Adrenocortical carcinoma: role of laparoscopic surgery in treatment

[Diagnosis and surgical treatment of adrenocortical cancer with invasion into great veins]

AIM

To estimate immediate and remote resaults of treatment of adrenocortical cancer with invasion into great veins.

MATERIAL AND METHODS

It was analyzed survey and treatment results in 3 patients with adrenocortical cancer and invasion into renal veins and inferior vena cava.

RESULTS

Radical surgery with tumoral thrombi removal from great vessels was performed in all cases. There were no complications and deaths in early postoperative period. Life expectancy after surgery was 6, 13 and over 58 months.

CONCLUSION

At present time surgical intervention for adrenocortical cancer with invasion into great veins is single method to prolong patients' life.

[Development and evolution of laparoscopic adrenalectomy in an specialized team: from the beginning to the outpatient setting]

BACKGROUND

After the first reports in 1992, laparoscopic adrenalectomy (LA) has evolved technically until becoming the standard approach for the treatment of most of the adrenal gland diseases.

MATERIAL AND METHODS

Retrospective and descriptive study of 67 patients who underwent 68 LA between January-1998 and December-2008 in the Laparoscopic Surgery Unit of the General and Digestive Surgery Service in a third level hospital (only one case of bilateral LA). The group was divided in 2 periods, P-1 (1998-2003, 22 cases) and P-2 (2004-2008, 45 cases), which have been compared to evaluate the evolution of the LA technique.

RESULTS

Indications for LA were: 19 incidentalomas, 19 primary hyperaldosteronism, 18 pheocromocitoms, 5 cases of symptomatic and non-functioning adrenal masses, 4 Cushing adenomas and 2 metastases. There was no mortality, only 4 patients had minor complications (6%) and conversion rate was only 3% (2 cases). Mean size of adrenal glands resected was 3.83 cm and the mean operative time was 86 minutes. Mean postoperative hospital stay was 3 days and in P-2 seventeen patients were discharged on an outpatient basis (hospital stay less than 23 hours).

CONCLUSIONS

In our experience, LA for the treatment of adrenal diseases has shown to be safe, effective and reproducible with low complications and excellent tolerance by patients. When the learning curve is overcome, hospital stay and operative time clearly decrease. As a consequence, LA can be planned in selected cases as outpatient surgery with good results.

NOTES new frontier: Natural orifice approach to retroperitoneal disease

AIM: To develop a pure transvaginal access to the retroperitoneum, that is simple, reproducible and uses endoscopic material available on the market.

METHODS: From February 2008 to April 2009, 31 pigs were operated on, with 17 as an acute experiment and 14 with a survival protocol. The animals were placed in a supine position and a 12-mm double-channel endoscope (Karl Storz™, Tuttlingen) was used for vision and dissection. During the same time period, the access experiment was reproduced on 3 human cadavers using material similar to that used in the animal model.

RESULTS: In the animal model, 37 interventions were done on the kidney, adrenal gland and pancreas. The mean time to fashion the access was 10 min (range 5 to 20 min). No intraoperative death was observed. Two major (5%) intraoperative complications occurred: one hemorrhage on the aorta and one tearing of the right renal vein. Peritoneal laceration was encountered in 5 cases without impairing the planned task. In the survival group, good clinical outcome was observed at a mean follow-up of 3 wk (range 2 to 6 wk). In the 3 cadavers, access was performed correctly. The mean time to fashion the access was 52 min (range 40 to 60 min). All the anatomical landmarks described in the pig model were clearly identified in the same sequence.

CONCLUSION: A retroperitoneal natural orifice translumenal surgical transvaginal approach is feasible in both animal and human models and allows performance of a large panel of interventions.

Laparoscopic adrenalectomy: Norwegian single-center experience of 242 procedures

BACKGROUND

The last 15 years have been characterized by a rapid expansion of minimally invasive surgery as treatment for adrenal diseases. During these years, both indications and surgical techniques have shown improvements. This study analyzed an 11-year single-center experience with laparoscopic adrenalectomy.

MATERIALS AND METHODS

Between January 1997 and April 2008, 242 laparoscopic adrenalectomies were performed in 220 patients at Rikshospitalet University Hospital. Of these, 192 patients were operated on for benign lesions, 23 for malignant lesions, and in 5 cases "en bloc" adrenalectomies were performed. Benign lesions included 136 hormonally active lesions (41 pheochromocytomas, 48 Conn adenomas, 25 Cushing adenomas, and 18 patients with Cushing's disease) and 56 with hormonally inactive lesions (among them, 47 nonfunctional adenomas). Malignant lesions included 16 adrenal metastases and 7 adrenocortical carcinomas.

RESULTS

All adrenalectomies were completed laparoscopically. The median time of unilatateral adrenalectomy was 85 (range, 35-325) minutes. The median blood loss was 0 (range, 0-1100) mL. There were 6 intraoperative and 7 postoperative minor complications. The number of complications did not differ between the types of adrenal pathology. Only 19% of the patients required opioids postoperatively. Per- and postoperative parameters were homogeneous among patients with different adrenal lesions. The patients with adrenocortical carcinoma had a distinctive intraoperative course with an evidently longer operative time and higher blood loss. The median postoperative hospital stay was 2 (range, 1-15) days. Hospital stay was the only postoperative parameter where a difference was found between patients with different adrenal lesions. The patients with carcinoma, pheochromocytoma, and Cushing's disease had the longest median postoperative stay, respectively, 5 (range, 2-6), 3 (range, 1-15), and 3 (range, 2-6) days.

CONCLUSIONS

Laparoscopic adrenalectomy is a safe, effective procedure providing improved fast and uncomplicated patient recovery independent of the type of adrenal lesion. Laparoscopic adrenalectomy can be easily introduced and may soon replace traditional open surgery in specialized centers.

Surgical access to the adrenal gland: the quest for a "no visible scar" approach

Surgery of the adrenal glands has various approaches and remains technically challenging. Many different techniques have been used to decrease morbidity. The most important one is probably laparoscopy which has already quite dramatically improved clinical outcome. The second one is the introduction of posterior endoscopic approach (retroperitoneoscopy), which entirely preserves peritoneal integrity. This concept seems to us to be a fundamental in surgery of the retroperitoneum. Recently, new developments have emerged in the field of abdominal surgery. The most radical concept, known as Natural Orifice Transluminal Endoscopic Surgery (NOTES), consists of the introduction of both endoscope and working instruments through natural orifices in order to eliminate skin incisions and their associated morbidities. Although transperitoneal adrenalectomy has previously been reported in a porcine model, here we report our initial experiences of extra-peritoneal transvaginal NOTES approach of the retroperitoneum, focused on the field of adrenal surgery in both porcine and cadaver models. Whether clinical applications will ultimately be derived of this concept is still not clear certainly it raises new possibilities for interesting developments.