The Effect of Surgeon Expertise on the Outcome of Patients with Adrenocortical Carcinoma

Complete surgical removal of adrenocortical carcinoma (ACC) represents the only chance of long-term cure. In this study, we compared the long-term outcomes of ACC patients depending on whether they had adrenal surgery performed in a high-volume (HVC) or in a low-volume (LVC) center. This retrospective study included 49 patients from the Croatian ACC Registry with the European Network for the Study of Adrenal Tumors (ENSAT) stage I–III ACC, of which 35 underwent surgery in a HVC whereas 14 of them were operated in one of the LVCs. Patients operated in the LVCs had a significantly higher rate of ACC recurrence (57.1% vs. 22.9%; p = 0.02). Accordingly, RFS was significantly longer in patients operated on in HVC (p = 0.04). The difference in RFS remained significant after controlling for age, gender, tumor size, Ki-67 index, Weiss score, and type of surgery (HR 4.55; 95% CI 1.16–17.88; p = 0.03). In addition, there is a tendency towards longer DSS in patients in the HVC group compared to those in the LVC group (p = 0.05). These results point to the centralization of adrenal surgery as a key prerequisite for improving the outcomes of ACC patients.

EP.WE.484Conservative management of post-operative chyle leak after surgery for a large adrenal cavernous haemangioma

Post-operative chyle leak is a rare but recognised complication after abdominal surgeries particularly those involving dissection adjacent to the retroperitoneal lymph nodes and/or lymphatic systems. There are limited cases of post-operative chyle leak associated with adrenal surgery reported in the literature with no consensus on its management. Lymphatics of the adrenal gland drain into the thoracic duct via regional lymph nodes or directly into the cisterna chyli, posterior to the aorta. If not adequately managed, chyle leak can be associated with hypovolemia, electrolyte imbalances, malnutrition and immunosuppression. These consequences can be attributed to the loss of fluid, electrolytes, lipids, proteins, and immunoglobulins. We hereby report a case of post-operative chyle leak in a 79-year-old male who underwent an open left adrenalectomy, left nephrectomy, splenectomy and distal pancreatectomy for a large, 20.8cm left adrenal cavernous haemangioma. Chyle leak was confirmed on post-operative day 7 based on high levels of triglycerides in the abdominal drain output. Intra-operatively there was no evidence of lymphatic damage. However, the major abdominal surgery involving retroperitoneal viscera close to the lymphatic trunk predisposed the patient to this complication. The patient was managed conservatively with the aim of decreasing chyle production by dietary manipulation and use of somatostatin. Enteral nutrition was continued with a strict low-fat diet and regular dietician input. These strategies contributed to the gradual resolution of chyle leak and the patient’s recovery.

Robotic Versus Laparoscopic Adrenalectomy: Systemic Review

Background: Minimal invasive surgery has become the standard for most surgical procedures now. Many studies have tried to compare robotic versus laparoscopic to adrenalectomy. Objectives: The aim of this study is to review most of the available studies comparing robotic to laparoscopic adrenalectomy to evaluate which procedure provides the superior clinical outcomes. Methods: A systematic literature search of ScienceDirect and PubMed databases. The perioperative clinical outcomes were collected by two independent reviewers. We used Random-effects (DerSimonian-Laird) models to get the pooled effect estimates. Results: 18 studies were eligible in our study. 10 of them were prospective and 8 were retrospective. A total of 1376 patients underwent adrenalectomy, 592 (43.02%) were treated with RA and 784 (56.9%) with the LA technique. There were no significant differences between both groups regarding the conversion rate (Odds ratio: 0.70, 95% CI 0.31-1.57, P= 0.65), intraoperative complications (OR: 2.18, 95% CI 0.49- 9.71, P= 0.28), post-operative complications (OR: 0.83, 95% CI: 0.55-1.24, P= 0.49), and mortality (OR: 0.42, 95% CI: 0.07-2.72, P= 0.98). However, robotic adrenalectomy was associated with longer operative times (MD: 9.89 min, 95% CI: -2.79 to 22.58), shorter hospital stay (MD: -0.33, 95% CI: -0.46 to -0.21) with less blood loss (MD: -25.34, 95% CI: -36.77 to -13.91). Conclusions: We proved that robotic adrenalectomy has equal safety and feasibility with similar clinical outcomes when compared with laparoscopic approach. However, better well-designed studies are required to determine the role and cost-effectiveness of robotic adrenal surgery.

Changes in the Size of a Ruptured Pheochromocytoma after Transcatheter Arterial Embolization

The spontaneous rupture of a pheochromocytoma is rare and can be potentially fatal. We report a case of a tumor size reduction of a ruptured pheochromocytoma after transcatheter arterial embolization (TAE). A 60-year-old Japanese woman was referred to the emergency department of another hospital with a sudden onset of left lateral pain. Computed tomography of the abdomen revealed adrenal hemorrhage with a 5.7 cm adrenal mass, and she was transferred to our hospital for treatment. Considering that she had marked hypertension (193/115 mmHg), we made a provisional diagnosis of left lateral pain due to a ruptured pheochromocytoma. She underwent TAE, and the hemorrhage was successfully controlled. She was started on oral doxazosin for hypertension. The dose of doxazosin was increased to the extent that orthostatic hypotension did not develop, and blood pressure was well controlled. After discharge, the tumor size gradually decreased to approximately 1.0 cm within six months. Six months after TAE, elective laparoscopic surgery was performed, and the diagnosis was confirmed by histopathology. We observed a decrease in the size of the ruptured pheochromocytoma after TAE. To reduce the risk of laparoscopic adrenal surgery, it may be useful to monitor the size of a ruptured pheochromocytoma after TAE before deciding the surgery time.