1
|
Pennestrì F, De Crea C, Voloudakis N, Raffaelli M. Laparoscopic transabdominal anterior bilateral adrenalectomy (La-TABA): an alternative approach for severe Cushing's syndrome. Updates Surg 2023; 75:2403-2411. [PMID: 37864624 DOI: 10.1007/s13304-023-01653-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/23/2023] [Indexed: 10/23/2023]
Abstract
Severe uncontrolled Cushing's syndrome (CS) is an acute life-threatening condition. As it is often not responsive to medical therapy, emergency bilateral adrenalectomy (BA) may present the only therapeutic option. Moreover, multiple bone fractures, representing one of the clinical consequences of hypercortisolism, may not permit both prone and lateral patient's positioning during surgery, thus making minimally invasive approaches nonfeasible. We report our preliminary experience with an alternative approach in this selected patients' category. Among 613 patients who underwent endoscopic adrenalectomy at our centre (34-5.6% BA) between January 1997 and October 2021, 3 patients were scheduled for laparoscopic transabdominal anterior bilateral adrenalectomy (La-TABA). Surgery was performed with patient in supine position, with fastened arms and legs to allow Trendelenburg and anti-Trendelenburg movements and lateral rotations. The procedure consisted in a synchronous bilateral adrenalectomy. A modern multi-articulated operative table provided rotations on the right and left side to perform left and right adrenalectomy, respectively. One male and two female patients with a mean age of 34 ± 3.1 years underwent La-TABA. Mean operative time was 200 ± 138.3 min. No perioperative complications were registered. Mean postoperative hospital stay was 8 ± 4.4 days. In very severe ACTH-dependent CS, BA should be performed as soon as possible. La-TABA may represent the most appropriate therapeutic option, as this patients' category is not able to tolerate prone and lateral positioning required during the conventional surgery. Despite the higher technical complexity of the procedure compared with the other endoscopic approaches to adrenalectomy, it retains the benefits of minimally invasive surgery in terms of postoperative complications and recovery.
Collapse
Affiliation(s)
- Francesco Pennestrì
- U.O.C. Chirurgia Endocrina e Metabolica, Centro Dipartimentale di Chirurgia Endocrina e dell'Obesità, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carmela De Crea
- U.O.C. Chirurgia Endocrina e Metabolica, Centro Dipartimentale di Chirurgia Endocrina e dell'Obesità, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Nikolaos Voloudakis
- U.O.C. Chirurgia Endocrina e Metabolica, Centro Dipartimentale di Chirurgia Endocrina e dell'Obesità, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marco Raffaelli
- U.O.C. Chirurgia Endocrina e Metabolica, Centro Dipartimentale di Chirurgia Endocrina e dell'Obesità, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
2
|
De Crea C, Pennestrì F, Voloudakis N, Sessa L, Procopio PF, Gallucci P, Bellantone R, Raffaelli M. Robot-assisted vs laparoscopic lateral transabdominal adrenalectomy: a propensity score matching analysis. Surg Endosc 2022; 36:8619-8629. [PMID: 36190555 PMCID: PMC9613740 DOI: 10.1007/s00464-022-09663-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 09/18/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Laparoscopic adrenalectomy (LA) is the gold standard treatment for adrenal lesions. Robot-assisted adrenalectomy (RAA) is a safe approach, associated with higher costs in absence of clear-cut benefits. Several series reported some advantages of RAA over LA in challenging cases, but definitive conclusions are lacking. We evaluated the cost effectiveness and outcomes of robotic (R-LTA) and laparoscopic (L-LTA) approach for lateral transabdominal adrenalectomy in a high-volume center. METHODS Among 356 minimally invasive adrenalectomies (January 2012-August 2021), 286 were performed with a lateral transabdominal approach: 191 L-LTA and 95 R-LTA. The R-LTA and L-LTA patients were matched for lesion side and size, hormone secretion, and BMI with propensity score matching (PSM) analysis. Postoperative complications, operative time (OT), postoperative stay (POS), and costs were compared. RESULTS PSM analysis identified 184 patients, 92 in R-LTA and 92 in L-LTA group. The two groups were well matched. The median lesion size was 4 cm in both groups (p = 0.533). Hormonal hypersecretion was detected in 55 and 54 patients of R-LTA and L-LTA group, respectively (p = 1). Median OT was significantly longer in R-LTA group (90.0 vs 65.0 min) (p < 0.001). No conversion was registered. Median POS was similar (4.0 vs 3.0 days in the R-LTA and L-LTA) (p = 0.467). No difference in postoperative complications was found (p = 1). The cost margin analysis showed a positive income for both procedures (3137 vs 3968 € for R-LTA and L-LTA). In the multiple logistic regression analysis, independent risk factors for postoperative complications were hypercortisolism (OR = 3.926, p = 0.049) and OT > 75 min (OR = 8.177, p = 0.048). CONCLUSIONS The postoperative outcomes of R-LTA and L-TLA were similar in our experience. Despite the higher cost, RAA appears to be cost effective and economically sustainable in a high-volume center (60 adrenalectomies/year), especially if performed in challenging cases, including patients with large (> 6 cm) and/or functioning tumors.
Collapse
Affiliation(s)
- Carmela De Crea
- U.O.C. Chirurgia Endocrina e Metabolica, Centro Dipartimentale di Chirurgia Endocrina e dell'Obesità, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Centro di Ricerca in Chirurgia Endocrina e dell'Obesità, Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Francesco Pennestrì
- U.O.C. Chirurgia Endocrina e Metabolica, Centro Dipartimentale di Chirurgia Endocrina e dell'Obesità, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
- Centro di Ricerca in Chirurgia Endocrina e dell'Obesità, Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy.
| | - Nikolaos Voloudakis
- U.O.C. Chirurgia Endocrina e Metabolica, Centro Dipartimentale di Chirurgia Endocrina e dell'Obesità, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luca Sessa
- Centro di Ricerca in Chirurgia Endocrina e dell'Obesità, Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy
- Centro Malattie Endocrine e Obesità, Fondazione Gemelli Giglio Cefalù, Cefalù, Palermo, Italy
| | - Priscilla Francesca Procopio
- U.O.C. Chirurgia Endocrina e Metabolica, Centro Dipartimentale di Chirurgia Endocrina e dell'Obesità, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Centro di Ricerca in Chirurgia Endocrina e dell'Obesità, Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Pierpaolo Gallucci
- U.O.C. Chirurgia Endocrina e Metabolica, Centro Dipartimentale di Chirurgia Endocrina e dell'Obesità, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rocco Bellantone
- U.O.C. Chirurgia Endocrina e Metabolica, Centro Dipartimentale di Chirurgia Endocrina e dell'Obesità, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Centro di Ricerca in Chirurgia Endocrina e dell'Obesità, Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Marco Raffaelli
- U.O.C. Chirurgia Endocrina e Metabolica, Centro Dipartimentale di Chirurgia Endocrina e dell'Obesità, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Centro di Ricerca in Chirurgia Endocrina e dell'Obesità, Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy
| |
Collapse
|
3
|
Xie W, Zhang Y, Cao R. Construction and validation of a prognostic model for predicting overall survival of primary adrenal malignant tumor patients: A population-based study with 1,080 patients. Front Surg 2022; 9:1025213. [PMID: 36353609 PMCID: PMC9637840 DOI: 10.3389/fsurg.2022.1025213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022] Open
Abstract
Objective Primary adrenal malignant tumor is rare. The factors affecting the prognosis remain poorly defined. This study targeted to construct and corroborate a model for predicting the overall survival of adrenal malignant tumor patients. Methods We investigated the SEER database for patients with primary adrenal malignant tumor. 1,080 patients were divided into a construction cohort (n = 756) and a validation cohort (n = 324), randomly. The prognostic factors for overall survival were evaluated using univariate and multivariate Cox analyses. The nomogram was constructed and then validated with C-index, calibration curve, time-dependent ROC curve, and decision curve analysis in both cohorts. Then we divided the patients into 3 different risk groups according to the total points of the nomogram and analyzed their survival status by Kaplan-Meier curve with log-rank test. Results The baseline characteristics of these two cohorts were not statistically different (P > 0.05). Using univariate and multivariate Cox analyses, 5 variables, including age, tumor size, histological type, tumor stage, and surgery of primary site, were distinguished as prognostic factors (P < 0.05). Based on these variables, we constructed a nomogram to predict the 3- year, 5- year, and 10-year overall survival. The C-indexes were 0.780 (0.760–0.800) in the construction cohort and 0.780 (0.751–0.809) in the validation cohort. In both cohorts, the AUC reached a fairly high level at all time points. The internal and external calibration curves and ROC analysis showed outstanding accuracy and discrimination. The decision curves indicated excellent clinical usefulness. The best cut-off values for the total points of the nomogram were 165.4 and 243.1, and the prognosis was significantly different for the three different risk groups (P < 0.001). Conclusion We successfully constructed a model to predict the overall survival of primary adrenal malignant tumor patients. This model was validated to perform brilliantly internally and externally, which can assist us in individualized clinical management.
Collapse
Affiliation(s)
| | | | - Runfu Cao
- Correspondence: Runfu Cao Yida Zhang
| |
Collapse
|
4
|
Feng Q, Li H, Qiu G, Cai Z, Li J, Zeng Y, Huang J. Case report: Significant liver atrophy due to giant cystic pheochromocytoma. Front Oncol 2022; 12:987705. [PMID: 36110948 PMCID: PMC9469016 DOI: 10.3389/fonc.2022.987705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Pheochromocytoma is a neuroendocrine tumor originating from chromaffin cells in the adrenal medulla. Giant pheochromocytomas with a maximum diameter of over 20 cm are particularly rare. Case presentation We present a case of giant cystic pheochromocytoma in a 64-year-old woman who was found to have a right abdominal mass during an ultrasound examination, which is the largest pheochromocytoma ever documented in China. Meanwhile, obvious atrophy of the right lobe of the liver was found in preoperative CT and during the operation. Our literature review identified 20 cases with a diameter of over 20 cm. The average age at diagnosis was 51.7 (range 17–85), and 35% of cases did not exhibit classic symptoms. Conclusion Giant pheochromocytoma is an uncommon neoplasm. It can be discovered late due to a lack of clinical manifestations. Diagnosis is dependent on imaging recognition together with catecholamine secretion. Surgical resection is the only curative treatment for such tumors.
Collapse
Affiliation(s)
- Qingbo Feng
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Hancong Li
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Guoteng Qiu
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Zhaolun Cai
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jiaxin Li
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Yong Zeng
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Jiwei Huang
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Jiwei Huang,
| |
Collapse
|