Originally published as Ann Surg Oncol Early Release 10.1245/ASO.2003.06.001 on October 13, 2003
Annals of Surgical Oncology 10:1012-1017 (2003)
© 2003 Society of Surgical Oncology
One Hundred Laparoscopic Adrenalectomies: A Single Surgeon’s Experience
Herbert J. Zeh, III, MD and
Robert Udelsman, MD, MBA
From the University of Pittsburgh (HJZ), Kaufmann Medical Building, Pittsburgh, Pennsylvania; and Department of Surgery (RU), Yale University, New Haven, Connecticut.
Correspondence: Address correspondence and reprint requests to: Robert Udelsman, MD, Yale University School of Medicine, 330 Cedar St., FMB 102, New Haven, CT 06520; Fax: 203-737-2116; E-mail: robert.udelsman{at}yale.edu
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ABSTRACT
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Background: Since the first laparoscopic adrenalectomy was performed in 1992, it has quickly gained acceptance as the standard of care for the treatment of benign adrenal neoplasms. We report a single surgeon’s experience with 100 consecutive laparoscopic adrenalectomies.
Methods: The records of all patients having adrenalectomy at the Johns Hopkins Hospital from 1993 until 2000 were reviewed. We examined the length of stay, time to diet resumption, perioperative morbidity, operative cost, and total cost of 100 consecutive laparoscopic adrenalectomies. These data are compared with those of 20 patients within our institution having open adrenalectomy and with 428 patients statewide having all forms of adrenalectomy during the same time period.
Results: A total of 93 patients had unilateral laparoscopic adrenalectomy and 7 had bilateral procedures. The mean age was 49 years (11 to 70). Indications were aldosteronoma (n = 40), pheochromocytoma (n = 22), glucocorticoid-producing adenoma (n = 14), nonfunctioning adenoma (n = 12) Cushing’s disease (n = 5), and others (n = 7). The median length of stay for this series was 1.0 day. Average length of stay and time to resumption of diet were 1.8 and 1.0 days, respectively. Patients having open procedures during this same time period had an average length of stay of 6.5 days.
Conclusions: Laparoscopic adrenalectomy provides clear advantages over open adrenalectomy. Patients having laparoscopic adrenalectomy have decreased length of stay, shorter time to resumption of diet, and lower total hospital charges when compared with those having open adrenalectomy.
Key Words: Adrenalectomy • Laparoscopic • Aldosteronoma • Outcomes
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INTRODUCTION
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Laparoscopic adrenalectomy is an excellent example of the successful application of minimally invasive surgical techniques to a procedure that was previously associated with significant cost and morbidity. Laparoscopic adrenalectomy is ideally suited for minimally invasive techniques because it provides improved visualization of anatomically complex areas through smaller, less painful incisions. In addition, it is primarily an ablative technique that does not require complex reconstruction and involves removal of a relatively small, easily extractable lesion. Since the initial description of laparoscopic adrenalectomy in 1992 by Gagner et al1 the indications for and application of this technique have been greatly refined and expanded. Numerous investigators have reported the advantages of laparoscopic approach over traditional open techniques including (1) lower complication rates, (2) less blood loss, (3) less-painful incisions, (4) less narcotic requirements, (5) earlier return to activity and diet, (6) shorter hospital stays, and (7) lower overall costs.2–10 Laparoscopic adrenalectomy is now considered to be the standard of care for the treatment for nearly all benign tumors of the adrenal gland. This report examines the experience of a single surgeon with 100 consecutive laparoscopic adrenalectomies. Comparison with open procedures and with Maryland Health Services Cost Review Commission (HSCRC) database during the same time period is made.
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METHODS
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The records of all patients having adrenalectomy at The Johns Hopkins Hospital between 1993 and 2000 were reviewed. We previously reported our first 33 patients and this inclusive series updates our experience.11 We examined the length of stay, time to diet resumption, perioperative morbidity, operative cost, and total cost of 100 consecutive laparoscopic adrenalectomies performed by the senior author. These data are compared with that of 20 patients having open adrenalectomy during the same time period (1993–2000). Laparoscopic adrenalectomies were performed via the lateral transperitoneal approach, as previously described.12 Open adrenalectomy was performed via midline laparotomy, thoracoabdominal, or retroperitoneal approach.
The state of Maryland has compiled and maintained a database of diagnosis, patient charge, and clinical outcome for all admissions to 52 nonfederal hospitals. All hospitals are required to submit these data directly to the state, designated the Health Services Cost Review Commission (HSCRC) database, which is blinded to prevent disclosure of the identity of either patients or surgeons. Because the HSCRC does not provide detailed patient histories or demographics, patients were analyzed solely on the basis of current procedural terminology (CPT) procedure codes for all forms of adrenalectomy. This analysis revealed 428 patients who had adrenalectomy in the state of Maryland for the years 1994–2000. These data were analyzed for postoperative length of stay, operating room charges, and total charges and compared with our laparoscopic and overall series during the same time period (1994–2000).
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RESULTS
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Beginning in 1993, the senior author performed 100 consecutive laparoscopic adrenalectomies, 93 unilateral and 7 bilateral and 20 open adrenalectomies. Demographic data are shown in Table 1. The mean age of those patients having laparoscopic was 49 years (11 to 79) and for those having open adrenalectomy, 56 years (30 to 83 years). A slight predominance in female patients was seen in both groups: 41% male and 61% female in laparoscopic group; 41% male and 53% female in the open group. The average size of the lesion in the laparoscopic group was 3.4 (.9 to 11.5) versus 6.6 cm (2.9 to 15) in the open group (P < .0003) The indications for adrenalectomy are depicted in Table 2. Indications for laparoscopic adrenalectomy were aldosteronoma (n = 42), pheochromocytoma (n = 21), Cushing’s adrenal adenoma (n = 13), nonfunctioning adenoma (n = 11) Cushing’s disease (n = 5), adrenal cortical cancer (incidentally discovered postoperatively) (n = 4), others (n = 3), and metastatic cancer (n = 1). Indications for open adrenalectomy were nonfunctioning adrenal mass (n = 4), pheochromocytoma (n = 7), adrenal cortical carcinoma (n = 4), metastatic cancer (n = 2), paraganglioma (n = 2) aldosteronoma (n = 1), dehydroepiandrosterone- or cortisol-producing adenoma (n = 1).
Four patients in the laparoscopic group incidentally were discovered to have adrenal cortical carcinomas. None of the four patients had clinical or radiographic evidence preoperatively suggestive of malignancy. The average size of the lesions in these patients was 4.5 cm (4.0 to 6.5) Final pathology in three of these patients confirmed the presence of invasive adrenal cortical carcinoma. In the fourth patient, the tumor had some features of adrenal cortical carcinoma, including size >5.0 cm, mitosis, cellular atypia, but no evidence of extracapsular invasion; accordingly, it was labeled as an adrenal cortical tumor of unknown malignant potential. No perioperative morbidity or mortality was seen in this subgroup. At 18 months follow-up, one of the patients had local and disseminated disease. Three patients currently have no evidence of disease at 1, 2, and 3 years, respectively. The last patient was lost to follow-up at 1 year, at which point no evidence was seen of disease. The most recent patient had remedial laparotomy with resection of retroperitoneal bed and port sites. No evidence was seen of residual tumor.
Morbidity in the laparoscopic series was 6%. Two patients each developed a pneumothorax, which required chest tube placement. Two patients required postoperative re-intubation for respiratory compromise and poor pulmonary toilet, both having had bilateral adrenalectomy for profound refractory Cushing’s disease. One patient developed a urinary tract infection, which was treated successfully with antibiotics. Finally, a single patient developed a non-q-wave myocardial infarction following removal of a pheochromocytoma. Four patients in the open group had complications. One patient had a subcutaneous wound infection, which was treated with local packing. One patient developed a pleural effusion, which required thoracentesis. One patient had urinary retention after removal of a pheochromocytoma requiring several days of bladder decompression. One patient with metastatic adrenal carcinoma with profound Cushing’s syndrome who was having debulking in an attempt to control her medically refractory steroid overproduction, required prolonged intubation, tracheostomy and drainage of an intraabdominal fluid collection. No 30-day perioperative mortality occurred in either group. The previously described patient with metastatic adrenal carcinoma died from her disease at home on postoperative day 47. In the laparoscopic series, a single patient with refractory Cushing’s disease had profound preoperative steroid-induced myopathy that required prolonged intubation and a hospital stay of 58 days. On the day of transfer to rehabilitation, the patient was found unresponsive in asystole.
In the laparoscopic group 13 patients were converted to open adrenalectomy. Indications for conversion to open procedure are reported in Table 3. Four patients were converted because of large tumors and concern of malignancy. None of these patients was subsequently found to have cancer. Four patients were converted because of poor visualization. Two patients were converted because of bleeding uncontrolled by laparoscopic techniques. Neither of these patients nor any of the laparoscopic adrenalectomy patients required a blood transfusion. One patient who had successful laparoscopic removal of a large tumor had to be converted to open adrenalectomy because of the concern for cancer when the diaphragm had to be resected en bloc because of adhesions from the tumor. This patient was subsequently found to have a benign adenoma. One patient was converted secondary to carbon dioxide retention, and one patient because of adhesions from prior surgery. The median length of stay for the laparoscopic group was 1 day. As depicted in Figure 1, most patients could be discharged on the first postoperative day. Very few patients required longer than 2 postoperative days. Two patients had prolonged hospitalizations, in excess of 30 days. The first is the previously described patient who had steroid-induced myopathy from refractory Cushing’s disease. His lengthy stay and hospital charges arose from his preexisting debilitation. The second patient developed a non-q-wave myocardial infarction following removal of a pheochromocytoma. A cardiac catheterization revealed severe triple vessel coronary artery disease and the patient had emergent coronary artery bypass grafting. His excessive length of stay was a result of the necessary second procedure.
We compared the length of stay, time to resumption of diet, operating room time and cost, and total cost of patients having laparoscopic versus open adrenalectomy during the same time period. Patients were analyzed according to intention to treat, so that all patients converted to open procedure were treated as laparoscopic cases. Median length of stay and resumption of diet were 1.0 days and 1.0 days compared with 5.0 and 4 days for patients having open procedure in the same time period (P < .0001 two-sided P-values from a two-sample Wilcoxon test) (Fig. 2). Operative times were slightly longer for open procedures. Operative charges were higher for laparoscopic adrenalectomies ($4218 vs. $2897). Overall charges were less for laparoscopic adrenalectomy ($10,929 vs. $13,336). Further, the proportion of patients having laparoscopic adrenalectomies with overall total patient charges <$10,000 was .7 compared with .4 for open procedures (Fig. 3). When our series of all adrenalectomies (1994—2000; 100 laparoscopic and 15 open) was compared against all adrenalectomies performed within the state of Maryland, during the same time period, length of stay for the our series was shorter (2.8 vs. 5.0 days) and total hospital charges were less ($11,787 vs. $12,716) (Figs. 4 and 5
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FIG. 2. Comparison of medium length of stay and median time until resumption of diet in patients undergoing laparoscopic adrenalectomy or open adrenalectomy. * P values are the two-sided P values from a two-sample Wilcoxon text.
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FIG. 4. Comparison of average length of stay between adrenalectomies performed at the Johns Hopkins Hospital and the Health Services Cost Review Commission (HSCRC) database.
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FIG. 5. Comparison of total cost between adrenalectomies performed at the Johns Hopkins Hospital and the Health Services Cost Review Commission (HSCRC) database.
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DISCUSSION
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Laparoscopic adrenalectomy is the procedure of choice for removal of most benign adrenal neoplasms. The world’s literature includes more than 1000 reported cases of laparoscopic adrenalectomy2–7,13 (Table 4). This collective experience has defined the appropriate indications, contraindications, refined the surgical approach, and documented improvements in morbidity and mortality. Laparoscopic adrenalectomy can be performed with the same or shorter operating room time, less blood loss, less narcotic requirements, and shorter hospital stays. These series have demonstrated the safety and efficacy of this procedure.
We have shown that laparoscopic adrenalectomy results in significantly shorter length of stay, decreased morbidity and mortality, and lower overall costs when compared with open procedures performed during this same time period. Most of the overall cost saving in this series was because of shorter hospital stay because operating room charges were slightly higher for the laparoscopic procedure. The smaller, less painful incisions with the laparoscopic approach resulted in earlier mobilization and return to diet, and fewer complications. The median length of stay in our series of 1 day speaks to the ease with which patients can recover. Most patients had returned to a diet and resumed independent activity by the first hospital day.
A new procedure should be compared with the conventional approach in the setting of a randomized trial. No such study has been completed to date. It is also unlikely, given the dramatic improvements demonstrated compared with historical controls with the laparoscopic adrenalectomy, that such a trial would be feasible or ethical. Several series have directly compared the outcomes in laparoscopic adrenalectomy with open adrenalectomy by using case or historical control retrospective designs.5,11,14–20 In these comparisons, the average length of stay for laparoscopic versus open adrenalectomy was 3.5 versus 7.9 days, respectively. Operative times and complications rates were not significantly different. In the few reports that have directly compared cost, an advantage was seen in savings in favor of laparoscopic adrenalectomy.21,11 We have confirmed this advantage in the present study.
The success of the laparoscopic adrenalectomy has deepened the debate over the appropriate management of the incidentally discovered adrenal mass. An asymptomatic adrenal mass is a serendipitous finding in 0.3% to 0.5% of all patients who have computed tomography scans for unrelated reasons.22 Appropriate management of these lesions is based largely on the results of biochemical testing, radiologic characteristics, and size of the mass. It is critical that all patients with incidentally discovered adrenal masses have biochemical testing to rule out the presence of a functional adrenal tumor. All functioning tumors should be removed. No universally accepted protocol exists for the work-up to rule out an occult functioning adrenal tumor. We previously proposed an algorithm for the management of incidentally discovered adrenal masses.11,12 Briefly, a detailed history and physical examination are critical. If no symptoms or signs of a functioning tumor are uncovered, a biochemical screen for a functioning adrenal tumor is indicated. This usually includes measurement of serum electrolytes and 24-hour measurements of urinary catecholamines or their metabolic products as well as urinary free cortisol levels. If an occult functioning tumor is demonstrated, then excision is recommended. For nonfunctioning lesions, the criteria for removal are largely based on size and radiographic characteristics. The radiographic discrimination between a benign adrenal neoplasm from malignant, however, can be difficult. Classically, tumors <5.0 cm with smooth margins and homogenous signal intensity were considered to be the hallmark of a benign lesion. Several series, however, have significant overlap in the size and attenuation criteria.23 We recommend 4.0 cm as a cut-off for proceeding to surgical resection, based on a systematic review of the literature that suggests that the chance of malignancy in lesions <4.0 cm is <2%.12 A recent National Institutes of Health consensus conference similarly found little evidence to support removing tumors <4 cm. In the present series, 11 patients had incidentally discovered adrenal masses (4.0 to 10.0 cm). Four of these patients were subsequently discovered to harbor malignant adrenal cortical carcinomas in the surgical specimen. None of these patients had tumors <4.0 cm (range, 4.5 to 6.2). Furthermore, none of the four patients had preoperative imaging studies that suggested malignant potential. One of our patients had a recurrence at 18 months following resection with local and peritoneal dissemination of tumor. Three are alive and well with no evidence of disease at 1, 2, and 3 years, respectively. In the most recent patient we performed a remedial laparotomy with resection of the retroperitoneal bed and port sites. No residual tumor was identified. The best course of action in the patient with an incidentally discovered adrenal cancer in a laparoscopically resected specimen is unclear. The literature on laparoscopic adrenalectomy for malignant disease is sparse. Suzuki et al.24 reported an en bloc laparoscopic adrenalectomy for a 4.5-cm adrenal cancer. Local recurrence and peritoneal dissemination occurred at 19 months. Similarly, Borelli et al. reported a single adrenal cancer in their series with early recurrence.6 Others have also reported incidentally discovered adrenal cancer in their respective series with no recurrences.13,25,26 We consider the preoperative diagnosis of adrenal cancer to be an absolute contraindication to laparoscopic adrenalectomy. Instead, those patients with preoperative imaging suggestive of adrenal cancer should have an open procedure with wide en bloc resection of the adrenal glad and surrounding tissues. In addition, we are liberal in converting to an open procedure if a concern is seen during laparoscopic adrenalectomy about the presence of an adrenal cancer. In the present series, four patients were converted to the open procedure because the intraoperative size of the tumor raised the concern of malignancy. Interestingly, none of these four patients was subsequently found to have cancer.
Although known primary adrenal cancer is considered by most to be a contraindication to the laparoscopic approach, resection of metastatic disease is not unreasonable.27–30 The adrenal gland is a frequent site of metastases from melanoma, lung, breast, and colon cancer. Most patients with metastatic lesions in the adrenal gland prove to have disseminated disease, which is not appropriate for resection. In select patients with isolated metastases to the adrenal gland, however, resection may provide significant disease-free survival. Heniford et al.29 recently reviewed a series of 11 patients who had laparoscopic adrenalectomy for metastases. In this highly selected series, no perioperative deaths occurred, morbidity was low, and 10 of the 11 patients have no evidence of disease with a mean follow-up of 8 months. In our series, a single patient with metastatic colorectal cancer had laparoscopic adrenalectomy. The postoperative course was unremarkable and the patient is alive with recurrent distant disease at 5 years.
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CONCLUSIONS
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Laparoscopic adrenalectomy is the procedure of choice for the removal of most benign lesions of the adrenal gland. Laparoscopic adrenalectomy offers shorter hospital stays, lower overall costs, and decreased morbidity when compared with conventional open procedures.
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FOOTNOTES
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The authors report a single surgeon’s experience with 100 consecutive laparoscopic adrenalectomies. Indications, length of stay and cost are compared with open procedures performed during a similar time period.
Received for publication June 4, 2002.
Accepted for publication July 7, 2003.
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ABSTRACT
INTRODUCTION
