Nelson's syndrome after bilateral adrenalectomy for Cushing's disease

BACKGROUND: Presentation and outcome of Nelson's syndrome after bilateral adrenalectomy is variable. METHODS: Clinical records of 39 patients who underwent bilateral adrenalectomy for primary or recurrent Cushing's disease during a 15-year period were analyzed for frequency and evolution of Nelson's syndrome. RESULTS: The study included 32 females and 7 males with a mean age of 31 years; 20 patients had a hypophysectomy as the initial procedure, and 19 had an adrenalectomy. Of the group, 17 patients received prophylactic radiation therapy to the pituitary gland. A total of 11 patients, none of whom had received prophylactic radiation therapy, developed Nelson's syndrome (determined by skin hyperpigmentation, elevated serum ACTH levels, and enlargement of a previous pituitary tumor or development of a new tumor in patients with no previous pituitary abnormality) over a mean follow-up period of 53 months. Treatment for Nelson's syndrome included valproic acid, radiation therapy, and hypophysectomy as monotherapy or combined therapy. Of the remaining 28 patients, 10 (7 without prophylactic radio therapy) developed skin hyperpigmentation and increased ACTH levels without a tumor. CONCLUSIONS: Nelson's syndrome is a frequent complication after bilateral adrenalectomy in the absence of prophylactic radiotherapy (28%). The syndrome can be successfully controlled by medical treatment and or radiotherapy; patients rarely require hypophysectomy.     

Laparoscopic lateral adrenalectomy versus open posterior adrenalectomy for the treatment of benign adrenal tumors

BACKGROUND: Minimally invasive techniques play an important role in adrenal gland surgery. The objective of this study was to compare laparoscopic transabdominal adrenalectomy in the lateral position to the open posterior adrenalectomy with respect to the intraoperative and the short-term postoperative course. METHODS: Forty laparoscopic adrenalectomies (LA) carried out between July 1998 and August 2001 were compared to 30 open posterior operations (PA) performed between July 1994 and June 1998. In all cases the indications for surgery was a benign lesion smaller than 8 cm. RESULTS: Age, gender, tumor size, and distribution of the tumor histology were comparable in both groups (LA vs PA). In favor of LA, statistically significant differences (p <0.05) were observed regarding the intraoperative blood loss (260 vs 380 mL), the postoperative narcotic equivalents (2.9 vs 6.4 mg), the morbidity rate (13 vs 27%), and the length of hospital stay (7 vs 10 days). Average operating time was significantly longer for LA (135 vs 106 min). There were two conversions to open adrenalectomy due to diffuse bleeding. Following LA, we observed one major complication (postoperative bleeding from the spleen making a laparotomy necessary) and four minor complications (one small retroperitoneal hematoma, two subcostal nerve irritations, one pleural effusion). PA resulted in one major (wound infection) and seven minor complications (two subcutaneous hematomas, two nerve irritations, two pleural effusions, one dystelectasis). CONCLUSIONS: Laparoscopic adrenalectomy proved as a safe and reliable procedure, displaying all advantages of minimal access surgery. In our institution, it has become the standard technique employed for benign adrenal disease. However, the operation is technically demanding, and as adrenal surgery is rare, it should be restricted to centers with special interest in laparoscopic and endocrine surgery.     

Laparoscopic partial adrenalectomy for recurrent pheochromocytoma after open partial adrenalectomy in von Hippel-Lindau disease

BACKGROUND AND PURPOSE: Unilateral total adrenalectomy is the standard treatment for benign unilateral adrenal tumors. Partial adrenalectomy has to be considered for bilateral adrenal tumors. Recently, our group has reported the feasibility of unilateral and bilateral partial adrenalectomy by means of laparoscopy. Now, we present a case of recurrent pheochromocytoma after open bilateral adrenalectomy and demonstrate that laparoscopic cortex-sparing surgery is feasible for a recurrence after open surgery. Case Report: At the age of 10 years, a boy was found to have bilateral adrenal pheochromocytoma and was treated by open bilateral partial adrenalectomy. Eight years later, the patient presented with palpitation, sweating, and severe hypertension. Investigations biochemically and radiologically demonstrated functional recurrent pheochromocytoma in the left adrenal gland. Genetic studies confirmed mutation of the von Hippel-Lindau (VHL) gene. The patient was prepared for surgery preoperatively by phenoxybenzamine and metropolol. The surgery was performed as planned, and the normal adrenal tissue was spared. The patient had an uneventful postoperative course. His blood pressure was normal on the day of discharge. CONCLUSIONS: In a specialized center with experienced laparoscopic surgeons, laparoscopic partial adrenalectomy for recurrent pheochromocytoma is feasible even after previous open surgery on the ipsilateral adrenal gland. Adrenal-sparing surgery is indicated in hereditary syndromes such as VHL and MEN II to avoid the problems of life-long steroid replacement. Recurrences have to be expected, but further surgery may be less difficult by the previous laparoscopic approach.     

The role of adrenalectomy in Cushing's syndrome

Forty-four patients with Cushing's syndrome were treated by adrenalectomy between 1975 and 1989. Twenty patients had adrenal adenomas: 13 with obvious Cushing's syndrome and 7 whose disease was subclinical, detected after evaluation of an incidentally discovered adrenal mass (es). Twelve patients underwent bilateral adrenalectomies for Cushing's disease after failed transsphenoidal explorations and pituitary irradiation. Six patients had primary adrenal hyperplasia, five as manifestations of Carney's complex. Two others underwent bilateral adrenalectomies for ectopic adrenocorticotropic hormone from carcinoid tumors. Four patients had adrenocortical carcinoma treated with transabdominal adrenalectomy. Three are alive from 8 years to 5 months. There was one postoperative death (2.3%) caused by coagulopathy and multiple organ failure and three (7%) minor postoperative complications. Follow-up showed good to excellent results in 95% of patients. It is concluded that adrenalectomy provides prompt relief from the severe morbidity of Cushing's syndrome regardless of the cause. It is the treatment of choice for adrenal adenomas, carcinomas, primary hyperplasia, and selected patients with Cushing's disease.     

Cushing's syndrome: adrenalectomy and long-term results

BACKGROUND: The objective of this study was to assess the preoperative symptoms, intra- and postoperative complications and follow-up in patients after uni- or bilateral adrenalectomy due to Cushing's syndrome (CS), independent of etiology. METHODS: Clinical charts of 42 patients (5 with ACTH-dependent, 37 with ACTH-independent CS) were reviewed, and follow-up data were obtained from re-examination of the patients. RESULTS: The symptoms most frequently seen were hypertension, changes of the skin and obesity. Eight bilateral and 36 unilateral adrenalectomies were carried out without any intraoperative complications. Postoperative complications occurred in 5 patients, 1 patient died on the fourth postoperative day. After a mean duration of 4.6 years 28 of 41 patients could be re-examined, 5 patients had died. One patient showed recurrence 4.3 years after unilateral adrenalectomy due to nodular hyperplasia, contralateral adrenalectomy again revealed nodular hyperplasia. CONCLUSION: Early diagnosis is essential in order to decrease the rate of pre-, intra- and postoperative complications. Endoscopic approach should be taken in a specialized center due to poor patient's condition. Recurrent disease on the contralateral side may represent bilateral adrenal hyperplasia with sequential tumor formation, demonstrating the importance of extensive preoperative biochemical and imaging testing and close follow-up.     

Role of bilateral adrenalectomy in Cushing's disease

Of 206 patients with Cushing's syndrome observed from 1975 through 1991, 144 (69.9%) had pituitary-dependent Cushing's disease. Of the 110 patients who underwent pituitary surgery, 31 (28%) developed an early recurrence and 23 patients (20%) had a late relapse 1 to 5 years after primary pituitary exploration. We performed a one- or two-step total bilateral adrenalectomy in 43 patients—9 men and 34 (79.4%) women, with an average age of 47.5 years (range 13–58 years). Thirty-three of these patients had already been treated by previous transsphenoidal surgery or alternatively by external pituitary irradiation over a period of 1 to 10 years prior to adrenal surgery. Thirty-one patients underwent adrenalectomy by a double lumbar access or left lumbar and right subcostal incisions. In our series of 55 operations, perioperative complications included two splenectomies and two hemorrhages (7.3%). The early mortality rate was 3.6% (two patients). Minor complications consisted of wound infection (13.5%), bronchopneumonia or pneumothorax (four cases) with a 7- to 12-day longer hospital stay. Nelson syndrome occurred in 6 of 41 patients (14.6%). We therefore believe that bilateral adrenalectomy does play a major role in the treatment of patients with pituitary-dependent Cushing's disease unsuccessfully managed by trans-sphenoidal surgery. It represents the definitive therapy for those patients in whom hypophysectomy was not able to provide satisfactory control of the disease.

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Resumen De 206 pacientes con síndrome de Cushing estudiados entre 1975 y el final de 1991, 144 (69.9%) presentaron enfermedad de Cushing dependiente de la pituitaria. Treinta y uno (28%) de 110 pacientes sometidos a cirugía hipofisiaria desarrollaron una recidiva precoz y 23 pacientes (20%) una recidiva tardía entre 1 y 5 años luego de la exploración de la pituitaria. Hemos practicado adrenalectomía total bilateral en una o dos etapas en 43 pacientes, 9 del sexo masculino y 34 (79.4%) del femenino, con una edad promedio de 47.5 años (rango 13–58). Treinta y tres de estos pacientes ya habían sido tratados mediante cirugía transesfenoidal previa o, alternativamente, mediante irradiaciòn externa de la pituitaria en un período de 1 a 10 años previos a la cirugía suprarenal. Treinta y un pacientes fueron sometidos a adrenalectomía por un doble acceso lumbar o por incisión lumbar izquierda y subcostal derecha. En nuestra serie de 55 operaciones las complicaciones perioperatorias incluyeron 2 esplenectomías y 2 hemorragias (7.3%). La tasa de mortalidad precoz fue 3.6% (2 pacientes). Las complicaciones menores consistieron en infección de la herida (13.5%), bronconeumonía o neumotórax (4 casos), con una prolongación de la hospital-ización de 7–12 días. El síndrome de Nelson se presentó en 6 de 41 pacientes (14.6%). Nuestra conclusión es que la adrenalectomía bilateral juega un papel de importancia en el tratamiento de la enfermedad de Cushing dependiente de la pituitaria cuando ha fallado la cirugía transesfenoidal, puesto que representa la modalidad terapéutica definitiva para estos pacientes en quienes la hipofisectomía no resultó en un control satisfactorio de la enfermedad.

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Résumé Parmi 206 patients ayant un syndrome de Cushing, observés entre 1975 et 1991, 144 (69.9%) avaient une maladie de Cushing hypophysaire. Trente et un (28%) parmi 110 patients qui ont été opérés de l'hypophyse ont eu une récidive précoce alors que 23 (20%) ont eu une récidive tardive, un à cinq ans après l'exploration initiale. Une surrénalectomie totale bilatérale a été réalisée chez 43 patients (9 hommes et 34 (79.4%) femmes, d'âge moyen de 47.5 ans (extrêmes 13–58)). Trente-trois de ces patients avaient déjà été traités par une chirurgie trans-sphénoïdienne ou, alternativement, par la radiothérapie externe hypophysaire, un à 10 ans avant la surrénalectomie. Trente et un patients ont eu une surrénalectomie bilatérale par une lombotomie bilatérale ou une lombotomie gauche associée à une à une incision sous-costale droite. Les complications périopératoires observées ont été deux splénectomies et deux hémorragies (7.3%). La mortalité précoce a été de 3.6% (2 patients). Les complications mineures ont été un abcès de paroi (13.5%), une infection pulmonaire ou pneumothorax (4 cas) rallongeant le séjour hospitalier de 7 à 12 jours. Un syndrome de Nelson a été observé chez 6 des 41 patients (14.6%). Nous pensons que la surrénalectomie bilatérale est une alternative importante dans le traitement de la maladie de Cushing hypophysaire ne réagissant pas à la chirurgie trans-sphénoïdienne, puisqu'elle représente une thérapeutique définitive pour les patients qui peuvent être traités efficacement par l'hypophysectomie.

     

Laparoscopic adrenalectomy for pheochromocytoma: comparison with conventional open adrenalectomy

PURPOSE: To compare the effectiveness and efficacy of laparoscopic transperitoneal adrenalectomy (LTA) with those of open adrenalectomy (OA) in patients with pheochromocytoma. PATIENTS AND METHODS: Among 24 patients (13 male, 11 female) who underwent surgical removal of pheochromocytoma, LTA and OA were performed in 15 and 9, respectively. The mean age was 45.2 years in the LTA group and 43.3 years in the OA group, and the mean tumor size was 5.2 +/- 2.0 (SE) cm and 6.4 +/- 2.6 cm, respectively. Retrospective analysis of their clinical outcomes was performed. The mean follow-up for OA and LTA groups was 36 months and 22 months, respectively. RESULTS: The mean operative time was 171 +/- 66.7 minutes in the LTA group and 200 +/- 73.3 minutes in the OA group. The mean blood loss was 189.5 +/- 50.4 mL and 397.1 +/- 144.7 mL, respectively (P = 0.0341). The mean number of intraoperative hypertensive crises was 0.6 +/- 0.5 during LTA and 1.67 +/- 1.1 during OA (P = 0.0146). In the LTA group, there were no conversions to open surgery and no intraoperative complications, and the blood pressure was well managed intraoperatively without medication. The mean time to oral intake was 1.1 +/- 0.3 days after LTA and 2.6 +/- 1.3 days after OA (P = 0.0037). The mean postoperative hospital stay was 5.6 +/- 2.0 days in the LTA group and 12.4 +/- 3.5 days in the OA group (P = 0.0001). Patient-controlled analgesia was needed by 2 patients (13.3%) in the LTA group and 6 (66.7%) in the OA group (P = 0.0413). In the OA group, three pneumothoraces and one case of sepsis occurred. After a mean follow-up of 36 months, two patients in the OA group redeveloped hypertension. With a mean follow-up of 22 months, none of the 15 LTA patients redeveloped hypertension. CONCLUSIONS: Laparoscopic adrenalectomy for pheochromocytoma is a safe and effective prodcedure providing the benefits of a minimally invasive approach.     

Cushing's syndrome: 20 years after adrenalectomy

The long term results (over 20 years) of our first 13 patients treated by adrenalectomy for Cushing's syndrome are described. Twelve survived operation and 5 of these died within 5 years, but thereafter the expectation of life of the treated patients was similar to that of the general population. At 20 years 7 patients were alive and 6 were well. If modern therapeutic measures to control adrenocortical function before operation has been available 20 years ago, some of the early deaths might have been prevented.     

Laparoscopic adrenalectomy for Conn's syndrome

Laparoscopic adrenalectomy is now used worldwide to resect adrenal adenomas and other adrenal tumors recently introduced in Pakistan. Two cases of endocrine hypertension, due to Conn s syndrome, undergoing laparoscopic adrenalectomy for the first time here, are reported.     

Laparoscopic versus open ileocolic resection for Crohn's disease

OBJECTIVE: Laparoscopic ileocolic (LI) resection for Crohn's disease has several potential advantages over the traditional open technique. The objective of this study was to compare early surgical outcomes in patients having laparoscopic versus open ileocolic resections for Crohn's disease. METHODS: Data collected prospectively from 21 patients having LI resection for Crohn's disease between 1995 and 2001 were compared to data from 19 patients having open ileocolic resection for Crohn's disease between 1990 and 1995. RESULTS: Patients in both groups had similar ages, sex distribution, and rates of previous abdominal surgery. Mean operating time was not significantly different between the groups. There was a nonsignificant trend to less postoperative analgesic requirement in the laparoscopic group. Resumption of liquid (P <.001) and solid (P =.01) diet, return of bowel function [flatus (P =.008), feces (P =.008)] and time to discharge (P =.001) all occurred significantly more quickly in the laparoscopic group. There was no difference in the rates of morbidity between the two groups. CONCLUSIONS: LI resection for Crohn's disease appears to be safe and has comparable if not superior results to open surgery in the short term.     

Current status of adrenalectomy for Cushing's disease

To evaluate the current use of adrenalectomy in the treatment of Cushing's disease, we reviewed seven consecutive patients who have undergone adrenalectomy for Cushing's disease at this medical center during 1983 to 1984. Seventy-one percent (5/7) had pituitary, or type I, Cushing's disease, while 29% (2/7) had adrenal, or type II, Cushing's disease from either an adenoma or an adrenocortical carcinoma. Presenting signs and symptoms, either initially or at the time of recurrence, were typical of Cushing's syndrome. Four of five patients with type I disease had recurrent disease after transphenoidal hypophysectomy, bilateral adrenalectomy, or unilateral adrenalectomy. In three of five patients, medical therapy of hypercortisolism was abandoned because of adverse side effects. Preoperative evaluation in all patients included cortisol and ACTH levels, dexamethasone suppression tests, and computerized tomography (both abdominal and head). In patients with a prior history of adrenalectomy, radiocholesterol scans were also performed and were useful. Angiographic procedures were not required in these patients. In patients with type I disease, posterior operative approaches were used. In patients with type II disease, an anterolateral approach was used. Posterolateral incisions are preferred over Hugh-Young incisions and provide better exposure with a reduced risk of poor wound healing. Morbidity and mortality included one death and three nonhealing wounds. In the six surviving patients, symptoms resolved with variable frequency. Findings suggestive of Nelson's syndrome (hyperpigmentation) have occurred in two patients; serial computerized tomographic scans fail to reveal evidence of pituitary tumors. We conclude that adrenalectomy remains an essential form of therapy for patients with Cushing's syndrome caused by adrenal tumors or recurrence after previous surgery. The response to the operation is generally good, but long-term surveillance is required for the development of Nelson's syndrome.     

Bilateral endoscopic adrenalectomy for Cushing's syndrome in a patient with polycystic liver and kidney disease

Microadenomectomy via a transsphenoidal approach is today's treatment of choice to achieve normal cortisol blood levels in patients with ACTH-secreting pituitary tumors. Should neurosurgery fail, bilateral adrenalectomy is recommended. Today the endoscopic, transabdominal or retroperitoneal adrenalectomy is regarded as the gold standard for the operation of endocrine-active adrenal tumors. Therefore, in principle, the question of the indication for the endoscopic operation no longer arises but only the question of the technical feasibility in individual cases. We report on a patient with a pituitary-dependent Cushing's syndrome after a twice-repeated unsuccessful transsphenoidal adenomectomy and with additional polycystic kidney and liver disease, who underwent bilateral retroperitoneoscopic adrenalectomy. Despite the massive enlargement of both kidneys, it was possible to safely perform a bilateral retroperitoneoscopic adrenalectomy. In the case of marked bilateral cystic kidneys, a bilateral retroperitoneoscopic adrenalectomy in Cushing's syndrome is technical possible and a safe and effective method of treatment.     

Synchronous bilateral adrenalectomy for adrenocorticotropic-dependent Cushing's syndrome.

Select patients with ACTH-dependent Cushing's syndrome, such as patients with persistent Cushing's disease after failed hypophysectomy or patients with ectopic ACTH production, may require bilateral adrenalectomy. Laparoscopic bilateral adrenalectomy has been described, offering definitive treatment with reduced morbidity compared with open techniques. We report on the performance of synchronous bilateral adrenalectomy treated using the da Vinci robot (Intuitive Surgical, Sunnyvale, CA). To our knowledge, the usage of this minimally invasive approach for this operation has yet to be reported in literature. The details of the case and a brief review of the literature are described herein.     

The pituitary before and after adrenalectomy for Cushing's syndrome

Seventy-nine patients underwent subtotal or total adrenalectomy for pituitary-dependent Cushing's syndrome (1953–1980); 76 survived the operation and 75 were followed for 1 to 27 (mean 11) years. Pigmentation, plasma ACTH, and sellar X-rays were assessed at intervals. Pigmentation developed in 37 (5 before and 32 after operation), most frequently after total adrenalectomy. The sella was definitely enlarged in 6 of 65 patients before the operation and in 14 of 65 after it. Enlargement was more common in pigmented than in non-pigmented patients. The plasma ACTH concentration rose after adrenalectomy. It was significantly higher in pigmented than in non-pigmented patients. It was also higher after total than after subtotal adrenalectomy. Pituitary tumors were confirmed histologically in 15 patients. The tumors presented at the same time as the Cushing's syndrome in 8 and after adrenalectomy in 7. They were malignant and fatal in 6. Pigmentation, present in 11 of these patients, developed only after adrenalectomy. In 9 other patients with benign lesions and 21 with clinically probable but histologically unconfirmed tumors, 7 were treated by hypophysectomy with or without irradiation (4 cured, 3 improved), and 4 by irradiation alone: external 3, internal 1 (all improved).

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Resumen Setenta y nueve pacientes fueron sometidos a adrenalectomía subtotal o total por síndrome de Cushing pituitario-dependiente (1953–1980); 76 sobrevivieron la operación y 75 fueron seguidos por 1 a 27 (media de 11) años. La pigmentación, los niveles plasmáticos de ACTH y radiografías de la silla turca fueron evaluados periódicamente.La pigmentación se desarrolló en 37 (5 antes y 32 después de la operación), más frecuentemente después de adrenalectomía total.La silla turca apareció claramente aumentada de tamano en 6 de 65 pacientes antes de la operación y en 14 de 65 después. El aumento de tamano fue más común en los pacientes pigmentados que en los no pigmentados.La concentración plasmática de ACTH ascendió después de la adrenalectomía. Se presentó en forma significativamente más alta en los pacientes pigmentados que en los no pigmentados. Fue más alta después de adrenalectomía total que de adrenalectomía subtotal.Tumores pituitarios fueron confirmados histológicamente en 15 pacientes. Se presentaron al tiempo con el síndrome de Cushing en 8 y después de adrenalectomía en 7. Los tumores fueron malignos y fatales en 6. La pigmentación, présente en la totalidad de los 11 pacientes, se desarrolló solo después de la adrenalectomía. En otros 9 pacientes con lesiones benignas y en 21 con tumores clínicamente probables pero histológicamente no confirmados, 7 fueron tratados con hipofisectomía con o sin irradiación (4 curados 3 mejorados) y 4 con irradiación solamente (externa 3, interna 1), todos mejorados.

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Résumé De 1953 à 1980, 79 malades atteints de maladie de Cushing hypophyso-dépendantes ont subi une surrénalectomie subtotale ou totale. Soixante-seize ont survécu à l'opération et 75 ont été suivis de 1 à 27 ans après l'intervention. On a évalué à intervalles réguliers la pigmentation, le taux plasmatique d'ACTH et l'état radiologique de la selle turcique.La pigmentation s'est développée chez 37 malades (5 avant et 32 après l'intervention) plus particulièrement après surrénalectomie totale.L'élargissement de la selle turcique a été constaté chez 65 sujets étudiés, 6 fois avant l'intervention et 14 fois après celle-ci, l'élargissement étant plus fréquent chez les sujets accusant une nette pigmentation.La concentration plasmatique en ACTH s'est élevée après surrénalectomie, le taux étant plus élevé chez les malades pigmentés et après surrénalectomie totale.Le diagnostic de tumeur hypophysaire a été confirmé histologiquement chez 15 sujets: 8 fois au moment de la découverte du Cushing et 7 fois après la surrénalectomie. Chez 6 de ces 7 opérés la tumeur de nature maligne entraîna la mort. Onze des 15 sujets développèrent une pigmentation après la surrénalectomie.Chez 9 autres malades qui présentaient des lésions bénignes et chez 21 qui présentaient une tumeur cliniquement probable mais qui ne fut pas confirmée histologiquement, 7 furent traités par hypophysectomie avec ou sans irradiation (4 guéris, 3 améliorés) et 4 par irradiation externe (3 cas) et interne (1 cas), tous les 4 améliorés.

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Supported by the State Scholarship Foundation of Greece (IKY) and the Yvonne Gregory Fund.     

Laparoscopic adrenalectomy for pheochromocytoma: comparison with open adrenalectomy and comparison of laparoscopic surgery for pheochromocytoma versus other adrenal tumors

OBJECTIVE: To compare the efficacy of laparoscopic adrenalectomy for pheochromocytoma with that of conventional open adrenalectomy for pheochromocytoma and laparoscopic surgery for other adrenal tumors. PATIENTS AND METHODS: Fifty-four patients with adrenal tumors, including 10 cases of pheochromocytoma, 18 cases of Cushing's syndrome, 20 cases of primary aldosteronism, and 6 cases of nonfunctioning tumors, were evaluated. A historical group of 7 consecutive patients who underwent conventional open adrenalectomy for pheochromocytoma was also studied. RESULTS: Laparoscopic adrenalectomy for pheochromocytoma was successful in 9 of the 10 patients. There was no difference in tumor size, operation time, estimated blood loss, or occurrence of hypertensive episodes during surgery between patients treated with laparoscopic procedures and those treated with open surgery. However, the number of days to first postoperative oral feeding and first ambulation, length of hospitalization, and number of patients requiring parenteral analgesics were significantly smaller after laparoscopic surgery than after open surgery. There was no significant difference in operation time, estimated blood loss, incidence of intraoperative complications, or postoperative recovery between patients who underwent laparoscopic adrenalectomy for pheochromocytoma and those who underwent laparoscopic surgery for other adrenal lesions. CONCLUSIONS: Laparoscopic adrenalectomy does not increase the specific risks associated with surgery for pheochromocytoma. It is a minimally invasive alternative to conventional open adrenalectomy.     

Laparoscopic versus open hemicolectomy

AIM: In the last decade, laparoscopic procedures are applied to the treatment of almost all colonic diseases, including both benign and malignant lesions. Focusing our attention to the laparoscopic operative technique, we compare the perioperative results and the oncological outcomes of laparoscopic hemicolectomy with those after open conventional hemicolectomy. METHODS: This prospective non randomized study is based on a series of 469 consecutive patients (73.6% with malignant lesions) operated on by the same surgical team following the same type of surgical technique, for laparoscopic and open approach, to perform right (RH) and left (LH) hemicolectomy, respectively, excluding segmental resections, emergency operations as well as transverse colon, splenic flexure and recurrent carcinomas. The treatment modality was selected by the patients after reading the informed consent form. Conversion rate to open surgery (for the laparoscopic group) and causes were assessed. Statistical significance (p) for operative time, resumption of gastrointestinal functions, length of stay, complications, perioperative mortality, as well as length of specimen, number of lymph-nodes harvest, incidence of local recurrences and distant metastases, and survival probability analysis in malignant cases, was assessed between the 2 groups (laparoscopic and open). RESULTS: From March 1992 to February 2003, 166 patients underwent RH and 303 LH. In the RH group, 108 patients underwent laparoscopic approach and 58 underwent open surgery (26 vs 13 for benign lesions and 82 vs 45 for adenocarcinomas, respectively). LH was performed by laparoscopy in 202 patients and by laparotomy in 101 (55 vs 30 for benign lesions and 147 vs 71 for adenocarcinomas, respectively). There were no conversions to open surgery in laparoscopic RH, while 10 patients (4.9%) in the laparoscopic LH group required conversion: 3 of 34 performed for diverticular disease and 7 of 147 performed for malignancy. Mean operative time for laparoscopic surgery was longer than for open surgery (182 vs 140 min for RH and 222 vs 190 min for LH, respectively), but with increasing experience this decreased significantly. Mean hospital stay in patients who underwent laparoscopic procedures was significantly shorter both in RH and LH groups (9.2 vs 13.2 days and 9.9 vs 13.2 days, respectively). Similar major complication rates were observed between the 2 laparoscopic and open groups (1.8% vs 1.7% for RH and 4.1% vs 4.9% for LH, respectively). Follow-up time ranged between 12 and 109 months (mean, 57.3 months) in RH groups and between 12 and 111 months (mean, 57.5 months) in LH groups. The follow-up dropout was of only 3 patients after RH (in the laparoscopic group) and 5 after LH (3 in the laparoscopic group and 2 in the open group). The local recurrence rate was lower after laparoscopic surgery in both arms (7% vs 8.8% for RH and 3.3% vs 7% for LH, respectively), but the differences were not statistically significant. Two port site recurrences were observed in the laparoscopic groups, 1 after a Dukes D palliative RH and 1 after a Dukes C LH converted to open surgery (1.7% and 0.9%, respectively). Metachronous metastases rates were similar between the laparoscopic and open groups (20.9% vs 17.6% for RH and 4.4% vs 5.3% for LH, respectively). Cumulative survival probability (CSP) at 72 months after laparoscopic RH was 0.791 as compared to 0.765 after open surgery (p=0.326) and 0.956 after laparoscopic LH as compared to 0.877 after open surgery (p=0.115). CSP for Dukes stage A, B and C in the laparoscopic RH group was 0.875, 0.846, and 0.727 as compared to 0.9 (p=0.815), 0.889 (p=0.87), and 0.6 (p=0.183) after open surgery, respectively. CSP for Dukes stage A, B and C in the laparoscopic LH group was 0.1, 0.966, and 0.885 as compared to 0.1 (p=0.936), 0.944 (p=0.466), and 0.7 (p=0.072) after open surgery, respectively. CONCLUSION: These results suggest that laparoscopic hemicolectomy for both benign and malignant lesions can be performed safely. Oncological outcomes were comparable with those of open surgery.