPS) assessing preparation for surgery, discharge experience, post-operative course, and overall satisfaction. Statistical analysis was performed using Kruskal Wallis, Wilcoxon-Mann Whitney, and Chi-square tests, as appropriate.

RESULTS

One hundred five adrenalectomy patients were identified, of which 98 were contacted and 58 responded (59%). Two surgeons contributed patients, with no difference in the percentage of patients in the outpatient group (51.7% versus 62.1%, P = 0.423). Outpatient adrenalectomy patients had slightly higher overall experience scores, but this difference was not statistically significant (9.12 ± 1.36 versus 8.93 ± 1.51, P = 0.367). Patients undergoing outpatient adrenalectomy were more likely to have their discharge plan discussed pre-operatively (94% versus 62%, P = 0.005), but no significant differences were noted between inpatient and outpatient groups regarding preparation for surgery, readiness for discharge, night of surgery experiences, or self-reported pain or complications (P > 0.05 for all). Significantly higher overall experience scores were reported by patients counseled about their discharge plan (9.27 versus 7.9, P = 0.036), felt prepared for recovery (9.39 versus 5.5, P < 0.001), received information about pain control (9.13 versus 7.00, P = 0.031), felt prepared at time of discharge (9.33 versus 5.80, P < 0.001), and received information about potential complications (9.29 versus 7.00, P = 0.001). Although not statistically significant, there was a trend towards outpatients being more likely to choose the same approach if they were to undergo surgery again (97% versus 84%, P = 0.081).

CONCLUSIONS

Patient satisfaction following adrenalectomy is significantly associated with patients' self-reported degree of preparation for surgery and discharge, with no significant difference in patient satisfaction between inpatient and outpatient groups. Patients undergoing outpatient adrenalectomy would be likely to choose the same approach compared to inpatients. Targeted pre-operative counseling can contribute to enhanced patient outcomes for all patients undergoing adrenalectomy.

Retroperitoneal laparoscopic partial adrenalectomy (RLPA) for 20-40 mm nonfunctional adrenal tumors in the day surgery mode

OBJECTIVES

To investigate the outcome and safety of retroperitoneal laparoscopic partial adrenalectomy in the treatment of nonfunctional unilateral adrenal tumors in the day surgery mode.

METHODS

Nineteen patients bearing nonfunctional unilateral 20-40 mm adrenal tumors were prospectively enrolled and underwent retroperitoneal laparoscopic partial adrenalectomy in the day surgery unit of our hospital between June 2021 and March 2022. All patients were diagnosed with non-functional adrenal tumors as outpatients before being admitted to the day surgery unit with their consent. Patient demographics and perioperative data were prospectively documented. The patients were followed up by telephone on day 1, 3 and 7 after discharge and followed up for 6 months.

RESULTS

The patient's age was 50.5 ± 11.9 yr (range from 19.0 - 69.0). Seven patients were female. Twelve patients underwent surgery on the left side. The maximal diameter of tumor was 28.3 ± 5.7 mm (20.0 - 40.0 mm). Operation time was 72.1 ± 14.9 min (58.0 - 120.0 min). Mean blood loss was 64.7 ± 50.4 ml (30.0 - 200.0 ml). The gastrointestinal function recovery time was 9.7 ± 2.6 h (6.0 - 16.0 h). Retroperitoneal drainage was removed 24.8 ± 13.3 h (range 18.0 - 72.0) after surgery. Four patients were transferred to the general ward for postoperative management, while others were discharged within 24 hours after surgery. Length of hospital stay was 48.8 ± 13.1 h (38.0 - 85.0h). Hospitalization expense was 24168.4 ± 2910.3 RMB¥ (20844.3 - 34369.8 RMB¥). Postoperative pathology revealed 17 cortical adenoma, 1 pheochromocytoma and 1 lymphatic duct tumor.

CONCLUSION

Retroperitoneal laparoscopic partial adrenalectomy for nonfunctional unilateral adrenal tumors in the day surgery mode is safe when strict selection criteria and perioperative management protocol are followed, which has the potential to shorten length of hospital stay and reduce lower hospitalization costs.

Impact of the COVID-19 pandemic on the practice of endocrine surgery

Background

This study investigates the impact of the COVID-19 pandemic on endocrine surgeons.

Methods

A survey on the professional, educational, and clinical impact was sent to active and corresponding members of the American Association of Endocrine Surgeons (AAES) in September 2020. Chi-square and paired t-test were used for analysis.

Results

77 surgeons responded (14.8 %). All reported suspension of elective surgeries; 37.7 % were reassigned to other duties during this time. The median number of cases backlogged was 30 (IQR 15–50). Most surgeons reported decreased clinical volume (74.6 %). The use of virtual platforms for clinical and educational purposes increased from pre-COVID-19 levels (all p < 0.001). Use of in-office procedures (p < 0.001) and length of observation prior to discharge for thyroid surgery (p < 0.05) decreased.

Conclusion

The COVID-19 pandemic led to suspension of operations and decreased practice volume for endocrine surgeons. Surgeons increased use of virtual platforms, decreased in-office procedures, and decreased duration of observation for thyroid surgery in response.

Outcomes of malignant pheochromocytoma based on operative approach: A National Cancer Database analysis

BACKGROUND

Malignant pheochromocytoma is often managed with adrenalectomy. Most literature focusing on postoperative outcomes are from single institutions. This study aimed to describe outcomes of adrenalectomy for malignant pheochromocytoma using a national database. We hypothesized that minimally invasive approaches might be associated with improved short-term outcomes but potentially inferior oncologic efficacy.

METHODS

Patients who underwent adrenalectomy for malignant pheochromocytoma were identified in the National Cancer Database (2010-2016). Patients were categorized as minimally invasive adrenalectomy or open adrenalectomy. Short- and long-term outcomes were compared.

RESULTS

A total of 276 patients underwent adrenalectomy for malignant pheochromocytoma: 50.7% open adrenalectomy and 49.3% minimally invasive adrenalectomy. Demographics were similar, except those who underwent open adrenalectomy had larger tumors compared to minimally invasive adrenalectomy (8.2 cm vs 4.7 cm; P < .001). Tumor size ≥6 cm was associated with a reduced likelihood of minimally invasive adrenalectomy (relative to open adrenalectomy) on multivariable regression (odds ratio = 0.23; P < .001). Open adrenalectomy was associated with longer duration of stay relative to minimally invasive adrenalectomy (6 vs 3 days; P < .001). Rates of positive margins, unplanned readmissions, or 30-/90-day mortalities were similar based on operative approach. Five-year survival rates were similar (open adrenalectomy 74.3%, minimally invasive adrenalectomy 79.1%). There was no association between overall survival and operative approach on multivariable Cox analysis when controlling for tumor size, laterality, and clinicodemographic variables.

CONCLUSION

Patients with larger malignant pheochromocytomas were more likely to undergo an open adrenalectomy. With the exception of an increased duration of stay, there was no difference in short- or long-term postoperative outcomes. These data suggest that minimally invasive adrenalectomy appears safe among tumors <6 cm.