Laparoscopic transperitoneal adrenalectomy in morbidly obese patients is not associated with worse short-term outcomes

Impact of Body Mass Index ≥35 kg/m2 on Minimally Invasive Adrenalectomy

Introduction: Obesity is associated with numerous chronic conditions and an increased risk for surgical complications. Laparoscopic and robotic adrenalectomy have proven effective in the resection of adrenal tumors. This study analyzes the outcomes of severely obese patients (body-mass index [BMI] ≥35 kg/m2) following minimally invasive adrenalectomy. Materials and Methods: A retrospective analysis of patients who underwent minimally invasive adrenalectomy at our institution between 2010 and 2023 was conducted. Two matching analyses were performed. The first analysis compared patients with BMI greater versus lower than 35 kg/m2. The second analysis compared outcomes between robotic and laparoscopic adrenalectomy in patients with a BMI ≥35 kg/m2. Results: A total of 278 patients were included in the study. The median tumor size was 29 mm. Adrenal tumors had similar laterality, and most were hormonally active (66.2%). The most common pathological diagnosis was pheochromocytoma (25.5%). No statistical difference was found in peri- and postoperative outcomes between patients with BMI ≥35 and <35 kg/m2 who underwent minimally invasive adrenalectomy. When the surgical approach was compared in severely obese patients, robotic adrenalectomy was associated with shorter hospital length of stay with similar operative time as the laparoscopic approach. Conclusions: Minimally invasive adrenalectomy is safe and feasible in patients with BMI ≥35 kg/m2. Robotic and laparoscopic approaches are both safe and efficient for the resection of adrenal tumors in severely obese patients.

Perirenal fat thickness is a powerful predictor for surgical outcomes of transperitoneal laparoscopic adrenalectomy

OBJECTIVES

Laparoscopic adrenalectomy has been the gold standard surgical procedure. However, the adaptation criteria for malignant tumors and predictors of perioperative outcomes are not well defined. Therefore, this study tried to identify valid predictors for perioperative outcomes of laparoscopic adrenalectomy and consider the adaptation criteria.

METHODS

We retrospectively reviewed the preoperative and perioperative data of 216 patients who underwent transperitoneal laparoscopic adrenalectomy in our hospital. Preoperative factors associated with perioperative outcomes were analyzed using multiple regression analysis.

RESULTS

Among 216 patients, 165 (76.4%), 26 (12.0%), and 25 (11.6%) were suspected of having benign tumors, pheochromocytoma, and malignant tumors, respectively. Median tumor size was 25.0 mm (interquartile range 18.0-35.0); median perirenal fat thickness was 9.2 mm (interquartile range 4.9-15.6) on preoperative computed tomography scans. The median operative time was 145.5 min (interquartile range 117.5-184.0) and the median estimated blood loss was 0.0 mL (interquartile range 0.0-27.3). Perirenal fat thickness (p < 0.001), tumor size (p < 0.001), and malignant tumors (p = 0.020) were associated with operative time, and perirenal fat thickness (p = 0.038) and malignant tumors (p = 0.002) were associated with estimated blood loss.

CONCLUSIONS

Perirenal fat thickness, tumor size, and malignant tumors are valid predictors of the surgical outcomes of transperitoneal laparoscopic adrenalectomy. As only perirenal fat thickness is associated with both surgical outcomes except for malignant tumors, it is a powerful predictor. Transperitoneal laparoscopic adrenalectomy for large malignant adrenal tumors with thick perirenal fat should be performed with caution.

Influence of obesity and overweight in surgical outcomes of adrenalectomy for primary adrenal disease: A cohort study of 146 cases

OBJECTIVE

To evaluate the impact of obesity and overweight on surgical outcomes in a large cohort of patients who underwent adrenalectomy due to benign or malignant primary adrenal disease.

METHODS

A retrospective single-center study of patients without history of active extraadrenal malignancy, with adrenal tumors operated on consecutively in our center between January 2010 and December 2022. Obesity was defined as a body mass index (BMI)≥30kg/m2 and overweight as BMI between 25.0 and 30.0kg/m2.

RESULTS

Of 146 patients with adrenal tumors who underwent adrenalectomy, 9.6% (n=14) were obese, 54.8% (n=80) overweight and 35.6% (n=52) normal weight. Obese patients had higher diastolic blood pressure (87.6±12.22 vs. 79.3±10.23mmHg, P=0.010) and a higher prevalence of dyslipidemia (57.1% vs. 25.8%, P=0.014) and bilateral tumors (14.3% vs. 3.1%, P=0.044) than non-obese patients. The rates of intraoperative and of postsurgical complications were similar between obese/overweight patients and patients with normal weight. However, a significantly higher rate of postsurgical complications (27.3% vs. 5.7%, P=0.009) and a longer hospital stay (5.4±1.39 vs. 3.5±1.78 days, P=0.007) were observed in patients with obesity than in non-obese patients. In the multivariant analysis, obesity, age, ASA>2 and tumor size were independent risk factors for postoperative complications, with obesity being the most important factor (OR 23.34 [2.23-244.24]).

CONCLUSION

Obesity and overweight are common conditions in patients who undergo adrenalectomy. Adrenalectomy is considered a safe procedure in patients with overweight, but it is associated with a higher risk of postsurgical complications and longer hospital stay in obese patients.

Laparoscopic versus robotic adrenalectomy in severely obese patients

BACKGROUND

Over the last 20 years, the prevalence of severe obesity (body mass index ≥ 35 kg/m²) has almost doubled. This condition increases the challenge of laparoscopic adrenalectomy (LA) by creating problems with instrument reach, adequate exposure, and visualization. The aim was to compare perioperative outcomes of laparoscopic versus robotic adrenalectomy (RA) in severely obese patients.

METHODS

This was an institutional review board-approved retrospective study. Prospectively collected clinical parameters of patients who underwent LA versus RA between 2000 and 2021 at a single center were compared using Mann-Whitney U, ANOVA, Chi-square, and multivariate regression analysis. Continuous data are expressed as median (interquartile range).

RESULTS

For lateral transabdominal (LT) adrenalectomies, skin-to-skin operative time (OT) [164.5 (71.0) vs 198.8 (117.0) minutes, p = 0.006] and estimated blood loss [26.2 (15.0) vs 72.6 (50.0) ml, p = 0.010] were less in RA versus LA group, respectively. Positive margin rate, hospital stay and 90-day morbidity were similar between the groups (p = NS). For posterior retroperitoneal (PR) approach, operative time and perioperative outcomes were similar between LA and RA groups. Multivariate analysis demonstrated robotic versus laparoscopic technique (p = 0.006) to be an independent predictor of a shorter OT.

CONCLUSION

There was a benefit of robotic over the laparoscopic LT adrenalectomy regarding OT and estimated blood loss. Although limited by the small sample size, there was no difference regarding perioperative outcomes between RA and LA performed through a PR approach.

Minimally invasive techniques in benign and malignant adrenal tumors

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.

Mayo Adhesive Probability Score Is Associated with the Operative Time in Laparoscopic Adrenalectomy

Background: Laparoscopic adrenalectomy (LA) is the standard treatment for adrenal benign tumors, including primary aldosteronism (PA) or Cushing's syndrome (CS). Several obesity-related factors were associated with prolonged total operative time (OT), but perinephric fat characteristics were not assessed. We investigated whether the Mayo adhesive probability (MAP) score, which evaluates perinephric fat characteristics, was associated with OT for LA. Methods: This single-center, retrospective cohort study examined 141 consecutive patients who underwent LA for PA or CS. We reviewed patients' characteristics and OT. MAP scores were recorded using preoperative imaging. The correlation among characteristics data, MAP score, and OT was evaluated. Results: Overall, we assessed 82 women and 59 men. Adrenal tumors were found in 80 PA and 61 CS patients. There were 74 left-sided and 67 right-sided tumors. For all patients, the median age, body mass index, and tumor size were 56 years (interquartile range [IQR] 46-65), 24.1 kg/m² (IQR 21.7-26.8), and 19 mm (IQR 13-26), respectively. A total of 91 patients had MAP scores of 0, and 50 had MAP >0. The median OT was 183.5 minutes (IQR: 156-224 minutes) in the MAP >0 group and 162 minutes (IQR: 135-194 minutes) in the MAP = 0 group. In single variable analysis (unadjusted), MAP scores >0 and left-sided tumors were correlated with longer OT. Multivariable regression analysis revealed that this correlation was only significant for MAP scores >0. Conclusions: MAP score may be useful in preoperative planning for PA or CS patients undergoing LA.

Robot-assisted adrenalectomy: state of the art

Currently, laparoscopic adrenalectomy is worldwide considered the gold standard technique. Both transperitoneal and retroperitoneal approaches have proved their efficacy with excellent outcomes. Since the introduction of da Vinci System (Intuitive Surgical, Sunnyvale, CA), robotic surgery has made many steps forward gaining progressively more diffusion in the field of general and endocrine surgery. The robotic technique offers advantages to overcome some laparoscopic shortcomings (rigid instruments, loss of 3D vision, unstable camera). Indeed, the robotic system is provided of stereoscopic 3D-magnified vision, additional degree of freedom, tremor-filtering technology and a stable camera. Recently, several case series have demonstrated the feasibility and the safety of robot-assisted adrenalectomy in high-volume centers with outcomes comparable to laparoscopic adrenalectomy. Notwithstanding, the technical advantages of the robotic system have not yet demonstrated significant improvements in terms of outcomes to undermine laparoscopic adrenalectomy. Moreover, robotic adrenalectomy harbor inherits drawbacks, such as longer operative time and elevated costs, that limit its use. In particular, the high cost associated with the use of the robotic system is primarily related to the purchase and the maintenance of the unit, the high instruments cost and the longer operative time. Notably, these aspects make robotic adrenalectomy up to 2.3 times more costly than laparoscopic adrenalectomy. This literature review summarizes the current available studies and provides an overview about the robotic scenario including applicability, technical details and surgical outcomes.

Obesity and postoperative outcomes of the patients with laparoscopic adrenalectomy: a systematic review and meta-analysis

Background

Studies have suggested differences in postoperative outcomes between patients with obesity and those without following adrenalectomy, but these remained to be ascertained with synthesis of available evidence. The aim of this systematic review and meta-analysis was to investigate the association between obesity and outcomes of patients after laparoscopic adrenalectomy.

Methods

We searched EMBASE, PubMed, Global Index Medicus, and Web of Science, without language restriction, to identify cohort studies published between January 1, 2000 and November 6, 2019. We considered studies with data comparing outcomes of adults with and without obesity after laparoscopic adrenalectomy. Random-effects meta-analysis was used to pool study-specific estimates. This review was registered with PROSPERO, CRD42018117070.

Results

Five studies with data on a pooled sample of 353 patients with obesity and 828 without were included in the meta-analysis. The risk of bias was moderate to low. We found no association between obesity and the various stages of postoperative complications: Clavien-Dindo grade 1 (OR = 1.57; 95%CI = 0.55–4.48; I² = 44.6%), grade 2 (OR = 1.12; 95%CI = 0.54–2.32; I² = 0.0%), grade 3 (OR = 1.79; 95%CI = 0.58–5.47; I² = 0.0%;), grade 4 (OR = 0.43; 95%CI = 0.05–3.71; I² = 0.0%), and grade 5 (death) (OR = 0.43; 95% CI = 0.02–14.31). Furthermore, no association was found between obesity and readmission rates (OR = 0.7; 95% CI = 0.13–3.62) and conversion of laparoscopic to open surgery (OR = 0.62; 95% CI = 0.16–2.34; I² = 19.5%).

Conclusions

This study suggests that obesity is not associated with complications following laparoscopic adrenalectomy. This meta-analysis might have been underpowered to detect a true association between obesity and patient outcome after laparoscopic adrenalectomy due to the small number of included studies. Larger studies are needed to clarify the role of obesity in patients undergoing laparoscopic adrenalectomy.

A clinicopathological analysis of adrenal tumors in patients with history of extra-adrenal cancers

Background

Adrenal tumors in patients with previous/synchronous extra-adrenal malignancy are diverse and are a dilemma in clinical practice. This study investigated the differentiation of adrenal malignant and benign tumors in these patients.

Methods

Data from patients with a pathological diagnosis of adrenal tumors were retrospectively retrieved from April 1991 to November 2015. Patients without extra-adrenal malignancy were excluded. Clinical and imaging characteristics, including sex, age, tumor size, tumor location, isolated lesion, time interval between the diagnosis of the two tumors and retrieved imaging diagnosis, were collected and analyzed. The selected patients were divided into 2 groups: those with primary or secondary malignancies (PSM) and those with primary benign tumors (PB). Chi-squared tests were used to evaluate differences between the two groups. Logistic regression was performed to explore potential risk factors related to the differentiation of PSM and PB, and a receiver operating characteristic (ROC) curve was used to evaluate their diagnostic values.

Results

Ninety-one patients were selected; 54 were male, and the median age was 56 years old. Between the groups of PSM and PB, sex (p = 0.004), age (p = 0.029), tumor size (p < 0.001), isolated lesion (p < 0.001) and imaging diagnosis (p < 0.001) were significantly different, while tumor size (p = 0.001), sex (p = 0.047) and imaging diagnosis (p = 0.002) were independent predictors of PSM. With ROC curve analysis, risk factors ≥2 was the optimal cutoff to differentiate these adrenal tumors, and their sensitivity and specificity were 73 and 77%, respectively. With a median follow-up of 32 months, only 4 of 32 patients with PB died from cancer, and 24 of 47 patients with PSM died from cancer, although aggressive treatment was performed.

Conclusions

Tumor size, sex and imaging diagnosis were independent predictors of adrenal primary or secondary malignancies. These predictors might be helpful for differentiation of adrenal tumors in patients with previous/synchronous extra-adrenal cancers.

Precision Surgery for Pheochromocytomas and Paragangliomas

Since Felix Fränkel's account of pheochromocytoma in 1886, great discoveries and vast advancements in the diagnosis, genetics, anatomical and functional imaging techniques, and surgical management of pheochromcytoma and paraganglioma (P-PGL) have been made. The improved insight in the pathophysiology of P-PGL and more accurate detection methods enable physicians to tailor the treatment plan to an individual based on the genetic profile and tumor behavior. This review will cover briefly the clinical features, diagnosis, genetic mutations, and imaging modalities that are used to guide current surgical management of these rare and interesting endocrinopathies.

Spontaneous adrenal hemorrhage with dehydroepiandrosterone-sulfate elevation in a patient with suspected adrenal cortical carcinoma

Introduction

Spontaneous adrenal hemorrhage is a relatively rare disease that is sometimes difficult to differentiate from adrenal cortical carcinoma. We herein report a case of spontaneous adrenal hemorrhage with dehydroepiandrosterone‐sulfate elevation.

Case presentation

The patient was a 78‐year‐old man with an adrenal tumor that had increased in size to 42 mm. With the exception of an elevated dehydroepiandrosterone‐sulfate level (2281 ng/mL), the results of a hormone analysis were almost normal. Laparoscopic adrenal tumor resection was performed. The pathological diagnosis was adrenal hematoma.

Conclusion

We reported a case of spontaneous adrenal hemorrhage in a patient with dehydroepiandrosterone‐sulfate elevation.

Minimally invasive approach to the adrenal gland in obese patients with Cushing's syndrome

Introduction: The combination of Cushing's syndrome and obesity, one of the most common manifestations of the syndrome itself, may be associated with the worsening of post-operative outcomes in case of laparoscopic adrenalectomy. This study focused on the laparoscopic treatment of Cushing's syndrome with the purpose to identify any relevant difference between morbidly obese, mildly obese and non-obese patients.Material and methods: Patients were retrospectively divided into three groups according to their Body Mass Index (BMI). Demographic characteristics, operative and post-operative data were collected. Data about different hemostatic devices were also collected and compared. Differences were analyzed with the Fisher's exact test for categorical variables, and the Mann-Whitney test for continuous variables.Results: No differences were found in operative time (101.5 ± 50.9 min; p = .919), conversion rate (2.6%; p = .655) or length of stay (4.3 ± 2.9 days; p = .886). Complication rate was 3% (p = .32), without any mortality. 95% of patients showed a complete resolution of hypercotisolyism-related symptoms, and a mean BMI reduction of 5 ± 3.2 kg/m² (follow up = 6.3 ± 4.2 years). Conclusions: Laparoscopic adrenalectomy is safe and feasible in obese patients affected with Cushing's disease and it can lead to the resolution of the related symptoms.

Operation duration and adrenal gland size, but not BMI, are correlated with complication rate for posterior retroperitoneoscopic adrenalectomy for benign diseases

BACKGROUND

We sought to determine whether obesity is correlated with complications after posterior retroperitoneoscopic adrenalectomy for benign diseases and to develop surrogate markers of abdominal fat in preoperative computed tomography.

METHODS

We conducted a retrospective chart review of all patients who had undergone posterior retroperitoneoscopic adrenalectomy and preoperative computed tomography between January 1, 2008 and December 31, 2015. The cross-sectional components of fat assessed by computed tomography included total fat area, subcutaneous fat area, retroperitoneal fat area, and peritoneal fat area. The patients were grouped into 2 categories according to the absence or presence of a postoperative complication (the no-complications group and the complications group, respectively).

RESULTS

Of 116 study patients, 20 patients (17%) had a postoperative complication. Operations of greater duration and smaller adrenal gland size were significantly correlated with complications both in univariate and multivariate analyses. Body mass index, total fat area, subcutaneous fat area, retroperitoneal fat area, peritoneal fat area, and distance of skin to muscle (in axial and sagittal images) correlated with complications in univariate analysis but not in multivariate analysis. In the no-complications group, the removed adrenal gland was larger than that removed in the complications group (6 vs 4 cm, respectively, P = .001), whereas the complications group had a greater operative duration (139 vs 104 min, respectively, P = .001) and a greater duration of hospital stay (3 days vs 1 day, respectively, P = .001).

CONCLUSION

In this study, operations of greater duration and smaller adrenal gland size were better predictors of complications after posterior retroperitoneoscopic adrenalectomy for benign disease than measures of obesity, including body mass index.

Obesity does not affect peri- and postoperative outcomes of transabdominal laparoscopic adrenalectomy

Laparoscopic adrenalectomy is the gold standard procedure for most adrenal tumors. Obesity is considered as a risk factor for surgical complications. This study aimed to evaluate whether obesity affects peri- and postoperative outcomes of transabdominal laparoscopic adrenalectomy using body mass index (BMI). This retrospective study included 98 patients who underwent transabdominal laparoscopic adrenalectomy between January 2011 and December 2016. We divided the patients into 2 groups: non-obese group (BMI < 25 kg/m2) and obese group (BMI ≥ 25 kg/m2). We assessed perioperative outcomes and postoperative complications between the groups. A total of 98 patients were analyzed (70 without obesity and 28 with obesity). There were no significant differences between the non-obese and obese groups regarding operative time (111 vs 107 min; p = 0.795), blood loss (3.5 vs 3.5 ml; p = 0.740), rate of placement of additional trocars (14.3% vs 17.9%; p = 0.657), rate of open conversion (2.6% vs 3.6%; p = 0.853), and postoperative length of hospital stay (6 vs 5 days; p = 0.237). Furthermore, obesity was not a significant risk factor for postoperative complications (postoperative bleeding, wound infection, and pneumonia). There are no significant differences in peri- and postoperative outcomes of transabdominal laparoscopic adrenalectomy in patients with obesity compared with those without obesity. Transabdominal laparoscopic adrenalectomy is feasible and safe for patients with obesity.

Adrenal Hemangioma: A Case of Retroperitoneal Tumor

Introduction

Adrenal hemangioma is a rare disease, with only some 60 cases reported previously. Due to the difficulty of the preoperative diagnosis of adrenal hemangioma, almost all of the cases were diagnosed by a histopathological analysis of surgical specimens.

Case Presentation

A 52-year-old man was referred to our department for further examination of his left retroperitoneal tumor. He had received hemodialysis due to chronic renal failure resulting from membranous nephropathy. Computed tomography revealed a mass around his left hilum. Magnetic resonance imaging (MRI) and positron-emission tomography (PET)-CT were unable to confirm or deny malignancy, and tumor markers, including CEA and CA19-9, showed slight elevation. His tumor grew from 38 mm to 54 mm in diameter in 7 months of follow-up. We therefore planned retroperitoneal tumor resection with left nephrectomy. Histopathologically, hyperplastic small vessels with hemorrhaging and denaturation were seen. The endothelial cells showed no variants or division of the nucleus. Based on this diagnosis, no further therapy was performed. He has had no recurrence in the eight months since the surgery.

Conclusion

We herein report a rare case of adrenal hemangioma.

Risk factors for prolonged hospitalization in patients undergoing laparoscopic adrenalectomy

Introduction

Even though laparoscopic adrenalectomy is currently a standard, there are important variations between different centres in short-term treatment results such as length of hospital stay (LOS) or morbidity.

Aim

To determine the factors affecting LOS in patients after laparoscopic transperitoneal lateral adrenalectomy (LTA).

Material and methods

The study enrolled 453 patients (173 men and 280 women, mean age 57 years) who underwent LTA between 2009 and 2017. Discharge from hospital after more than median hospital stay was considered as prolonged LOS. We evaluated factors that potentially may influence LOS (primary length of stay after surgery, excluding readmissions). Logistic regression models were used in univariate and corrected multivariate analyses, in order to identify the factors related to prolonged LOS.

Results

The median LOS after LTA in the studied group was 2 days. One hundred seventy-five (38.5%) patients required prolonged hospitalization. Univariate logistic regression showed that the following factors were related to prolonged LOS: presence of any comorbidity, cardiovascular disease, intraoperative complications, postoperative complications, day of the week of operation (surgery on Thursday or Friday), intraoperative blood loss, need for transfusion, hormonal activity, postoperative drainage, ASA (III–IV) and histological type – pheochromocytoma. Multivariate logistic regression showed that only complications (OR = 3.86; 95% CI: 1.84–8.04), day of the week of operation (Thursday or Friday) (OR = 4.85; 95% CI: 3.04–7.73), need for drainage (OR = 3.63; 95% CI: 1.55–8.52), and histological type – pheochromocytoma (OR = 2.48; 95% CI: 1.35–4.54) prolonged LOS.

Conclusions

Prolonged length of hospital stay following laparoscopic transperitoneal lateral adrenalectomy is strongly associated with the presence of postoperative complications, day of the week of operation (Thursday or Friday), need for drainage, and histological type – pheochromocytoma.