loader
Home/
Journal of General Surgery

Full Text


Research Article

Adrenalectomy for Benign and Malignant Adrenal Tumors Experience From Misurata Cancer Center

Ala Wafa, Ali Ghellai, Mohamed Elfagieh, Abdullah Juwid, Abu baker Aboshnaf

Correspondence Address :

Ala Wafa
Surgical oncology department
Misurata Cancer Center
Misurata University
Libya
Tel: 00218917164032
Email: Dr.alawafa@gmail.com

Received on: , Accepted on: , Published on:

Citation: Ala Wafa, Ali Ghellai, Mohamed Elfagieh, Abdullah Juwid, Abubaker Aboshnaf (2018). Adrenalectomy for Benign and Malignant Adrenal Tumors Experience From Misurata Cancer Center

Copyright: 2018 Ala Wafa et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

  • Abstract

  • Fulltext

  • References

  • Tables & Figures

  • Download PDF

Abstract
Background: laparoscopic adrenalectomy is the standard management of benign adrenal tumors. Open adrenalectomy is still the gold standard surgical treatment for adrenocortical carcinoma and malignant pheochromocytoma while the role of minimal invasive surgery is still controversial. Laparoscopic adrenalectomy associated with low morbidity rate, short hospital stay and rapid recovery to work. The aim of study is identifying the advantages of Laparoscopic adrenalectomy in comparison to open adrenalectomy.
Methods: A retrospective study of 21 adrenal tumors that underwent surgical resection at Misurata Cancer Center from April 2013 up to April 2018. we compared: age, sex, marital status, past medical history, function and size of the tumor, type of surgery, duration of surgery, estimated blood loss, preparation of patient for surgery, postoperative complications, postoperative discharge day and mortality
Results: There were 21 adrenal tumors, 61.9% were females and 38.1% were males, median age of 41 year. 61.9% hypertensive patients, 71.4% functional tumors and 28.6% nonfunctional tumors. 71.4% benign tumors and 28.6% malignant. Laparoscopic adrenalectomy for 15 cases(71.4%), open adrenalectomy for 6 cases(28.6%), and 4 cases(19%) converted to open surgery, morbidity was 19% , and 30 days mortality rate was 4,7%.
Conclusion: Surgical treatment of adrenal tumors consists of laparoscopic and open adrenalectomy. The type of surgery depend on the size of the tumor and suspicious of malignancy in imaging study, Laparoscopic adrenalectomy is safe and effective for benign tumors with decreased operative time, less post-operative pain, and decreased hospital stay.

Keywords: Laparoscopic adrenalectomy, Pheochromocytoma, Functional adenoma

Fulltext
Introduction
Laparoscopic adrenalectomy is the gold standard treatment of both functioning and nonfunctioning benign adrenal tumors of less than 6cm in size [1,2]. Open adrenalectomy is still the treatment of choice for malignant neoplasm of adrenal gland [1,3]. Laparoscopic adrenalectomy has many advantages, including decreased the length of hospital stay, reduced postoperative pain, and early return to work [4,5].
Laparoscopic adrenalectomies can be done by transabdominal or retroperitoneal approaches. The choice depends on the size of the tumor and expertise of the surgeon [6]. Open adrenalectomy can be done by anterior transabdominal approach via long vertical midline incision or long subcostal incision, and posterior retroperitoneal approach via incision at bed of 12th rib with the patient lying prone. Open surgery associated with more pain, ileus, atelectasis, longer period of recovery, and increase risks of poor wound healing especially for patient with Cushing syndrome [2].
Functioning adenoma is indication for adrenalectomy. Pheochromocytoma is functional tumor of adrenal medulla secreting catecholamines causing symptoms of hypertension inform of headache, palpitation, and diaphoresis. Conns adenoma is tumor of adrenal cortex where Zona Glomerulosa secreting excess of aldosterone causing symptoms of hypertension, fatigability and muscle weakness due to hypokalemia.
Cushing adenoma is tumor of adrenal cortex where Zona Fasciculata secreting excess of Cortisol causing symptoms of Cushing syndrome, truncal obesity, hirsutism, moon face, acne, striae, buffalo hump, hypertension, and diabetes [7].
Laboratory tests used to identify the adrenal function including tests for serum metanephrine and noremetaniphrine are of 99% sensitive and 89% specific, and 24hr urine collection of catecholamine and there metabolite are of 88% sensitive and 95% specific for pheochromocytoma [8,9]. Conns adenoma diagnoses by high serum aldosterone level, high serum aldosterone/serum renin ratio, and low serum potassium level [7,10]. Cushing adenoma diagnosed by high level of 24 hour urinary free cortisol, high serum cortisol and low serum ACTH [11,12] .
Radiological imaging is useful to reach the diagnosis of adrenal lesion and differ between benign and malignant feature [11]. Contrast enhanced CT scan is useful imaging modality. The criteria of benign lesions are size <4cm, homogenous, well defined borders, rapid washout of contrast, low vascularity, and high level of intracellular lipids. The criteria of malignant lesions are size >6cm, heterogenous, ill-defined borders, necrosis, calcification and hemorrhage within the mass, high vascularity and low level of intracellular lipids [12,13].

Aims and Objectives of the Study

Advantages of Laparoscopic adrenalectomy in comparison to open adrenalectomy inform of operative time, less postoperative pain and hospital stay.

Methods and Materials

From April 2013 to April 2018, the series of adrenalectomies performed at the Misurata Cancer Center, department of surgical oncology, Misurata, Libya. This study involved 21 patients with various adrenal tumors. The two type of surgery were used, Transperitoneal laparoscopic and open adrenalectomies. Diagnosis was obtained on the basis of clinical examination, laboratory values and imaging techniques (Computed tomography and Magnetic Resonance Imaging).Patients evaluation included preoperative, intraoperative and postoperative data.
All patients underwent routine laboratory tests (complete blood count, urea, creatinine, sodium, potassium, blood sugar), and hormonal tests for adrenal function(serum metanephrine, serum noremetanephrine, serum aldosterone, serum renin, aldosterone renin ratio, serum and urine cortisol), chest x-ray, ECG, and cardiological evaluation . Patients diagnosed with Pheochromocytoma underwent an alpha blocker-Prazosin 7 to 10 days until blood pressure controlled and patient developed postural hypotension, then tachycardia treated with beta blocker-Propranolol until heart rate became less than 100bpm.
Also plasma volume expanded using crystalloid solutions. Patient diagnosed with Conns adenoma with low serum potassium level, underwent an potassium sparing diuretics-Spironolactone and potassium chloride until serum potassium level return to normal. Intraoperative management: All patients received general anesthesia, antithrombotic prophylaxis( Fraxiparine 2500 I.U. s.c), and antibiotic prophylaxis (Ceftriaxone i.v). In patients with pheochromocytoma arterial line is used for invasive monitoring of blood pressure intraoperatively. Laparoscopic adrenalectomy in which the patients placed in lateral position with angle of 60 degree, using 4 trocars. Pneumoperitoneum initiated with veress needle technique and maintained at 13-14 mmHg by insufflation of Carbon dioxide. In laparoscopic approach we used a combination of monopolar cautery and ligasure for dissection..
For right laparoscopic adrenalectomy monitor were placed at right shoulder of the patients while surgeon and assistant stand on the left side of the patient. The site of the troacars were the first one at anterior axillary line 2 finger breadth below the costal margin, this was the site of the camera were we used 10mm 30 degree scope, second one at mid axillary line just below costal margin 5mm trocar for left hand instrument of the surgeon, third one at midclavicular line just below the costal margin 5mm trocar for the instrument of the right hand of the surgeon, fourth one at epigastric area 5mm trocar for liver retractor. we start dissection by elevating liver by laparoscopic retractor then releasing the liver from upper pole of the gland by using of monopolar cautery, then we started dissection at medial side of the inferior vena cava until we identified the adrenal vein were its usually sited at upper medial part of the gland posterolateral to inferior vena cava, we use laparoscopic clips for ligation of the vein, two clips medially and one laterally the we cut in between by scissors. Then dissection by ligasure started up to right renal vein inferiorly and ligation of superior, middle and inferior adrenal arteries by ligasure. Medial to lateral dissection until the gland removed from its bed, specimen extracted through retrieval bag through mini laparotomy incision, one tube drain inserted at sub-hepatic area. In left laparoscopic adrenalectomy the monitor were placed at left side of the patient while surgeon and assistant at right side of the patient. The sites of the trocars were the first one at anterior axillary line hand breadth below costal margin for the camera 10mm 30 degree scope, second one at mid clavicular line 2 finger below costal margin for left hand instrument of the surgeon 5mm trocar, third one at mid axillary line just below costal margin 5mm trocar for the instrument of the right hand of the surgeon. we start dissection by mobilization of splenic flexure, lateral attachments of the spleen are taken down, care must be taken to avoid capsular tear. Splenic mobilization continued until the greater curvature of the stomach and left crus of diaphragm became visible, take care not injury the pancreatic tail. Dissection continued up to left renal vein inferiorly. Identification of adrenal vein joining the inferior phrenic vein. Adrenal vein ligated with two clips medially and one laterally and cut in between with scissors, dissection of the gland with ligasure sealed the small superior, middle and inferior adrenal arteries. Dissection of the gland circumferentially until it removed from its bed and extracted through retrieval bag through a mini laparotomy incision. Tube drain inserted at perispleenic area.
Postoperative management: All patients received i.v fluid inform of crystalloids, analgesia and vital sign monitoring. Patient with Cushing syndrome received i.v hydrocortisone which started after removal of the Cushing adenoma. Early mobilization in the same day of surgery and feeding started in first postoperative day for laparoscopic surgery, while mobilization is delayed until the first postoperative day in open surgery due to postoperative pain.

Results

There were 21 adrenal tumors, 13 were female (61.9%), and 8 were males (38.1%). The age of patients classified equal and less than 40 years and other group more than 40 years, 11 were >40years (52.3%), and 10 were <40years (47.7%). Patients classified geographically as 8(38.1%) were lived in Misurata city and 13(61.9%) lived outside the city. Most common symptoms was headache seen in 7 patients (33.4%) all patients were hypertensive. Functional tumor seen in 15 cases (71.4%), nonfunctional tumors in 6 cases (28.6%). Malignant tumors seen in 6 cases (28.6%), benign tumors in 15 cases (71.4%) (Table 1).
Pheochromocytoma seen in 4 cases (19.05%), Conns adenoma seen in 3 cases (14.2%), Cushing syndrome in 4 cases (19.05%), Malignant pheochromocytoma in 4 cases (19.05%), Incidentoloma in 4 cases (19.05%), Adrenocortical carcinoma in 2 cases (9.6%). Serum potassium level were low in 3 cases (14.3%), normal in 18 cases (85.7%). Hypertension seen in 13 patients (61.9%), while 8 patients were blood pressure were normal (38.1%). Right adrenal tumor were in 14 cases (66.6%), left adrenal tumor in 7 cases (33.4%). The size of the tumor were 9 cases equal or less than 4 cm (42.9%), and 12 cases more than 4cm (57.1%). MRI were done for 5 cases only (23.8%)(Figure 1).
Laparoscopic adrenalectomy done for 14 cases (66.6%), Open adrenalectomy for 7 cases (33.4%), three cases converted to open (14.3%). Operative time divided in two groups, less than 2hours group were 11 cases (52.4%), ten of them were laparoscopic (91%) and one of them was open (9%), more than 2 hours group were 10 cases (47.6%), four of them were laparoscopic (40%), six of them were open (60%), P= 0.05.
Preoperative preparation for 10 cases (52.4%) and eleven cases with no need for preparation (47.6%). Early ambulation in same day of surgery were 11 cases all of them were laparoscopic, P=0.0005. CT scan and histopathological measurement were same in 2 cases (14.3%), while the sizes were more by one or half centimeter in histopathological measurement in 18 cases (85.7%). Patient discharged in postoperative day 3 or less were 11 cases (52.4%), all are laparoscopic cases (100%). Patients discharged in postoperative day >3 were 10 cases (47.6%), three of them were laparoscopic (30%), while seven of them were open (70%), P=0.0002. Thirty days mortality was (4.7%) (Figure 2,3 and 4).

Discussion

The first successfully performed LA by Gagner in 1991, the transperitoneal approach is the most common surgery for adrenal tumors. The suspected primary malignant adrenal tumors should be considered for open resection, but still the best surgical approach is a matter of debate. The suspicious of malignancy were identified by preoperative imaging on CT scan with: local invasion of adjacent structure, distant metastasis, size >6cm, irregular borders, hemorrhage within the mass, low level of intracellular lipid, and high vascularity.
Of 21 adrenal tumors, female to male ratio was 2:1, but the incidence in other literature were same [7,8]. The age of patients were >40years (52.3%), and <40years (47.7%), were the the average age by American cancer society was 46years. The most common symptoms were headache seen in (33.4%), were the most commonly adrenal tumors incidentally discovered with other symptoms[7-14]. The most common tumors in our research were Functional tumors seen in (71.4%), nonfunctional tumors in (28.6%), but in American cancer society and literature [7-12] the nonfunctional tumors were most common forming 60% of adrenal tumors. Malignant tumors seen in (28.6%), benign tumors in (71.4%), same as in American cancer society and literature [12-15] were benign tumors formed >90% of cases. Pheochromocytoma seen in (19.05%), in literature
pheochromocytoma were 10% [9]. Conns adenoma seen in (14.2%), in literature Aldosteronoma were 1% [10]. Cushing syndrome seen in (19.05%), In America [7] the cortisol producing adenoma were 5%. Malignant pheochromocytoma seen in (19.05%), in literature [15] the malignant pheochromocytoma were 4%. Incidenteloma seen in (19.05%), in [11] the non functioning adenoma were 60%. Adrenocortical carcinoma seen in (9.6%), in literature [1] the adrenocortical carcinoma were 5%. Right adrenal tumor were in (66.6%), left adrenal tumor in (33.4%), so right adrenal tumor were more common in our research and same to the literature [16]. The size of the tumor were equal or less than 4 cm (42.9%), all of this cases were benign,
more than 4cm (57.1%), malignant tumors seen in 6 cases and all of them >9cm. MRI were done for only (23.8%), other cases MRI not done due to unavailability. Laparoscopic adrenalectomy done for (66.6%), Open adrenalectomy for (33.4%), three cases converted to open (14.3%) , the first case due to bleeding liver injury which cannot be controlled laparoscopically, the second case due to bleeding from splenic tear, and the third case due to multiple intraabdominal adhesions due to previous open right hemicolectomy. Operative time divided in two groups, less than 2hours group were (52.4%), were laparoscopic (91%) and open (9%), more than 2 hours group were (47.6%), four of them were laparoscopic (40%), six of them were open (60%), so we found that the laparoscopic approach were associated with less operative time. Postoperative blood sugar level seen low in 2 cases (9.5%), normal in 15 cases (71.5%) and high in 4 cases (19%). Patient discharged in postoperative day 3 or less were (52.4%), all are laparoscopic cases(100%). Patients discharged in postoperative day >3 were (47.6%), three of them were laparoscopic (30%), while seven of them were open (70%) , so in our research we found that the laparoscopic adrenalectomy associated with less hospital stay as in the literature[17,18]. In comparison of the size of adrenal tumors between CT scan and histopathological measurement were same in 2 cases (14.3%), while the sizes were more by one or half centimeter in histopathological measurement in 18 cases (85.7%). Our complications rate were (19.1%) while in literature [7,19-21] were 13-27% . Thirty days mortality was( 4.7%) in our research, while 2.2% in literature [3].

Conclusion

Surgical treatment of adrenal tumors consists of laparoscopic and open adrenalectomy. The type of surgery depend on the size of the tumor and suspicious of malignancy in imaging study, Laparoscopic adrenalectomy is safe and effective for benign tumors with decreased operative time, less postoperative pain, and decreased hospital stay.
References
1. Lal G, Duh QY. Laparoscopic adrenalectomy - indications and technique. Surg Oncol 2003;12(2):105-123.
2. K. J. Hallfeldt, T. Mussack, A. Trupka, F. Hohenbleicher, S. Schmidbauer. Laparoscopic lateral adrenalectomy versus open posterior adrenalectomy for the treatment of benign adrenal tumors K Surgical Endoscopy And Other Interventional Techniques. 2003;17(2): 264-267.
3. Marco Barreca, Luigi Presenti, Cristina Renzi, et al. Expectations and Outcomes When Moving from Open to Laparoscopic Adrenalectomy: Multivariate Analysis. World J. Surg. 2003;27:223-228.
4. Jacobs JK, Goldstein RE, Geer RJ. Laparoscopic adrenalectomy. A new standard of care. Ann Surg. 1997;225(5):495-501; discussion 501-502.
5. Smith CD, Weber CJ, Amerson JR. Laparoscopic adrenalectomy: new gold standard. World J Surg. 1999;23(4):389-396.
6. Terzolo M, Bavio S, Pia A, Reimondo G, Angeli A. Management of adrenal incidentaloma. Best Pract Res Clin Endocrinol Metab. 2009;23(2):233-243.
7. Courtney M.Townsend, R.Daneil Beauchamp, B.Mark Evers, Kennethl. Mattox, Sabiston textbook of surgery 19th edition. 2012: 963-993.
8. Kudva YC, Sawka AM, Young WF, Jr. Clinical review 164: The laboratory diagnosis of adrenal pheochromocytoma: The Mayo Clinic experience. J Clin Endocrinol Metab.2003; 88:4533-4539
9. Walz MK, Alesina PF, Wenger FA et al. Laparoscopic and retroperitoneoscopic treatment of pheochromocytomas and retroperitoneal paragangliomas: results of 161 tumors in 126 patients. World J Surg. 2006; 30(5):899-908.
10. Sukor N, Kogovsek C , Gordon RD, Robson D, Stowasser M. Improved quality of life, blood pressure, and biochemical status following laparoscopic adrenalectomy for unilateral primary aldosteronism. J Clin Endocrinol Metab. 2010.95(3):1360-1364.
11. Christian de Virgilio, AregGrigorian, Paul N. Frank, Surgery A Case Based Clinical Review. 2015;8:77-87.
12. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing's syndrome and pheochromocytoma. N Engl J Med. 1992;327(14):1033.
13. White ML, Gauger PG, Doherty GM, et al. The role of radiologic studies in the evaluation and management of primary hyperaldosteronism. Surgery. 2008;144(6):926-933.
14. Lenders JW, Pacak K, Walther MM, et al. Biochemical diagnosis of pheochromocytoma: Which test is the best?. JAMA. 2002;287(11):1427-1434.
15. Marescaux J, Mutter D, Vix M, et al. Endoscopic surgery: ideal for endocrine surgery?. World Journal of Surgery. 1999;23(8):825-834.
16. Toniato A, Boschin IM, Opocher G, Guolo A, Pelizzo M, Mantero F. Is the laparoscopic adrenalectomy for pheochromocytoma the best treatment?. Surgery. 2007;141:723-727.
17. Shen WT, Lee J, Kebebew E, Clark OH, Duh QY. Selective use of steroid replacement after adrenalectomy: Lessons from 331 consecutive cases. Arch Surg.2006;141(8):771-774.
18. Welbourn RB. Early surgical history of pheochromocytoma. Br J Surg.1987;74(7):594-596
19. Imani F,Agopian VG, Auerbach MS, et al. 18F-FDOPA PET and PET/CT accurately localize pheochromocytomas. J Nucl Med. 2009;50(4):513-519.
20. Young WF. Clinical practice. The incidentally discovered adrenal mass. N Engl J Med. 2007;356(6):601-610.
21. Kazaryan AM, Kuznetsov NS, Shulutko AM, Beltsevich DG, Edwin B. Evaluation of endoscopic and traditional open approaches to pheochromocytoma. Surg Endosc. 2004;18(6):937-941.

Tables & Figures

Figure 1


Figure 2



Figure 3

Figure 4


Table 1
Download PDF