Thierry Defechereux

Complications of Laparoscopic Adrenalectomy: Results of 169 Consecutive Procedures

Laparoscopic adrenalectomy (LA) has become the gold standard for adrenalectomy. Review of the literature indicates that the rate of intra- and postoperative complications is not negligible. The aim of this study was to evaluate the complications observed in a series of 169 consecutive LAs performed at a same center for a variety of endocrine disorders. Between June 1994 and December 1998 a series of 169 LAs were performed in 159 patients: 149 unilateral LAs and 10 bilateral LAs. There were 98 women and 61 men with a mean age of 49.7 years (range 22–76 years). There were patients with 61 Conn syndrome, 41 with Cushing syndrome, 1 androgen-producing tumor, 29 pheochromocytomas, and 37 nonfunctioning tumors. Mean tumor size was 32 mm (range 7–110 mm). LA was performed by a transperitoneal flank approach in the lateral decubitus position. Mean operating time was 129 minutes (range 48–300 minutes) for unilateral LA and 228 minutes (range 175–275 minutes) for bilateral LA. There was no mortality. Twelve patients had a significant complication (7.5%): three peritoneal hematomas requiring (in two cases) laparotomy and (in one case) transfusion; one parietal hematoma; three intraoperative bleeding episodes without need for transfusion; one partial infarction of the spleen; one pneumothorax; one capsular effraction of the tumor; and two deep venous thromboses. Eight tumors were malignant at final histology (4.7%), of which four were completely removed laparoscopically. Conversion to open surgery was required in eight cases (5%): for malignancy in four cases, difficulty of dissection in three cases, and pneumothorax in one case. With a mean follow-up of 26.58 months (range 6–60 months) all patients are disease-free. We conclude that LA is a safe procedure. With increasing experience the morbidity becomes minor. To avoid complications LA should be converted to open surgery if local invasion is suspected or if there is difficulty with the dissection.

Should laparoscopic approach be proposed for large and/or potentially malignant adrenal tumors?

Abstract  Introduction: Laparoscopic adrenalectomy (LA) is safe and effective for small, benign, functioning tumors. Whether it should be performed for other adrenal tumors is questionable. The aim of this study was to evaluate and compare the complications and results of 150 consecutive LAs performed either for small benign tumors or for large and/or potentially malignant tumors. Methods: Between June 1994 and August 1998, we performed 150 LAs in 142 patients. We used a transperitoneal flank approach in the lateral decubitus position. Initially, our indications for LA were limited to small (<4 cm) benign tumors (group I, n=102): 56 aldosteronomas, 33 Cushing’s syndrome, 11 pheochromocytomas and 2 nonfunctional tumors. Progressively, based on increasing experience, LA was also proposed for tumors larger than 4 cm or potentially malignant (group II, n=48): 5 Cushing’s syndrome, 1 androgen-producing tumor, 14 pheochromocytomas and 28 nonfunctional tumors. Preoperative demonstration of invasive extra-adrenal carcinoma remained an absolute contraindication for LA. Results: Mean tumor size was 21.1 mm in group I and 51.6 mm in group II. All tumors in group I were benign. Six of the 48 tumors in group II were malignant (12.5%). The rate of complication was, respectively, 7.8% and 8.3% in groups I and II. The rate of conversion was, respectively, 4.9% and 6.2% in groups I and II. Mean operative time was 131 min in group I and 129 min in group II. The endocrinopathy was cured in all patients. To date, no recurrences have been observed. Conclusions: LA can be proposed for large (<12 cm) or potentially malignant adrenal tumors provided preoperative investigations have not demonstrated invasive carcinoma. An open procedure should be performed instead if local invasion is observed at the start of the operation.

Bilateral neck exploration under hypnosedation : A new standard of care in primary hyperparathyroidism?

OBJECTIVE The authors review their experience with initial bilateral neck exploration under local anesthesia and hypnosedation for primary hyperparathyroidism. Efficacy, safety, and cost effectiveness of this new approach are examined. BACKGROUND Standard bilateral parathyroid exploration under general anesthesia is associated with significant risk, especially in an elderly population. Image-guided unilateral approaches, although theoretically less invasive, expose patients to the potential risk of missing multiple adenomas or asymmetric hyperplasia. Initial bilateral neck exploration under hypnosedation may maximize the strengths of both approaches while minimizing their weaknesses. METHODS In a consecutive series of 121 initial cervicotomies for primary hyperparathyroidism performed between 1995 and 1997, 31 patients were selected on the basis of their own request to undergo a conventional bilateral neck exploration under local anesthesia and hypnosedation. Neither preoperative testing of hypnotic susceptibility nor expensive localization studies were done. A hypnotic state (immobility, subjective well-being, and increased pain thresholds) was induced within 10 minutes; restoration of a fully conscious state was obtained within several seconds. Patient comfort and quiet surgical conditions were ensured by local anesthesia of the collar incision and minimal intravenous sedation titrated throughout surgery. Both peri- and postoperative records were examined to assess the safety and efficacy of this new approach. RESULTS No conversion to general anesthesia was needed. No complications were observed. All the patients were cured with a mean follow-up of 18 +/- 12 months. Mean operating time was <1 hour. Four glands were identified in 84% of cases, three glands in 9.7%. Adenomas were found in 26 cases; among these, 6 were ectopic. Hyperplasia, requiring subtotal parathyroidectomy and transcervical thymectomy, was found in five cases (16.1%), all of which had gone undetected by localization studies when requested by the referring physicians. Concomitant thyroid lobectomy was performed in four cases. Patient comfort and recovery and surgical conditions were evaluated on visual analog scales as excellent. Postoperative analgesic consumption was minimal. Mean length of hospital stay was 1.5 +/- 0.5 days. CONCLUSIONS Initial bilateral neck exploration for primary hyperparathyroidism can be performed safely, efficiently, and cost-effectively under hypnosedation, which may therefore be proposed as a new standard of care.

Surgical Management of Amiodarone-associated Thyrotoxicosis: Too Risky or Too Effective?

Abstract. Amiodarone-associated thyrotoxicosis, often clinically mild and resolutive after amiodarone discontinuation or under medical therapy, is sometimes drug unresponsive and not uncommonly follows a dramatic, even fatal course. Therefore, we considered a surgical solution in 15 severely amiodarone-associated thyrotoxic patients. Twelve men and three women (mean age 68 years, range 50–84 years) underwent radical thyroidectomy for clinical and biologically proved amiodarone-associated thyrotoxicosis. In six surgery was the first-line therapeutic option. In the other nine thyroidectomy seemed unavoidable considering the unresponsiveness to medical therapy and rapid deterioration of the patients’ clinical condition, with life-threatening cardiac failure in three. In every patient surgery was conducted without immediate or delayed complications. Total thyroidectomy proved uniformly, definitively, and rapidly effective in controlling thyrotoxicosis in all patients, with a spectacular reversal of cardiac failure in the three most critical cases. Surgery was beneficial to our 15 patients and undoubtedly life-saving in the three most worrying cases. These results suggest that thyroidectomy should be more liberally regarded as an interesting alternative to conventional, but unpredictably effective, medical therapies.

Iatrogenic thyrotoxicosis. Causal circumstances, pathophysiology and principles of treatment. Review of the literature

Thyrotoxicosis is the clinical syndrome that results when tissues are exposed to high levels of circulating thyroid hormones. In most instances thyrotoxicosis is due to hyperthyroidism, a term reserved for disorders characterized by overproduction of thyroid hormones by the thyroid gland. Nevertheless, thyrotoxicosis may also result from a variety of conditions other than thyroid hyperfunction. The present report focuses on the etiologies, pathophysiology, and treatment of iatrogenic thyrotoxicosis. Iatrogenic thyrotoxicosis may be caused by (1) subacute thyroiditis (a result of lymphocytic infiltration, cellular injury, trauma, irradiation) with release of preformed hormones into circulation; (2) excessive ingestion of thyroid hormones (“thyrotoxicosis factitia”); (3) iodine-induced hyperthyroidism (radiologic contrast agents, topical antiseptics, other medications). Among these causes of iatrogenic thyrotoxicosis, that induced by the iodine overload and cytotoxicity associated with amiodarone represents a significant challenge. Successful management of amiodarone-induced thyrotoxicosis requires close cooperation between endocrinologists and endocrine surgeons. Surgical treatment may have a leading yet often underestimated role in view of the potential life-threatening severity of this disease, whereas others kinds of iatrogenic thyrotoxicosis are usually treated conservatively.

Evidence of in vivo Free Radical Generation by Spin Trapping with α-Phenyl N-Tert-Butyl Nitrone During Ischemia/Reperfusion in Rabbit Kidneys

By using alpha-phenyl N-tert-butyl nitrone (PBN) as spin trap molecule and the electron paramagnetic resonance (EPR) technique, we obtained the first direct evidence of in vivo intervention of free radicals during an ischemia (50 minutes) reperfusion phenomenon in kidney of an intact rabbit. An EPR signal (triplet of doublets) characterized by coupling constants aN = 14.75-15 G and aH beta = 2.5-3 G was detected in blood samples. The signal was consistent with a nitroxyl-radical adduct resulting from the spin trapping by PBN of either oxygen-or carbon-centered radicals. Control experiments indicated that the EPR signal was not due to a toxic effect of the spin trap molecule.

[Supernumerary ectopic hyperfunctioning parathyroid gland: a potential pitfall in surgery for sporadic primary hyperthyroidism].

STUDY AIM The aim of this retrospective study was to report a series of nine patients with a sporadic primary hyperparathyroidism, operated on for an ectopic supernumerary hyperfunctioning parathyroid gland. PATIENTS AND METHOD From 1973 to 1998, among a total of 1,307 patients operated on for a primary hyperparathyroidism, 9 (0.69%) had an ectopic supernumerary hyperfunctioning gland. There were six women and three men (mean age: 63 years) with a sporadic hyperparathyroidism. Initial cervicotomy was performed in our institution in 6 cases. The nine patients underwent 19 operations including one through sternotomy. The ectopic parathyroid gland was localized in the eight patients who had preoperative localization studies. RESULTS The supernumerary gland was located in the anterior mediastinum (n = 6), in the carotid sheath (n = 2) and within the vagus nerve (n = 1). In three patients, it was found during the initial cervicotomy. In the 6 other patients, it was found in the course of a reoperation. With a mean follow-up of five years, all the patients were biochemically cured. One patient had a permanent recurrent nerve palsy and a definitive hypoparathyroidism. CONCLUSIONS The low incidence of an ectopic supernumerary hyperfunctioning parathyroid gland in sporadic hyperparathyroidism does not justify the routine use of preoperative localization studies and intra-operative quick parathormon assay. During an initial conventional cervicotomy the search for a 5th gland is highly recommended when 4 normal glands have been found in the neck. This research should also be performed in case of multi-glandular disease.

Surgical management of adrenal tumours lessons from a 10 years personal experience

Abstract Objective: To review our personal experience of the last 10 years with adrenal surgery in order to define the indications of laparoscopic adrenalectomy (LA) and open adrenalectomy (OA), respectively. Patients and methods: From November 1993 to June 2003, we performed 105 adrenalectomies on 97 patients (29 males and 68 females). The lesions resected were preoperatively considered non-secreting in 47 cases (45%) and hormonally active in 58 cases (55%). In 78 patients (80%), La was performed and 84 adrenal glands were resected. In 19 patients (20%), OA was considered the best modality of resection and 21 adrenal glands were resected. The average tumour size was 37.2 mm (range 25-90) in LA group and 82.6 mm (30-260) in the OA group. All the LA were performed using a trans-peritoneal approach. Depending on the particularities of the lesions and of the patients, the OA were performed by anterior or lumbar incisions. Results: There was no mortality. Conversion from LA to open surgery was necessary in two patients. Mean operating time was 110 minutes for LA and 135 minutes for OA. Two (2.6%) patients suffered complications after LA and 4 (19%) after OA. Conclusions: In our experience, trans-peritoneal LA proved to be a safe and reliable procedure for benign adrenal disease. In our institution, it has become the gold standard technique for the resection of adrenal tumours, except for those suspected or proven malignant.

Die transperitoneale Adrenalektomie: Erfahrungen an 169 Patienten

SummaryBackground: Several techniques have been proposed to remove the adrenal glands laparoscopically. There is still some debate about the respective advantages and inconveniences of the transperitoneal and retroperitoneal approaches. In this study the authors report their experience with the transperitoneal flank approach.Methods: Between June 1994 and January 1999, 217 adrenalectomies were performed in our department. There were 169 laparoscopic adrenalectomies (LA) — (78 %): 61 Conn’s syndrome, 41 Cushing’s syndrome, 29 pheochromocytomas, 1 androgen producing tumor and 37 non functioning tumors. An open approach was used in 48 patients (22 %). Large and/or malignant or suspected malignant tumors (26 cases) multiple and/or extra adrenal pheochromocytomas (12 cases), previous surgery in the adrenal area (10 cases).Results: LA was unilateral in 149 patients and bilateral in 10 patients. Mean tumor size was 32 mm (7–110). Eight tumors were malignant (4.7 %). Four out of these 8 malignant tumors were completely removed laparoscopically. Conversion to open surgery was required in 8 patients (5 %). Twelve patients (7.5 %) had significant complications. There was no mortality. Mean operative time was 126 minutes (48–300) for unilateral LA and 228 minutes (175–275) for bilateral LA. The average length of hospital stay was 5.4 days (3–15). The endocrinopathy was successfully cured in all patients with functioning tumors.Conclusions: There are few absolute contraindications for LA. LA is the procedure of choice for small benign and functioning tumors. Invasive adrenal carcinoma is an absolute contraindication for LA. Nevertheless, depending on the experience of the operator, LA can be also proposed for large tumors or tumors at risk for malignancy. If local invasion is observed at the start of the procedure, LA should be immediately converted to open surgery.ZusammenfassungGrundlagen: Zahlreiche Techniken werden zur endoskopischen Entfernung der Nebenniere vorgeschlagen. Es gibt nach wie vor Diskussionen über Vor- und Nachteile des laparoskopischen und retroperitoneoskopischen Vorgehens. In vorliegender Untersuchung berichten die Autoren über eigene Erfahrungen des lateralen, transperitonealen Vorgehens.Methodik: Zwischen Juni 1994 und Jänner 1999 wurden 217 Adrenalektomien durchgeführt. 169 (78 %) wurden laparoskopisch (LA) ausgeführt. Bei 61 Patienten lag ein Conn Syndrom, bei 41 Patienten ein Cushing Syndrom, bei 29 Patienten ein Phäochromozytom, bei einem Patienten ein Androgen produzierender Tumor und bei 37 Patienten ein hormoninaktiver Tumor vor. Ein offenes Verfahren wurde bei 48 Patienten (22 %) gewählt. Gründe dafür waren Größe und/oder maligne oder malignomverdächtige Tumoren (26 Patienten), multiple und/oder extraadrenale Phäochromozytome (12 Patienten) bzw. Reeingriffe an der Nebenniere (10 Patienten).Ergebnisse: Bei 149 Patienten wurde die LA einseitig, bei 10 Patienten beidseitig durchgeführt. Der mittlere Tumordurchmesser betrug 32 mm (7–110). Acht Tumore (4,7 %) waren bösartig. Vier dieser acht bösartigen Tumore wurden vollständig laparoskopisch entfernt. Bei 8 Patienten (5 %) mußte zur offenen Operation konvertiert werden. 12 Patienten (7,5 %) hatten signifikante Komplikationen. Kein Patient ist verstorben. Die mittlere Operationszeit betrug 126 Minuten (48–300) bei einseitiger und 228 Minuten (175–275) bei beidseitiger LA. Die durchschnittliche Krankenhausaufenthaltsdauer betrug 5,4 Tage (3–15).Schlußfolgerungen: Es gibt einige absolute Kontraindikationen für eine LA. LA ist die Methode der Wahl für kleine gutartige und hormonaktive Tumoren. Invasive Nebennierenkarzinome sind eine absolute Kontraindikation für die LA. Abhängig von der Erfahrung des Operateurs kann die LA auch bei großen und malignomverdächtigen Tumoren eingesetzt werden. Sollte sich am Beginn der LA Hinweise für eine Invasion zeigen, ist sofort zum offenen Vorgehen zu konvertieren.Grundlagen: Zahlreiche Techniken werden zur endoskopischen Entfernung der Nebenniere vorgeschlagen. Es gibt nach wie vor Diskussionen uber Vor- und Nachteile des laparoskopischen und retroperitoneoskopischen Vorgehens. In vorliegender Untersuchung berichten die Autoren uber eigene Erfahrungen des lateralen, transperitonealen Vorgehens.

Transabdominal laparoscopic approach for adrenalectomy: Experience in 169 consecutive cases

SummaryBackground: Several techniques have been proposed to remove the adrenal glands laparoscopically. There is still some debate about the respective advantages and inconveniences of the transperitoneal and retroperitoneal approaches. In this study the authors report their experience with the transperitoneal flank approach.Methods: Between June 1994 and January 1999, 217 adrenalectomies were performed in our department. There were 169 laparoscopic adrenalectomies (LA) — (78 %): 61 Conn’s syndrome, 41 Cushing’s syndrome, 29 pheochromocytomas, 1 androgen producing tumor and 37 non functioning tumors. An open approach was used in 48 patients (22 %). Large and/or malignant or suspected malignant tumors (26 cases) multiple and/or extra adrenal pheochromocytomas (12 cases), previous surgery in the adrenal area (10 cases).Results: LA was unilateral in 149 patients and bilateral in 10 patients. Mean tumor size was 32 mm (7–110). Eight tumors were malignant (4.7 %). Four out of these 8 malignant tumors were completely removed laparoscopically. Conversion to open surgery was required in 8 patients (5 %). Twelve patients (7.5 %) had significant complications. There was no mortality. Mean operative time was 126 minutes (48–300) for unilateral LA and 228 minutes (175–275) for bilateral LA. The average length of hospital stay was 5.4 days (3–15). The endocrinopathy was successfully cured in all patients with functioning tumors.Conclusions: There are few absolute contraindications for LA. LA is the procedure of choice for small benign and functioning tumors. Invasive adrenal carcinoma is an absolute contraindication for LA. Nevertheless, depending on the experience of the operator, LA can be also proposed for large tumors or tumors at risk for malignancy. If local invasion is observed at the start of the procedure, LA should be immediately converted to open surgery.ZusammenfassungGrundlagen: Zahlreiche Techniken werden zur endoskopischen Entfernung der Nebenniere vorgeschlagen. Es gibt nach wie vor Diskussionen über Vor- und Nachteile des laparoskopischen und retroperitoneoskopischen Vorgehens. In vorliegender Untersuchung berichten die Autoren über eigene Erfahrungen des lateralen, transperitonealen Vorgehens.Methodik: Zwischen Juni 1994 und Jänner 1999 wurden 217 Adrenalektomien durchgeführt. 169 (78 %) wurden laparoskopisch (LA) ausgeführt. Bei 61 Patienten lag ein Conn Syndrom, bei 41 Patienten ein Cushing Syndrom, bei 29 Patienten ein Phäochromozytom, bei einem Patienten ein Androgen produzierender Tumor und bei 37 Patienten ein hormoninaktiver Tumor vor. Ein offenes Verfahren wurde bei 48 Patienten (22 %) gewählt. Gründe dafür waren Größe und/oder maligne oder malignomverdächtige Tumoren (26 Patienten), multiple und/oder extraadrenale Phäochromozytome (12 Patienten) bzw. Reeingriffe an der Nebenniere (10 Patienten).Ergebnisse: Bei 149 Patienten wurde die LA einseitig, bei 10 Patienten beidseitig durchgeführt. Der mittlere Tumordurchmesser betrug 32 mm (7–110). Acht Tumore (4,7 %) waren bösartig. Vier dieser acht bösartigen Tumore wurden vollständig laparoskopisch entfernt. Bei 8 Patienten (5 %) mußte zur offenen Operation konvertiert werden. 12 Patienten (7,5 %) hatten signifikante Komplikationen. Kein Patient ist verstorben. Die mittlere Operationszeit betrug 126 Minuten (48–300) bei einseitiger und 228 Minuten (175–275) bei beidseitiger LA. Die durchschnittliche Krankenhausaufenthaltsdauer betrug 5,4 Tage (3–15).Schlußfolgerungen: Es gibt einige absolute Kontraindikationen für eine LA. LA ist die Methode der Wahl für kleine gutartige und hormonaktive Tumoren. Invasive Nebennierenkarzinome sind eine absolute Kontraindikation für die LA. Abhängig von der Erfahrung des Operateurs kann die LA auch bei großen und malignomverdächtigen Tumoren eingesetzt werden. Sollte sich am Beginn der LA Hinweise für eine Invasion zeigen, ist sofort zum offenen Vorgehen zu konvertieren.Grundlagen: Zahlreiche Techniken werden zur endoskopischen Entfernung der Nebenniere vorgeschlagen. Es gibt nach wie vor Diskussionen uber Vor- und Nachteile des laparoskopischen und retroperitoneoskopischen Vorgehens. In vorliegender Untersuchung berichten die Autoren uber eigene Erfahrungen des lateralen, transperitonealen Vorgehens.