Efficacy and safety of laparoscopic surgery for pheochromocytoma

Comparison of transperitoneal laparoscopic versus open adrenalectomy for large pheochromocytoma: A retrospective propensity score-matched cohort study

BACKGROUND

Surgical resection is the main treatment strategy for pheochromocytoma. Whether laparoscopic techniques are feasible for large pheochromocytoma treatments is controversial. The aim of this study was to evaluate the feasibility and safety of transperitoneal laparoscopic adrenalectomy (LA) compared with open adrenalectomy (OA).

METHODS

We retrospectively studied 182 patients with radiographic tumor sizes ≥ 6 cm who underwent adrenalectomy at our center between 1 January 2007 and 31 December 2017. After propensity score-matching to balance baseline variables, 82 patients treated with LA and 100 patients treated with OA were grouped into 64 pairs. Patient demographics, and extensive peri-operative and oncologic data were recorded and compared.

RESULTS

In the matched group, the incidence of intra-operative hemodynamic instability, transfusion rate, prolonged hypotension, and cardiovascular morbidity in the LA group were lower than the OA group (25.0% vs. 48.4%, 29.7% vs. 46.9%, 4.7% vs. 23.4%, and 14.1% vs. 37.5%, respectively). The estimated blood loss was less (100 ml vs. 300 ml) and bowel recovery was quicker (1.9 d vs. 2.3 d) in the LA group. The proportion of patients in whom blood pressure returned to normal (P = 0.184), had recurrences (P = 0.197), and survived (P = 0.763) were equivalent. The surgical approach (OA vs. LA) was an independent risk factor for IHD, prolonged hypotension, cardiovascular morbidity, and longer bowel recovery.

CONCLUSIONS

This propensity score-matched cohort study showed that LA was feasible, safe, and superior to OA for patients with large pheochromocytoma, meanwhile LA had comparable oncological outcomes compared with OA after a lengthy follow-up.

Laparoscopic resection of adrenal and extra-adrenal pheochromocytoma

BACKGROUND AND PURPOSE

Laparoscopic resection of extra-adrenal pheochromocytoma (EAPs) necessitates meticulous surgical procedures because of changes in anatomic disposition and/or proximity to major blood vessels. Complete resection can be traumatic and may cause an increase in catecholamine levels. We present our experiences with laparoscopic resection of EAP (LEAP) and compare the intraoperative hemodynamics with those during laparoscopic resection of adrenal pheochromocytoma (LAP).

PATIENTS AND METHODS

We retrospectively reviewed the medical records of five patients who underwent LEAP (retrocaval EAP, n=2; interaortocaval EAP, n=1; periadrenal EAP, n=2) and five who underwent LAP between October 2001 and October 2011. We also evaluated fluctuations in blood pressure (BP) reported during both surgeries.

RESULTS

The tumors were successfully resected under laparoscopic guidance in both groups, and conversion to open surgery or blood transfusion was not needed. Intraoperative hypertension (BP>200 mm Hg) was observed in three LEAP and four LAP patients, whereas intraoperative hypotension (BP<80 mm Hg) was observed in five LEAP and three LAP patients. No significant differences were observed between groups, however.

CONCLUSIONS

Laparoscopy is the method of choice for surgeons experienced in EAP resection because it is feasible and reproducible with appropriate preoperative planning, similar to LAP.

Long-term results of laparoscopic adrenalectomy for primary aldosteronism

BACKGROUND

The management of primary aldosteronism is currently achieved by both medical and surgical treatment. Laparoscopy has in recent years unquestionably become the gold standard in adrenal surgery for benign lesions. This study aims to evaluate our clinical results among patients who underwent laparoscopic adrenalectomy (LA) for primary aldosteronism.

METHODS

From January 1994 to January 2006, amid LA series, 59 primary aldosteronism patients were treated in our institution. Patients were 33 males and 26 females with mean age 49.3 yr (19-78). The mean body mass index was 25.9 kg/m2 (20.5-33.3). The mean size of lesion was 2.9 cm (1-5.5). Clinical symptoms were as follows: hypertension and symptomatic/asymptomatic hypokalemia (54), hypokalemia (5).

RESULTS

Thirty-five left and 24 right LA were performed. On the left side, 22 procedures were carried out by anterior approach, 9 by anterior submesocolic route, and 4 by means of flank approach. All right procedures were completed by the anterior supine approach. The mean operative time was 103.5 min for left and 92.8 min for right adrenalectomy. There was one major complication, a colonic post-operative fistula, regarding a left adrenalectomy case. The mean post-operative hospital stay was 3 days (1-9). The cure rate of hypertension and hypokalemia was similar to the current literature results.

CONCLUSIONS

LA is a safe and effective option in the treatment of primary aldosteronism. Appropriate selection of patients, larger adrenal masses and duration of symptoms are determining factors in the success rate of hypertension management.

Laparoscopic adrenalectomy for pheochromocytoma: take the vein last?

BACKGROUND

Traditionally, the adrenal vein has been ligated early during excision of a pheochromocytoma. Patient anatomy or size of the lesion can sometimes make early vein dissection difficult or unsafe. This study aimed to demonstrate the safety and efficacy of delayed adrenal vein ligation during laparoscopic adrenalectomy for pheochromocytoma.

METHODS

A retrospective review of all laparoscopic adrenalectomies for pheochromocytoma from 1997 to 2007 was conducted. All the patients had confirmed histologic evidence of pheochromocytoma. The procedures were performed using the same technique, which involved division of the adrenal vein late in the procedure after the gland had been dissected free. Patient records were reviewed for evidence of intraoperative hemodynamic variations, blood loss, length of stay, and postoperative morbidity.

RESULTS

The review examined 27 adrenalectomies performed for 25 patients. Intraoperative hypertension exceeding 170 mmHg was observed in seven patients (26.9%). The overall morbidity was 7.7%, and the mean length of hospital stay was 1.7 days. No deaths occurred.

CONCLUSIONS

Delayed adrenal vein ligation during laparoscopic adrenalectomy for pheochromocytoma is safe and effective. The intraoperative hemodynamic parameters are comparable with those reported in the literature for the "vein first" technique. Dividing the vein late is an alternative approach to laparoscopic excision of adrenal pheochromocytoma and should be considered in appropriate situations.

Laparoscopic adrenalectomy for large adrenal masses

Open adrenalectomy has been the gold-standard therapy for adrenal neoplasms. Minimally invasive treatments, however, have assumed a more central role in the management of these lesions. The traditional benefits of laparoscopy, including reduced blood loss, shorter hospital duration, and improved convalescence, extend to adrenal disease without compromising the oncologic efficacy of the surgery. Contemporary series suggest that minimally invasive surgery is also a reasonable therapeutic modality for larger adrenal masses. Laparoscopic adrenalectomy for these large masses is a technically demanding procedure that should be undertaken by experienced laparoscopic surgeons familiar with retroperitoneal anatomy and adept with vascular techniques in the event of an open conversion. Oncologic outcomes collectively suggest that in the setting of adequate surgical resection, recurrence patterns relate more to disease-process biology than surgical approach. Neither size criteria, suspicion of malignancy, nor locally invasive disease should be considered an absolute contraindication to laparoscopic adrenalectomy.

Flank approach versus anterior sub-mesocolic access in left laparoscopic adrenalectomy: a prospective randomized study

BACKGROUND

Laparoscopy is commonly recognized as the gold standard in adrenal surgery. The most used surgical access is at present the so-called flank approach. The aim of this study was to compare the flank approach and the anterior sub-mesocolic access carrying out left laparoscopic adrenalectomy (LA).

METHODS

From January 2003 to January 2006 50 eligible left LAs were randomized to the flank (n = 25, group A) or sub-mesocolic transperitoneal approach (n = 25, group B). The two groups were similar concerning patient and lesion features. Comparing the two approaches, the main parameters analyzed, adjusted for tumor size and histology, were operating time (OpT), complication rate, and hospital stay.

RESULTS

There were no converted procedures. Mean overall OpT was 76.4 min (54-96 min) versus 65.6 min (45-95 min) in group A and B, respectively (p = 0.001), while the OpT required to tie the adrenal vein was 42.8 min (26-55 min) and 24.5 min (16-41 min) (p = 0.000). Oral feeding resumed within 12-24 h in both groups. Mean hospital stay was 3 and 2.4 days in groups A and B, respectively (p = 0.04). Mean tumor size was similar in group A and B: 3.6 cm (1.5-6.5 cm) and 3.8 cm (2-6 cm), respectively. Definitive histology in groups A and B were: Cushing adenoma (6 and 4), Conn adenoma (5 and 6), pheochromocytoma (4 and 9), and incidentaloma (8 and 5, respectively). A myelolipoma and an adrenogenital adenoma were observed in group A and one carcinoma was observed in group B.

CONCLUSIONS

Sub-mesocolic approach provides a statistically significant shorter OpT and hospital stay. Identification and early closure of the adrenal vein by means of a really minimal dissection and no-touch gland technique resulted in the main benefits of this approach.

Retrospective comparison of retroperitoneoscopic versus open adrenalectomy for pheochromocytoma

PURPOSE

We compared the clinical outcomes of retroperitoneoscopic and open adrenalectomy for pheochromocytoma.

MATERIALS AND METHODS

Clinical data on 56 patients who underwent retroperitoneoscopic lateral adrenalectomy were retrospectively compared with those on 50 who underwent open adrenalectomy for pheochromocytoma, including patient demographic data, perioperative indexes and clinical outcomes.

RESULTS

Demographic data on patients were similar in the 2 groups. In the retroperitoneoscopic group such perioperative indexes were significantly different from those of the open group (each p <0.05), including operative time (mean +/- SD 52 +/- 22 vs 120 +/- 42 minutes), estimated blood loss (74 +/- 34 vs 187 +/- 64 ml), resumption of oral intake (1 vs 2 days), postoperative hospital stay (5.2 +/- 1.7 vs 8.3 +/- 1.8 days), incidence of intraoperative hypertension (17.0% or 9 of 53 patients vs 36.0% or 18 of 50) and number of patients requiring blood transfusion(1.8% or 1 of 53 vs 16.0% or 8 of 50). The incidence of systemic inflammatory response syndrome was much less in the retroperitoneoscopic group (20.8% or 11 of 53 patients vs 42.0% or 21 of 50, p <0.05). However, the duration of systemic inflammatory response syndrome and postoperative complications were similar in the 2 groups (p >0.05). Blood pressure returned to normal 3 months after the operation in 81% of the patients in the retroperitoneoscopic group and in 84% in the open group. During the followup of 5 to 36 months no tumor recurrence and/or metastasis developed.

CONCLUSIONS

Compared with open surgery retroperitoneoscopic lateral adrenalectomy for pheochromocytoma is a safe, minimally invasive and effective procedure.

Adrenalectomy in Hong Kong: a critical review of adoption of laparoscopic approach

BACKGROUND

A population-based study on adrenal surgery for treatment of adrenal diseases is still lacking. The aim of the present study is to evaluate the practice and the adoption of laparoscopic adrenalectomy (LA) in a stable population, as well as the potential impact of case volume on outcomes.

METHODS

Patients undergoing elective adrenalectomy (n = 486) from 15 Hong Kong public hospitals over a 6-year period were reviewed. Patients undergoing LA (n = 353) were compared to those undergoing open adrenalectomy (n = 133).

RESULTS

The overall number of adrenalectomies and the number and proportion of laparoscopic approach increased progressively during this period. The median operating time was similar but the median blood loss (50 mL vs 300 mL, P < .01) was less and the mean hospital stay (4.4 days vs 9.4 days) was shorter for LA. Smaller lesions tended to be selected for LA. There was no correlation between postoperative outcome with respect to length of stay and case volume for LA.

CONCLUSIONS

The adoption of LA in Hong Kong hospitals was propagating progressively. Patients selected for LA had improved outcome although there seemed to be no significant correlation between postoperative outcome and case volume.

Retroperitoneoscopic Adrenalectomy Without Previous Control of Adrenal Vein Is Feasible and Safe for Pheochromocytoma

OBJECTIVES

To evaluate the effectiveness and safety of retroperitoneal laparoscopic adrenalectomy for pheochromocytoma and report our experience in adrenalectomy without previous control of the adrenal vein.

METHODS

From January 2000 to December 2005, 56 patients underwent 58 retroperitoneal laparoscopic adrenalectomy procedures for the treatment of pheochromocytoma. Adequate preoperative antihypertensive preparation was performed. Intraoperative hemodynamic changes were documented in detail. During surgery, the adrenal vein was identified and ligated after dissection and mobilization of the adrenal gland.

RESULTS

One patient required conversion to open surgery. The mean operative time and estimated blood loss was 50.4 +/- 19.8 minutes (range 25 to 150) and 76.4 +/- 23.5 mL (range 20 to 300), respectively. A systolic blood pressure greater than 200 mm Hg or less than 80 mm Hg was observed in 6 and 3 patients, respectively. Moreover, an upward fluctuation of systolic blood pressure (20 mm Hg or greater) was recorded during laparoscopic manipulation in 21 patients (37.5%), and in 8 of them, it was 50 mm Hg or greater. The mean diameter of the excised masses was 4.6 +/- 1.7 cm (range 1.5 to 10.0). The mean hospital stay was 5.2 +/- 1.3 days (range 3 to 9). No patients had a major complication and none died. During the follow-up period of 5 months to 3 years, 36 patients recovered normal blood pressure without antihypertensive drugs. No tumor recurrences developed.

CONCLUSIONS

Retroperitoneal laparoscopic adrenalectomy without previous control of the adrenal vein is effective and safe for ablation of pheochromocytoma. For experienced surgeons, the tumors larger than 6 cm in diameter can also be removed using the retroperitoneal endoscopic approach.

Laparoscopic adrenalectomy for adrenal carcinoma and metastases

PURPOSE OF REVIEW

This review article discusses topics concerned with laparoscopic adrenalectomy for adrenal pathologies.

RECENT FINDINGS

Over the past decade, laparoscopic adrenalectomy has become the operation of choice for the resection of adrenal tumors, and provides dramatically reduced morbidity associated with the operation. Although current laparoscopic adrenalectomy for metastatic or primary adrenal malignancy is a feasible procedure, great care is required. Laparoscopic adrenalectomy for these adrenal pathologies should be converted to open adrenalectomy or hand-assisted laparoscopic adrenalectomy for difficult dissection, invasion, adhesions or surgeon inexperience. In general, laparoscopic adrenalectomy can be performed with acceptable outcomes in carefully selected patients with small, organ-confined, solitary adrenal metastasis or primary adrenal carcinoma.

SUMMARY

As surgical technique and complete resection are crucial to the success of the procedure, appropriate and careful judgment on the part of the surgeon is the most important factor in the care of a patient with such adrenal malignancies.

Prospective comparison of early and late experience with laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy has gained acceptance in the treatment of adrenal tumors. We examine our initial 73 patients and highlight the change in patient selection and outcome that experience brings.

METHODS

A prospective study from 2000 to 2005 enrolled 73 consecutive laparoscopic adrenalectomy patients at the University of British Columbia and Vancouver General Hospitals.

RESULTS

Forty patients in an initial cohort and 33 in the follow-up group underwent adrenalectomy. The follow-up group had a greater proportion of pheochromocytomas (33.3% versus 7.5%), larger tumors (4.25 versus 1.97 cm), and higher American Society of Anesthesiologist (ASA) scores (2.82 versus 2.38) and lengths of stay (2.35 versus 1.55 days). Minor complication rates (12% versus 5%) were also higher. Operative times and blood loss were similar. Pheochromocytoma was associated with higher ASA scores and longer lengths of stay. Operative times and blood loss were not affected by diagnosis.

CONCLUSIONS

Increasing experience in laparoscopic adrenalectomy allows broadening of indications to include a sicker patient population.