An Analysis of Factors Affecting the Surgical Approach and Timing of Bilateral Adrenalectomy

Billy Y Lan, Eren Taskin, MD, Erol Aksoy, MD, Onur Birsun, MD, Jaime Mitchell, MD, Allan Siperstein, Eren Berber, MD. Cleveland Clinic Foundation.

Background: The optimal management of patients requiring bilateral adrenalectomy in regards to the surgical technique and timing of surgery has not been clearly defined. The aim of this study is to analyze the patient factors affecting the feasibility and outcomes of different surgical approaches to determine an algorithm for bilateral adrenalectomy.

Methods: Between 2000 and 2012, a total of 285 patients underwent adrenalectomies at a single academic institution. Of these patients, 26 (9%) underwent planned bilateral adrenalectomy. Pre-operative patient characteristics and intra-operative factors were compared for analysis.

Results: Of the 26 patients that underwent bilateral adrenalectomy, eleven were male and 15 were female with a mean age of 58, median ASA of 3 and mean BMI of 32. Diagnosis in these patients included Cushing’s disease in 19 patients (7 with pituitary, 4 with ectopic, 7 with bilateral macronodular hyperplasia, and 1 with micronodular hyperplasia), pheochromocytoma in 5 patients, and adrenal metastasis in 2 patients. Of these 26 patients, successful laparoscopic bilateral adrenalectomy was performed in 18 patients, robotic in 6 patients, and open in 2 patients. Twenty-three out of the 26 adrenalectomies were completed in a single stage, while 3 adrenalectomies were performed as a staged approach due to deterioration in intraoperative respiratory status in two patients and morbid obesity in 1 patient. The operative times for the initial stage in these patients were 200, 306, and 420 minutes, respectively. Of the adrenalectomies completed using the minimally invasive approach, a posterior retroperitoneal (PR) approach was performed in 15 patients (63%) and lateral transabdominal (LT) approach in 9 patients (37%). An LT approach was favored due to tumor size greater than 6 cm in 6 patients, morbid obesity (BMI >35) in 2 patients, and need for a concomitant splenectomy for ITP in 1 patient. The total operative time was 315 minutes with average blood loss of 75mL for laparoscopic cases compared to 389 minutes and 136mL for robotic cases. Robotic cases had a shorter length of stay compared to laparoscopic cases (2.6 vs 3.5 days). The average hospital stay was 3.6 days for all minimally invasive adrenalectomies compared to 5 and 12 days for the two open cases There were no 30-day hospital mortality and only 3 minor complications (11%) for the entire group.

Conclusion: A minimally invasive operation is feasible in 92% of patients undergoing bilateral adrenalectomy with 63% of adrenalectomies completed using the PR approach not requiring repositioning of the patient. Indications for an LT approach are morbid obesity, tumor size > 6 cm and other concomitant intra-abdominal pathology. Single stage adrenalectomies are feasible in most patients. However, prolonged operative time greater than 200 minutes is a risk factor for a staged approach due to intraoperative respiratory decompensation.

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