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Ahuja V, Gibson C, Machado N, King JT. Impact of frailty on complications and length of stay after minimally invasive adrenalectomy surgery. Surgery 2024; 175:336-341. [PMID: 38049363 DOI: 10.1016/j.surg.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 10/05/2023] [Accepted: 10/24/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Adrenal disease requiring surgery incidence increases with age, and minimally invasive adrenalectomy procedures have improved the safety of adrenal surgery. This study evaluates the perioperative outcomes of elective adrenalectomies when performed in older patients and how frailty affects such outcomes. METHODS Patients undergoing elective minimally invasive adrenalectomy were identified using the American College of Surgeon's National Surgical Quality Improvement Program Participant Use Targeted File years 2005 to 2020. The surgical indication was categorized as a benign disease, an endocrine disorder, or a malignant disease. Frailty was defined using the 5-item modified frailty index. Multivariable regressions were used to model the relationship of age and frailty with surgical outcomes. RESULTS In 8,693 minimally invasive adrenalectomy patients, 5,281 (61%) were female, 5,026 (58%) were White, and 1,924 (22%) were aged 65 years or older. Surgical indications were benign disease 5,487 (63%), endocrinopathy 2,850 (33%), and malignancy 356 (4%). Patients aged <65 years (compared to those aged ≥65) were more likely to have a 5-item modified frailty index = 0 (26% vs 14%, respectively) and less likely to have a 5-item modified frailty index = ≥3 (2% vs 4%, respectively; P < .001). OUTCOMES 30-day mortality 20 (0.2%), complications 459 (5%), return to operating room 73 (0.8%), and median length of stay 2 days. Thirty-day mortality was associated with a 5-item modified frailty index ≥3 (P = .009) and endocrine disease (P = .005) but not with age. Complications were associated with a 5-item modified frailty index ≥2 (≤P < .001) and malignant disease (P = .002), but not with age. CONCLUSION Minimally invasive adrenalectomy has low 30-day mortality and complication rates that increase with frailty and not age. Frailty is a better predictor than the age of most adverse outcomes after elective minimally invasive adrenalectomy.
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Affiliation(s)
- Vanita Ahuja
- Department of Surgery, Yale University School of Medicine, New Haven, CT; Surgical Service, VA Connecticut Healthcare System, West Haven, CT.
| | - Courtney Gibson
- Department of Surgery, Yale University School of Medicine, New Haven, CT; Surgical Service, VA Connecticut Healthcare System, West Haven, CT
| | - Nikita Machado
- Department of Surgery, Yale University School of Medicine, New Haven, CT; Surgical Service, VA Connecticut Healthcare System, West Haven, CT
| | - Joseph T King
- Surgical Service, VA Connecticut Healthcare System, West Haven, CT; Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
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Fouche D, Chenais G, Haissaguerre M, Bouriez D, Gronnier C, Collet D, Tabarin A, Najah H. Risk factors for intraoperative complications, postoperative complications, and prolonged length of stay after laparoscopic adrenalectomy by transperitoneal lateral approach: a retrospective cohort study of 547 procedures. Surg Endosc 2023; 37:7573-7581. [PMID: 37442834 DOI: 10.1007/s00464-023-10148-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/19/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Laparoscopic adrenalectomy (LA) is the gold standard for the resection of most adrenal lesions. A precise delineation of factors influencing its outcomes is lacking. The aim of this study was to assess factors associated with intraoperative complications, postoperative complications, and prolonged length of stay (LOS) after LA. METHODS Patients who underwent LA from 1999 to 2021 in a single-academic-institution were included. Patient and disease-specific data, intraoperative complications, postoperative complications according to Dindo-Clavien (DC) scale, and LOS were recorded. Predictive factors of complications and prolonged LOS were determined by logistic regression. RESULTS We identified 530 patients who underwent 547 LA. Intraoperative complications occurred in 33 patients (6.0%). Postoperative complications ≥ DC grade 2 occurred in 73 patients (13.35%); severe postoperative complications ≥ DC grade 3 in 14 patients (2.56%). Postoperative complications were positively associated with age ≥ 72 (OR 1.14 [95% CI 1.02-1.29]), intraoperative complications (OR 1.36 [95% CI 1.14-1.63]), and negatively associated with non functional adenomas (OR 0.88 [95% CI 0.7-0.99]), and right adrenalectomy (OR 0.91 [95% CI 0.86-0.97]). Severe postoperative complications were positively associated with chronic obstructive pulmonary disease (COPD, OR 1.08 [95% CI 1.00-1.17]), and negatively associated with right adrenalectomy (OR 0.97 [95% CI 0.92-0.99]). Prolonged LOS was associated with age ≥ 72 (OR 1.21 [95% CI 1.05-1.41]), and COPD (OR 1.20 [95% CI 1.01-1.44]). CONCLUSIONS LA remains safe when performed by surgeons with expertise. Right adrenalectomy resulted in less postoperative overall and severe complications. The risk-benefit equation should be carefully assessed before left LA in older patients with COPD.
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Affiliation(s)
- Donatien Fouche
- Digestive and Endocrine Surgery Department, Magellan Center, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Gabrielle Chenais
- University of Bordeaux, INSERM, BPH U1219, F-33000, Bordeaux, France
| | - Magalie Haissaguerre
- Endocrinology Department, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Damien Bouriez
- Digestive and Endocrine Surgery Department, Magellan Center, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Caroline Gronnier
- Digestive and Endocrine Surgery Department, Magellan Center, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Denis Collet
- Digestive and Endocrine Surgery Department, Magellan Center, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Antoine Tabarin
- Endocrinology Department, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Haythem Najah
- Digestive and Endocrine Surgery Department, Magellan Center, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France.
- Department of Endocrine Surgery, Hôpital Haut Lévêque, University Hospital of Bordeaux, Avenue Magellan, 33604, Pessac, France.
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Green RL, Gao TP, Hamilton AE, Kuo LE. Older age impacts outcomes after adrenalectomy. Surgery 2023; 174:819-827. [PMID: 37460336 DOI: 10.1016/j.surg.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/21/2023] [Accepted: 06/18/2023] [Indexed: 09/16/2023]
Abstract
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.
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Affiliation(s)
- Rebecca L Green
- Department of Surgery, Temple University Hospital, Philadelphia, PA.
| | - Terry P Gao
- Department of Surgery, Temple University Hospital, Philadelphia, PA. https://twitter.com/terrypgao
| | - Audrey E Hamilton
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA. https://twitter.com/AudreyHamilton
| | - Lindsay E Kuo
- Department of Surgery, Temple University Hospital, Philadelphia, PA. https://twitter.com/lindsaykuo
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Factors associated with postoperative complications and costs for adrenalectomy in benign adrenal disorders. Surgery 2021; 171:1519-1525. [PMID: 34857386 DOI: 10.1016/j.surg.2021.10.065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND The incidence of adrenal incidentaloma has been increasing, and indications of and approaches to adrenalectomy are diverse. Drivers of complications and costs are not well identified. METHODS The 2016 National Inpatient Sample data were used to identify patients who underwent adrenalectomy for benign adrenal disorders, such as Cushing syndrome, primary hyperaldosteronism, pheochromocytoma, and other benign neoplasms defined using the 10th Revision of the International Classification of Diseases. The primary outcome was determining the factors associated with clinical outcomes, perioperative complications, and hospitalization costs. RESULTS Using weighted estimates of the national sample data, 5,140 patients were identified. The mean age was 55 years. The majority of adrenalectomies were performed laparoscopically (48.5%) followed by a robotic approach (32.7%). The postoperative complication rate was 7.6%. In adjusted multivariable analyses, independent risk factors for perioperative complications included Hispanic race (odds ratio, 2.5; P = .01), and perioperative comorbid heart failure (odds ratio, 6.3; P < .001) and respiratory failure (odds ratio, 9.9; P < .001). The mean cost was $18,122. Independent risk factors associated with decrease of cost were female sex and primary hyperaldosteronism; factors associated with increased cost were pheochromocytoma, intraoperative complications, perioperative underlying comorbid respiratory failure and heart failure, and postoperative complications (P < .001). CONCLUSION Among patients undergoing adrenalectomy for benign adrenal disorders, underlying comorbidities, including heart and respiratory failure, should be considered when recommending adrenalectomy, as these may increase the postoperative complication rates and hospitalization costs.
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Ravivarapu KT, Garden EB, Al-Alao O, Small AC, Palese MA. Adrenalectomy outcomes predicted by a 5-item frailty index (5-iFI) in the ACS-NSQIP database. Am J Surg 2021; 223:1120-1125. [PMID: 34857360 DOI: 10.1016/j.amjsurg.2021.11.020] [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: 09/12/2021] [Revised: 10/22/2021] [Accepted: 11/15/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Frailty has been shown to be a predictor of adverse postoperative outcomes. This study aims to evaluate a 5-item frailty index (5-iFI) as a predictor of complications as well as healthcare resource utilization (HCRU) following adrenalectomy. METHODS All adrenalectomy cases recorded in the ACS-NSQIP database from 2015 to 2018 were analyzed. Primary outcomes of interest were Clavien-Dindo [CD] I/II or CD IV complications and HCRU. HCRU outcomes were prolonged length of stay (PLOS), discharge to continued care (DCC), and unplanned 30-day readmission (UR). RESULTS 4358 patients were included. Higher 5-iFI scores were associated with higher rates of CDI/II, CDIV, and increased HCRU (p < 0.05). On multivariate analysis, 5-iFI scores were found to be independent predictors of adverse clinical and HCRU outcomes. CONCLUSIONS Frailty tools like the 5i-FI can be useful in preoperative risk-benefit analysis, patient counseling, and planning prehabilitation interventions.
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Affiliation(s)
- Krishna T Ravivarapu
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Evan B Garden
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Osama Al-Alao
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexander C Small
- Department of Urology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael A Palese
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Rodríguez-Hermosa JI, Delisau O, Planellas-Giné P, Cornejo L, Ranea A, Maldonado E, Fernández-Real JM, Codina-Cazador A. Factors associated with prolonged hospital stay after laparoscopic adrenalectomy. Updates Surg 2020; 73:693-702. [PMID: 32940830 DOI: 10.1007/s13304-020-00880-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Abstract
Laparoscopy is the standard technique for resecting adrenal tumors, but short-term outcomes such as length of stay (LOS) vary widely between centers. We aimed to identify factors associated with LOS after lateral transperitoneal laparoscopic adrenalectomy (LTLA). We analyzed consecutive patients undergoing unilateral LTLA between April 2003 and April 2020. Prolonged LOS was defined as a stay longer than the 75th percentile of the overall cohort. To identify potential factors associated with prolonged LOS, we compared collected data from patients with LOS ≤ 2 days versus LOS > 2 days and elaborated multivariate logistic regression models. We included 150 patients (73 men and 77 women, median age 54 years), with benign (n = 128) and malignant tumors (n = 22). The median LOS after LTLA was 2 days; 64 (42.7%) patients had prolonged hospitalization. Variables significantly associated with prolonged LOS in the univariate analysis included ASA III + IV (p = 0.016), pheochromocytoma (p < 0.001), learning curve (p = 0.032), surgery on Thursday or Friday (p < 0.001), 2D laparoscopy (p = 0.003), operative time (p < 0.001), estimated blood loss (p < 0.001), drainage (p < 0.001), specimen size (p = 0.011), conversions (p = 0.002), complications (p = 0.019), and hospital stay (p < 0.001). After adjustment for patient, surgical, and tumor characteristics, risk factors associated with prolonged LOS in the multivariate analysis were specimen size > 9 cm (OR:13.03, p = 0.005), surgery on Thursday or Friday (OR:6.92, p = 0.001), estimated blood loss ≥ 60 ml (OR:6.22, p = 0.021), and drainage (OR:5.29, p = 0.005). Prolonged length of stay after LTLA was associated with specimen size > 9 cm, operating on Thursday or Friday, estimated blood loss ≥ 60 mL, and drainage.
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Affiliation(s)
- José Ignacio Rodríguez-Hermosa
- Endocrine Surgery Unit, Department of Surgery, Department of Medical Sciences, Faculty of Medicine, Dr. Josep Trueta University Hospital, Girona Biomedical Research Institute (IDIBGI), University of Girona, Avda. França, s/n, 17007, Girona, Spain.
| | - Olga Delisau
- Department of Surgery, Department of Medical Sciences, Faculty of Medicine, Dr. Josep Trueta University Hospital, Girona Biomedical Research Institute (IDIBGI), University of Girona, Girona, Spain
| | - Pere Planellas-Giné
- Department of Surgery, Department of Medical Sciences, Faculty of Medicine, Dr. Josep Trueta University Hospital, Girona Biomedical Research Institute (IDIBGI), University of Girona, Girona, Spain
| | - Lídia Cornejo
- Department of Surgery, Department of Medical Sciences, Faculty of Medicine, Dr. Josep Trueta University Hospital, Girona Biomedical Research Institute (IDIBGI), University of Girona, Girona, Spain
| | - Alejandro Ranea
- Endocrine Surgery Unit, Department of Surgery, Department of Medical Sciences, Faculty of Medicine, Dr. Josep Trueta University Hospital, Girona Biomedical Research Institute (IDIBGI), University of Girona, Avda. França, s/n, 17007, Girona, Spain
| | - Eloy Maldonado
- Department of Surgery, Department of Medical Sciences, Faculty of Medicine, Dr. Josep Trueta University Hospital, Girona Biomedical Research Institute (IDIBGI), University of Girona, Girona, Spain
| | - José Manuel Fernández-Real
- Department of Endocrinology, Department of Medical Sciences, Faculty of Medicine, Dr. Josep Trueta University Hospital, Girona Biomedical Research Institute (IDIBGI), University of Girona, Girona, Spain
| | - Antoni Codina-Cazador
- Department of Surgery, Department of Medical Sciences, Faculty of Medicine, Dr. Josep Trueta University Hospital, Girona Biomedical Research Institute (IDIBGI), University of Girona, Girona, Spain
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7
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Zhou Q, Liu X, Zhang H, Zhao Z, Li Q, He H, Zhu Z, Yan Z. Adrenal Artery Ablation for the Treatment of Hypercortisolism Based on Adrenal Venous Sampling: A Potential Therapeutic Strategy. Diabetes Metab Syndr Obes 2020; 13:3519-3525. [PMID: 33116703 PMCID: PMC7547795 DOI: 10.2147/dmso.s262092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/18/2020] [Indexed: 12/22/2022] Open
Abstract
AIM Hypercortisolism is characterized by metabolic disorders and high mortality rates. Adrenalectomy and medical therapies are considered major treatment options. However, some patients, especially young patients, are strongly against undergoing surgery in case of secondary hypocortisolism or relapses that require replacement supplements or pharmacological interventions. In such cases, alternative therapies are needed to treat hypercortisolism. METHODS We report a 27-year-old Chinese female with adrenal cortisol-producing adenoma. The patient's circadian rhythm and concentrations of cortisol were abnormal, accompanying with an increased 24-hour urinary cortisol level. Computed tomography (CT) revealed a nodular soft-tissue mass in the right adrenal gland. RESULTS Cortisol hypersecretion from the right adrenal gland was verified by adrenal venous sampling (AVS). Adrenal artery ablation was performed. After ablation, long-term follow-up showed that the patient's symptoms subsided and abnormal laboratory test results returned to normal without pharmacological treatment. CONCLUSION AVS might be a promising method to aid the diagnosis of cortisol-producing adenoma. Adrenal artery ablation is minimally invasive and may be useful for the treatment of adrenal adenoma or nodular diseases, especially in patients who cannot undergo surgery.
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Affiliation(s)
- Qing Zhou
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Chongqing Institute of Hypertension, Daping Hospital and the Research Institute of Surgery, Army Medical University, Chongqing400042, People’s Republic of China
| | - Xiaoli Liu
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Chongqing Institute of Hypertension, Daping Hospital and the Research Institute of Surgery, Army Medical University, Chongqing400042, People’s Republic of China
| | - Hexuan Zhang
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Chongqing Institute of Hypertension, Daping Hospital and the Research Institute of Surgery, Army Medical University, Chongqing400042, People’s Republic of China
| | - Zhigang Zhao
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Chongqing Institute of Hypertension, Daping Hospital and the Research Institute of Surgery, Army Medical University, Chongqing400042, People’s Republic of China
| | - Qiang Li
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Chongqing Institute of Hypertension, Daping Hospital and the Research Institute of Surgery, Army Medical University, Chongqing400042, People’s Republic of China
| | - Hongbo He
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Chongqing Institute of Hypertension, Daping Hospital and the Research Institute of Surgery, Army Medical University, Chongqing400042, People’s Republic of China
| | - Zhiming Zhu
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Chongqing Institute of Hypertension, Daping Hospital and the Research Institute of Surgery, Army Medical University, Chongqing400042, People’s Republic of China
| | - Zhencheng Yan
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Chongqing Institute of Hypertension, Daping Hospital and the Research Institute of Surgery, Army Medical University, Chongqing400042, People’s Republic of China
- Correspondence: Zhencheng Yan Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Chongqing Institute of Hypertension, Daping Hospital and the Research Institute of Surgery, Army Medical University, Chongqing400042, People’s Republic of ChinaTel +86-23-68757883 Email
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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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9
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Anderson JE, Seib CD, Campbell MJ. Association of Patient Frailty With Increased Risk of Complications After Adrenalectomy. JAMA Surg 2019; 153:966-967. [PMID: 29971357 DOI: 10.1001/jamasurg.2018.1749] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Jamie E Anderson
- Department of Surgery, University of California Davis Medical Center, Sacramento
| | - Carolyn D Seib
- Department of Surgery, University of California San Francisco Medical Center, San Francisco
| | - Michael J Campbell
- Department of Surgery, University of California Davis Medical Center, Sacramento
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10
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Chen Y, Scholten A, Chomsky-Higgins K, Nwaogu I, Gosnell JE, Seib C, Shen WT, Suh I, Duh QY. Risk Factors Associated With Perioperative Complications and Prolonged Length of Stay After Laparoscopic Adrenalectomy. JAMA Surg 2019; 153:1036-1041. [PMID: 30090934 DOI: 10.1001/jamasurg.2018.2648] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Laparoscopic adrenalectomy is the gold standard for most adrenal disorders and its frequency in the United States is increasing. While national and administrative databases can adjust for patient factors, comorbidities, and institutional variations, granular disease-specific data that may significantly influence the incidence of perioperative complications and length of stay (LOS) are lacking. Objective To investigate factors associated with perioperative complications and LOS after laparoscopic adrenalectomy. Design, Setting, and Participants This cohort study was carried out at a single academic medical center, with all patients who underwent laparoscopic adrenalectomy between 1993 and 2017 by the endocrine surgery department. Multivariable linear and logistic regression were used to obtain adjusted odds ratios (ORs). Main Outcomes and Measures The primary outcome was perioperative complications with a Dindo-Clavien grade of 2 or more. The secondary outcome was prolonged length of stay, defined as a stay longer than the 75th percentile of the overall cohort. Results We identified 640 patients who underwent 653 laparoscopic adrenalectomies, of whom 370 (56.7%) were female. The median age was 51 (range, 5-88) years. A total of 76 complications with a Dindo-Clavien grade of 2 or more occurred in 55 patients (8.4%), with postoperative mortality in 2 patients (0.3%). The median hospital length of stay was 1 day (range, 0-32 days). Factors independently associated with increased complications were American Society of Anesthesiologists class 3 or 4 (OR, 2.78 [95% CI, 1.39-5.55]; P < .01), diabetes (OR, 2.39 [95% CI, 1.14-5.01]; P = .02), conversion to hand-assisted or open surgery (OR, 5.32 [95% CI, 1.84-15.41]; P < .01), a diagnosis of pheochromocytoma (OR, 4.31 [95% CI, 1.43-13.05]; P = .01), and a tumor size of 6 cm or greater (OR, 2.47 [95% CI, 1.05-5.78]; P = .04). Prolonged length of stay was associated with age 65 years or older (OR, 2.44 [95% CI, 1.31-4.57]; P = .01), an American Society of Anesthesiologists class 3 or 4 (OR, 3.48 [95% CI, 1.88-6.41]; P < .01), any procedural conversion (OR, 63.28 [95% CI, 12.53-319.59]; P < .01), and a tumor size of 4 cm or larger (4-6 cm: OR, 2.38 [95% CI, 1.21-4.67]; P = .01; ≥6 cm: OR, 2.46 [95% CI, 1.12-5.40]; P = .03). Conclusions and Relevance Laparoscopic adrenalectomy remains safe for most adrenal disorders. Patient comorbidities, adrenal pathology, and tumor size are associated with the risk of complications and length of stay and should all be considered in selecting and preparing patients for surgery.
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Affiliation(s)
- Yufei Chen
- Department of Endocrine Surgery, University of California, San Francisco
| | - Anouk Scholten
- Department of Endocrine Surgery, University of California, San Francisco
| | | | - Iheoma Nwaogu
- Department of Endocrine Surgery, University of California, San Francisco
| | - Jessica E Gosnell
- Department of Endocrine Surgery, University of California, San Francisco
| | - Carolyn Seib
- Department of Endocrine Surgery, University of California, San Francisco
| | - Wen T Shen
- Department of Endocrine Surgery, University of California, San Francisco
| | - Insoo Suh
- Department of Endocrine Surgery, University of California, San Francisco
| | - Quan-Yang Duh
- Department of Endocrine Surgery, University of California, San Francisco
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11
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Kazaure HS, Sosa JA. Volume-outcome relationship in adrenal surgery: A review of existing literature. Best Pract Res Clin Endocrinol Metab 2019; 33:101296. [PMID: 31331729 DOI: 10.1016/j.beem.2019.101296] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The relationship between operative volume and perioperative outcomes after several oncologic operations is well documented. Recent studies on adrenalectomy reveal a robust association between higher surgeon volume and improved patient outcomes. Statistical analyses have demonstrated that outcomes are improved when surgeons perform at least six adrenalectomies annually; based on this threshold definition of a 'high-volume' surgeon, more than 80% of adrenalectomies in the United States are performed by 'low-volume' surgeons. When compared to low-volume surgeons, high-volume surgeons on average achieve lower rates of postoperative complications and mortality, as well as a shorter length of hospital stay, and lower cost of hospitalization. There does not appear to be a similar association between hospital adrenalectomy volume and improved patient outcomes; however, there is evidence of benefit for the subset of patients with adrenocortical carcinoma. Despite limitations of existing literature, evidence is sufficient to recommend the referral of patients with adrenal tumors to high-volume surgeons.
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Affiliation(s)
- Hadiza S Kazaure
- Department of Surgery, Section of Endocrine Surgery, Duke University Medical Center, Durham, NC, USA
| | - Julie A Sosa
- Department of Surgery, University of California at San Francisco (UCSF), San Francisco, CA, USA.
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12
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Accreditation of endocrine surgery units. Langenbecks Arch Surg 2019; 404:779-793. [PMID: 31494716 DOI: 10.1007/s00423-019-01820-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 08/26/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND/PURPOSE A key measure to maintain and improve the quality of healthcare is the formal accreditation of provider units. The European Society of Endocrine Surgeons (ESES) therefore proposes a system of accreditation for endocrine surgical centers in Europe to supplement existing measures that promote high standards in the practice in endocrine surgery. METHODS A working group analyzed the current healthcare situation in the field of endocrine surgery in Europe. Two surveys were distributed to ESES members to acquire information about the structure, staffing, caseload, specifications, and technology available to endocrine surgery units. Further data were sought on tracer diagnoses for quality standards, training provision, and research activity. Existing accreditation models related to endocrine surgery were included in the analysis. RESULTS The analysis of existing accreditation models, available evidence, and survey results suggests that a majority of ESES members aspire to a two-level model (termed competence and reference centers), sub-divided into those providing neck endocrine surgery and those providing endocrine surgery. Criteria for minimum caseload, number and certification of staff, unit structure, on-site collaborating disciplines, research activities, and training capacity for competence center accreditation are proposed. Lastly, quality indicators for distinct tracer diagnoses are defined. CONCLUSIONS Differing healthcare structures, existing accreditation models, training models, and varied case volumes across Europe are barriers to the conception and implementation of a pan-European accreditation model. However, there is consensus on accepted standards required for accrediting an ESES competence center. These will serve as a basis for first-stage accreditation of endocrine surgery units.
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Srougi V, Barbosa JAB, Massaud I, Cavalcante IP, Tanno FY, Almeida MQ, Srougi M, Fragoso MC, Chambô JL. Predictors of complication after adrenalectomy. Int Braz J Urol 2019; 45:514-522. [PMID: 31038857 PMCID: PMC6786121 DOI: 10.1590/s1677-5538.ibju.2018.0482] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 01/13/2019] [Indexed: 11/25/2022] Open
Abstract
Purpose: To investigate risk factors for complications in patients undergoing adrenalectomy. Materials and Methods: A retrospective search of our institutional database was performed of patients who underwent adrenalectomy, between 2014 and 2018. Clinical parameters and adrenal disorder characteristics were assessed and correlated to intra and post-operative course. Complications were analyzed within 30-days after surgery. A logistic regression was performed in order to identify independent predictors of morbidity in patients after adrenalectomy. Results: The files of 154 patients were reviewed. Median age and Body Mass Index (BMI) were 52-years and 27.8kg/m2, respectively. Mean tumor size was 4.9±4cm. Median surgery duration and estimated blood loss were 140min and 50mL, respectively. There were six conversions to open surgery. Minor and major post-operative complications occurred in 17.5% and 8.4% of the patients. Intra-operative complications occurred in 26.6% of the patients. Four patients died. Mean hospitalization duration was 4-days (Interquartile Range: 3-8). Patients age (p=0.004), comorbidities (p=0.003) and pathological diagnosis (p=0.003) were independent predictors of post-operative complications. Tumor size (p<0.001) and BMI (p=0.009) were independent predictors of intra-operative complications. Pathological diagnosis (p<0.001) and Charlson score (p=0.013) were independent predictors of death. Conclusion: Diligent care is needed with older patients, with multiple comorbidities and harboring unfavorable adrenal disorders (adrenocortical carcinoma and pheocromocytoma), who have greater risk of post-operative complications. Patients with elevated BMI and larger tumors have higher risk of intra, but not of post-operative complications.
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Affiliation(s)
- Victor Srougi
- Divisão de Urologia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - João A B Barbosa
- Divisão de Urologia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Isaac Massaud
- Divisão de Urologia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Isadora P Cavalcante
- Divisão de Endocrinologia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Fabio Y Tanno
- Divisão de Urologia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Madson Q Almeida
- Divisão de Endocrinologia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Miguel Srougi
- Divisão de Urologia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Maria C Fragoso
- Divisão de Endocrinologia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - José L Chambô
- Divisão de Urologia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
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Beck AC, Goffredo P, Hassan I, Sugg SL, Lal G, Howe JR, Weigel RJ. Risk factors for 30-day readmission after adrenalectomy. Surgery 2018; 164:766-773. [PMID: 30097166 DOI: 10.1016/j.surg.2018.04.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 03/27/2018] [Accepted: 04/03/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Readmissions represent a substantial burden to the health care system. Risk factors for 30-day readmission after adrenalectomy were examined. METHODS Patients who underwent adrenalectomy were selected from the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2015. RESULTS Among 4,221 patients who underwent adrenalectomy, 216 (5.1%) were readmitted. On multivariate analysis, pre-operative predictive factors associated with readmission were American Society of Anesthesiologists classification (odds ratio [OR] 1.4, confidence interval [CI] 1.1-1.8), disseminated cancer (OR 1.6, CI 1.1-2.5), and adrenal injury (OR 10.9, CI 1.8-68.9). Elective procedures had fewer readmissions (OR 0.50, CI 0.33-0.76). and procedures with greater relative value units had greater readmission rates (OR 1.01, CI 1.004-1.02). An open adrenalectomy (21% of patients) had a higher rate of readmission than a laparoscopic approach (8.0% vs 4.3%, OR 1.5, CI 1.1-2.0). Postoperative risk factors affecting readmission included reoperations (OR 3.2, CI 1.3-8.0), wound complications (OR 6.6, CI 3.8-11.7), systemic infection (OR 6.5, CI 3.9-10.7), renal complications (OR 7.1, CI 2.6-19.2), venous thrombotic events (OR 11.3, CI 5.6-22.6), and discharge to home (OR 0.40, CI 0.22-0.73). CONCLUSION Encouraging the appropriate use of laparoscopic adrenalectomy, preventing venous thrombotic events and surgical infections, and improving early post-operative follow-up in high-risk patients may decrease readmissions.
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Affiliation(s)
- Anna C Beck
- From the Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Paolo Goffredo
- From the Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Imran Hassan
- From the Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Sonia L Sugg
- From the Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Geeta Lal
- From the Department of Surgery, University of Iowa, Iowa City, Iowa
| | - James R Howe
- From the Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Ronald J Weigel
- From the Department of Surgery, University of Iowa, Iowa City, Iowa..
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15
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Palazzo F, Dickinson A, Phillips B, Sahdev A, Bliss R, Rasheed A, Krukowski Z, Newell-Price J. Adrenal surgery in England: better outcomes in high-volume practices. Clin Endocrinol (Oxf) 2016; 85:17-20. [PMID: 26776382 DOI: 10.1111/cen.13021] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 11/19/2015] [Accepted: 01/10/2016] [Indexed: 11/29/2022]
Abstract
AIMS AND BACKGROUND Adrenal surgery is performed by a variety of surgical specialities in differing environments and volumes. International data suggest that there is a correlation between adrenal surgery volume and outcomes but there are no UK data to support this or UK surgical guidelines. A multidisciplinary team representing the stakeholders in adrenal disease is preparing a national guidance on adrenal surgery. A review of the outcomes for adrenal surgery in England was performed to correlate outcomes with the volume of surgeon practice. METHODS Hospital Episode Statistics (HES) data for the National Health Service (NHS) in England in the tax year 2013-2014 were examined for adrenal surgery. Length of hospital stay and rate of postoperative readmission were assessed as surrogate quality markers and a comparison made between 'high-' and 'low-' volume surgeons. RESULTS A total of 795 adult adrenalectomies were performed by 222 different surgeons with a range of between 1 and 34 adrenalectomies performed per surgeon. Only thirty-six (16%) adrenal surgeons performed 6 or more adrenalectomies. A total of 186 surgeons (84%) performed a median of one adrenalectomy a year. Length of stay and readmission rate within thirty days of operation was 60% longer and 47% higher, respectively, when performed by low-volume surgeons. CONCLUSION The current provision of adrenal surgery in the UK is not in the best interests of patients and is not cost-effective for the NHS. Adrenal surgery is best performed by higher volume surgeons in centres with dedicated adrenal multidisciplinary teams expert in all aspects of care of the adrenal patient.
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Affiliation(s)
| | | | | | - Anju Sahdev
- Radiology, St Bartholomew's Hospital, London, UK
| | - Richard Bliss
- Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | - John Newell-Price
- Academic Unit of Diabetes, Endocrinology & Metabolism, University of Sheffield, Sheffield, UK
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16
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Abstract
Over the last decade minimally invasive adrenalectomy has become the gold standard in adrenal surgery. Laparoscopic adrenalectomy with the patient in the lateral decubitus position and posterior retroperitoneoscopic adrenalectomy have gained worldwide acceptance. In this overview the complications of minimally invasive adrenalectomy are analyzed based on the published data. Die incidence of intraoperative and postoperative complications ranges from 0 % to 15 % for unilateral adrenalectomy and rises up to 23 % for bilateral surgery. No significant differences were found between laparoscopic and retroperitoneoscopic operations. Nevertheless, splenic injuries and intra-abdominal abscesses are reported only after laparoscopic procedures, while relaxation and/or hypoesthesia of the abdominal wall are typical for posterior retroperitoneoscopic surgery. Conversion to open surgery significantly influences the rate of perioperative and postoperative complications (odds ratio 6.2); therefore, high surgeon and center case volume could improve the results of adrenal surgery.
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Affiliation(s)
- P F Alesina
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Henricistr. 92, 45136, Essen, Deutschland,
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17
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Fujita T. Resident exposure to complex surgery while ensuring patient safety. J Am Coll Surg 2014; 220:118-20. [PMID: 25515161 DOI: 10.1016/j.jamcollsurg.2014.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 10/08/2014] [Indexed: 11/25/2022]
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Özgör F, Binbay M, Akbulut MF, Şimsek A, Şahan M, Berberoğlu AY, Sarılar Ö, Müslümanoğlu AY. Laparoscopic transperitoneal adrenalectomy: Our initial results. Turk J Urol 2014; 40:99-103. [PMID: 26328159 DOI: 10.5152/tud.2014.09076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 01/06/2014] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To present the first 24 laparoscopic adrenalectomies performed in our clinic because of an adrenal mass. MATERIAL AND METHODS The medical files of 24 patients who underwent laparoscopic adrenalectomy between December 2008 and March 2013 at Haseki Teaching and Research Hospital were analyzed retrospectively. The demographic characteristics of the patients were recorded. Lateral transperitoneal laparoscopic adrenalectomy was performed in all patients. The operation time was defined as the interval between the first incision of the skin and closure of the skin. Intraoperative complications, estimated blood loss and hospital stays of the patients were evaluated. Final pathologies were recorded. RESULTS The mean age of the patients was 44.2±8.58 years (range: 29-66 years). Nine patients were female and 15 were male. A total of 24 masses were identified in the right (n=11), and left (n=13) adrenal glands masses were identified., Eighteen patients (75%) had no symptoms, and the masses were identified incidentally. The mean operation time was 144±46.1 minutes (range: 90-320 minutes), and the mean blood loss was 74±12.3 mL (range: 50-130 mL). None of the patients required a blood transfusion. In one patient, liver injury was identified intraoperatively due to traction. The mean duration of hospitalization was 2.9±1.1 days (range: 2-5 days). Adrenocortical adenoma and pheochromocytoma were the most common pathologies. CONCLUSION Laparoscopic adrenalectomy is a safe and effective method for the treatment of adrenal masses with low complication rates.
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Affiliation(s)
- Faruk Özgör
- Department of Urology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Murat Binbay
- Department of Urology, Haseki Training and Research Hospital, İstanbul, Turkey
| | | | | | - Murat Şahan
- Department of Urology, Haseki Training and Research Hospital, İstanbul, Turkey
| | | | - Ömer Sarılar
- Department of Urology, Haseki Training and Research Hospital, İstanbul, Turkey
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Benassai G, Desiato V, Benassai G, Bianco T, Sivero L, Compagna R, Vigliotti G, Limite G, Amato B, Quarto G. Adrenocortical carcinoma: what the surgeon needs to know. Case report and literature review. Int J Surg 2014; 12 Suppl 1:S22-8. [PMID: 24866075 DOI: 10.1016/j.ijsu.2014.05.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 05/03/2014] [Indexed: 11/29/2022]
Abstract
Adrenocortical carcinoma is a rare and aggressive cancer and its prognosis is frequently unsatisfactory. Due to its rarity there's a lack of prospective randomized studies. Without experience in the approach of this kind of tumor, managing becomes challenging and, moreover, we have only few recommendations, based on weak evidence. We report a case that has some peculiarities and is an excellent food for thought. Then we deal with a literature review to highlight and summarize most significant aspects of epidemiology, clinic, diagnosis, therapy and prognosis in an exquisitely surgical point of view.
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Affiliation(s)
- Giacomo Benassai
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Italy
| | - Vincenzo Desiato
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Italy.
| | - Gianluca Benassai
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Italy
| | - Tommaso Bianco
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Italy
| | - Luigi Sivero
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Italy
| | - Rita Compagna
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Italy
| | - Gabriele Vigliotti
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Italy
| | - Gennaro Limite
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Italy
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Italy
| | - Gennaro Quarto
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Italy
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Abstract
The surgical treatment of adrenal tumours has evolved over the past century, as has our understanding of which hormones are secreted by the adrenal glands and what these hormones do. This article reviews the preoperative evaluation of patients with adrenal tumours that could be benign or malignant, including metastases. The biochemical evaluation of excess levels of hormones is discussed, as are imaging characteristics that differentiate benign tumours from malignant tumours. The options for surgical management are outlined, including the advantages and disadvantages of various open and laparoscopic approaches. The surgical management of adrenocortical carcinoma is specifically reviewed, including controversies in operative approaches as well as surgical management of invasive or recurrent disease.
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Affiliation(s)
- Barbra S Miller
- University of Michigan Health System, 1500 East Medical Center Drive, 2920F Taubman Center, Ann Arbor, MI 48109-5331, USA
| | - Gerard M Doherty
- Department of Surgery, Boston University, 75 East Newton Street, Boston, MA 02118, USA
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21
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Central lymph node dissection in patients with papillary thyroid cancer: a population level analysis of 14,257 cases. Am J Surg 2013; 205:655-61. [PMID: 23414635 DOI: 10.1016/j.amjsurg.2012.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Revised: 05/16/2012] [Accepted: 06/08/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study analyzes the impact of demographics and tumor size on the use of central compartment lymph node dissection (CLND) for papillary thyroid cancer (PTC) in the United States. METHODS Adult patients with PTC and the follicular variant of PTC who underwent thyroidectomy with or without CLND and were reported in the Surveillance Epidemiology and End Results (SEER) database from 2004 to 2008 were included. Bivariate and multivariate analyses were performed to determine the effects of demographic and clinical characteristics on the likelihood of a patient undergoing CLND. RESULTS Of 14,257 patients included, 80.3% were women, 84.3% were white, average age was 50.1 years, and 37.1% had CLND. Over 5 years, there was an 18.3% increase in CLND, with the greatest increase seen in patients with T1 tumors (23.2%). Patients who were older, men, black, and from the South were less likely to undergo CLND; however, there were no differences in the total number of lymph nodes examined based on patient demographics or the year of their thyroid cancer diagnoses. CONCLUSIONS Being older, black, and from the South are negatively associated with CLND. This practice variation suggests potential disparity in access and quality of surgical care for PTC in the United States.
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Bittner JG, Gershuni VM, Matthews BD, Moley JF, Brunt LM. Risk factors affecting operative approach, conversion, and morbidity for adrenalectomy: a single-institution series of 402 patients. Surg Endosc 2013; 27:2342-50. [PMID: 23404146 DOI: 10.1007/s00464-013-2789-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 12/31/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Risk factors for selecting patients for open adrenalectomy (OA) and for conversion are limited in most series. This study aimed to investigate variables that are important in selecting patients for OA, predict risk of conversion from laparoscopic adrenalectomy (LA), and impact 30-day outcomes of OA and LA. METHODS A retrospective cohort study of prospectively collected data was conducted. Patients (≥ 16 years old) who underwent adrenalectomy in the Division of General Surgery at Barnes-Jewish Hospital (1993-2010) were grouped by operative approach (LA vs. OA) and compared using nonparametric tests and regression analyses (α < 0.05). RESULTS In total, 402 patients underwent 422 adrenalectomies. Compared to LA patients, those in the OA group were older (p = 0.02), had higher ASA scores (p = 0.04), larger tumor size (p < 0.01), and fewer functioning lesions (p < 0.01). OA patients more often required concurrent procedures (p < 0.01), had a longer operative time (p = 0.04), more intraoperative complications (p = 0.02), higher estimated blood loss (EBL), and larger transfusion requirement. Preoperative factors that predicted selection for OA were higher patient age (p = 0.01), higher ASA score (p = 0.03), larger tumor size (p < 0.01), nonfunctioning lesion (p < 0.01), diagnosis of adrenocortical carcinoma (p < 0.01), and the need for concomitant procedures (p < 0.01). Conversion to open or hand-assisted approach occurred in 6.2 % of LA patients. Preoperative risks for conversion included large tumor size (>8 cm) and need for concomitant procedures (p < 0.01). Multivariate analysis revealed that large indeterminate adrenal mass, adrenocortical carcinoma, tumor size (>6 cm), an open operation, conversion, concomitant procedures, operative time >180 min, and EBL >200 mL were predictors of 30-day morbidity. CONCLUSIONS Adrenal tumor size and need for concurrent procedures significantly impact the selection of patients for OA, the likelihood of conversion, and perioperative morbidity. These metrics should be considered when assessing operative approach and risks for adrenalectomy.
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Affiliation(s)
- James G Bittner
- Section of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8109, St. Louis, MO 63111, USA.
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Laparoscopic versus open adrenalectomy: another look at outcome using the Clavien classification system. Surgery 2013; 152:1090-5. [PMID: 23158180 DOI: 10.1016/j.surg.2012.08.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 08/15/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND A laparoscopic approach to adrenalectomy has become the procedure of choice for most adrenal resections. We hypothesized that laparoscopic adrenalectomy is less likely to result in intensive care unit (ICU) level complications or death than open adrenalectomy, despite baseline comorbidity mix. METHODS Using the National Surgical Quality Improvement Program (NSQIP) participant use files for 2005-2009, all laparoscopic and open adrenalectomies were identified by current procedural terminology. Adverse outcomes tracked in NSQIP were mapped to Clavien level based on need for ICU care or death. Univariate and multivariate analysis were used to compare groups. RESULTS There were 1,980 laparoscopic and 592 open procedures. Clavien 4 and 5 complications occurred in 45 (7.6%) of open and 35 (1.8%) of laparoscopic operations. The univariate odds ratio showed a 4.6-fold greater likelihood that a patient would have an ICU level complication (P < .001), and 4.9 odds ratio of death (P < .001) if an open rather than laparoscopic operation was performed. Regression modeling showed persistence of the protective effect of laparoscopy after adjusting for comorbidities with a multivariate odds ratio of 3.3 (P < .001). CONCLUSION The laparoscopic approach to adrenalectomy has an independent protective effect on ICU level complications and mortality when compared with open procedures. This correlation persists after correcting for multiple comorbidities.
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Wang TS, Cheung K, Roman SA, Sosa JA. A cost-effectiveness analysis of adrenalectomy for nonfunctional adrenal incidentalomas: is there a size threshold for resection? Surgery 2012; 152:1125-32. [PMID: 22989893 DOI: 10.1016/j.surg.2012.08.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 08/10/2012] [Indexed: 01/15/2023]
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare, but aggressive, malignancy. Current American Association of Clinical Endocrinologists (AACE)/American Association of Endocrine Surgeons (AAES) guidelines recommend resection of nonfunctional adrenal neoplasms ≥ 4 cm. This study evaluates the cost-effectiveness of this approach. METHODS A decision tree was constructed for patients with a nonfunctional, 4-cm adrenal incidentaloma with no radiographic suspicion for ACC. Patients were randomized to adrenalectomy, surveillance per AACE/AAES guidelines, or no follow-up ("sign-off"). Incremental cost-effectiveness ratio (ICER) includes health care costs, including missed ACC. ICER (dollar/life-year-saved [LYS]) was determined from the societal perspective. Sensitivity analyses were performed. RESULTS In the base-case analysis, assuming a 2.0% probability of ACC for a 4-cm tumor, surgery was more cost-effective than surveillance (ICER $25,843/LYS). Both surgery and surveillance were incrementally more cost-effective than sign-off ($35/LYS and $8/LYS, respectively). Sensitivity analysis demonstrated that the model was sensitive to patient age, tumor size, probability of ACC, mortality of ACC, and cost of hospitalization. The results of the model were stable across different cost and complications related to adrenalectomy, regardless of operative approach. CONCLUSION In our model, adrenalectomy was cost-effective for neoplasms >4 cm and in patients <65 years, primarily owing to the aggressiveness of ACC. Current AACE/AAES guideline recommendations for the resection of adrenal incidentalomas ≥ 4 cm seem to be cost-effective.
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Affiliation(s)
- Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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25
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Zini L, Porpiglia F, Fassnacht M. Contemporary management of adrenocortical carcinoma. Eur Urol 2011; 60:1055-65. [PMID: 21831516 DOI: 10.1016/j.eururo.2011.07.062] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 07/26/2011] [Indexed: 12/15/2022]
Abstract
CONTEXT Adrenocortical carcinoma (ACC) is a rare and typically aggressive malignancy. Available recommendations are based primarily on retrospective series or expert opinions, and only few prospective clinical studies have yet been published. OBJECTIVE To combine the available evidence for diagnostic work-up and treatment of ACC to a contemporary recommendation on the management of this disease. EVIDENCE ACQUISITION We conducted a systematic literature search for studies conducted on humans and published in English using the Medline/PubMed database up to 31 January 2011. In addition, we screened published abstracts at meetings and several Web sites for recommendations on ACC management. EVIDENCE SYNTHESIS In patients with suspected localised ACC, a thorough endocrine and imaging work-up is followed by complete (R0) resection of the tumour by an expert surgeon. In experienced hands, laparoscopic adrenalectomy is probably as effective and safe for localised and noninvasive ACC as open surgery. Most clinicians agree that mitotane should be used as adjuvant therapy in the majority of patients, as they have a high risk for recurrence. An international panel has suggested using tumour stage, resection status, and the proliferation marker Ki67 as guidance for or against adjuvant therapy. In patients with advanced disease at presentation or recurrence not amenable to complete resection, a surgical approach is frequently inadequate. In these cases, mitotane alone or in combination with cytotoxic drugs is the treatment of choice. The most promising regimens (etoposide, doxorubicin, cisplatin plus mitotane, and streptozotocin plus mitotane) are currently compared in an international phase 3 trial, and results should be available by the end of 2011. Several targeted therapies are under investigation and may lead to new treatment options. Management of endocrine manifestations with steroidogenesis inhibitors is required in patients suffering uncontrolled hormone excess. CONCLUSIONS Detailed recommendations are provided to guide the management of patients with ACC.
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Affiliation(s)
- Laurent Zini
- Department of Urology, Hôpital Huriez, Lille University Hospital, Lille, France.
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