Laparoscopic surgery of adrenal glands: indications and limits

Over the last four years it has been demonstrated that laparoscopy can be used successfully for adrenalectomy, providing certain advantages over conventional open surgery. The aim of this study was to determine the indications for laparoscopic approach in adrenal surgery. From June 1994 to June 1996 laparoscopic transabdominal flank approaches were proposed in patients with a unilateral 8 cm or less, non-malignant tumors of the adrenal gland. For tumors under 4 cm in diameter only secreting tumors were removed. Among 77 patients requiring ablation of the adrenal gland, 50 (65%) underwent a laparoscopic procedure: 29 Conn adenomas, 10 Cushing adenomas, 6 Pheochromocytomas, 4 incidentalomas. One patient had Cushing's disease and underwent bilateral resection. Mean tumor size was 26 mm (7-75 mm). Malignancy was demonstrated in 2 tumors: one cortisone secreting tumor and one leiomyosarcoma. Conversion was required in 4 cases (8%). Mean operative time for unilateral adrenalectomies was 147 minutes (50-300'). There were no deaths. Morbidity included: one hemorrhage via the trocar orifice requiring reoperation, one infarction of the spleen which regressed spontaneously, one parietal hematoma, and one case of phebitis of the lower limb. The endocrinopathy was successfully cured in all patients with secreting tumors. The 27 other patients underwent open adrenalectomy. Laparoscopic approach was not proposed due to suspected malignancy in 13 cases, previous surgery in 8 cases and multiple, bilateral and/or extra adrenal tumors in 6 cases. Laparoscopic approach to the adrenal gland is the procedure of choice in patients with Conn adenomas, Cushing adenomas and in most cases of pheochromocytomas. It is not indicated for malignant and large tumor (> 8 cm). Currently two-thirds of our patients requiring and adrenalectomy are operated laparoscopically.     

Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures

One hundred consecutive laparoscopic adrenal procedures for a variety of endocrine disorders were reviewed. There was no mortality, morbidity was 12%, and conversions was 3%. During follow-up, none had recurrence of hormonal excess. Laparoscopic adrenalectomy is the procedure of choice for adrenal removal except in carcinoma or masses > 15 cm. OBJECTIVE: The authors evaluate the effectiveness of laparoscopic adrenalectomy for a variety of endocrine disorders. SUMMARY BACKGROUND DATA: Since the first laparoscopic adrenalectomy was performed in 1992, this approach quickly has been adopted, and increasing numbers are being reported. However, the follow-up period has been too short to evaluate the completeness of these operations. METHODS: One hundred consecutive laparoscopic adrenal procedures from January 1992 until November 1996 were reviewed and followed for adequacy of resection. RESULTS: Eighty-eight patients underwent 97 adrenalectomies and biopsies. The mean age was 46 years (range, 17-84 years). Indications were pheochromocytomas (n = 25), aldosterone-producing adenomas (n = 21), nonfunctional adenomas (n = 20), cortisol-producing adenomas (n = 13), Cushing's disease (n = 8), and others (n = 13). Fifty-five patients had previous abdominal surgery. Mean operative time was 123 minutes (range, 80-360 minutes), and estimated blood loss was 70 mL (range, 20-1300 mL). There was no mortality, and morbidity was encountered in 12% of patients, including three patients in whom venous thrombosis developed with two sustaining pulmonary emboli. During pheochromocytoma removal, hypertension occurred in 56% of patients and hypotension in 52%. There were three conversions to open surgery. The average length of stay has decreased from 3 days (range, 2-19 days) in the first 3 years to 2.4 days (range, 1-6 days) over the past 16 months. During follow-up (range, 1-44 months), two patients had renovascular hypertension and none had recurrence of hormonal excess. CONCLUSION: Laparoscopic adrenalectomy is safe, effective, and decreases hospital stay and wound complications. Prior abdominal surgery is not a contraindication. Pheochromocytomas can be resected safely laparoscopically despite blood pressure variations. Venous thrombosis prophylaxis is mandatory. The laparoscopic approach is the procedure of choice for adrenalectomy except in the case of invasive carcinoma or masses > 15 cm.     

Laparoscopic adrenalectomy. A new standard of care

OBJECTIVE: The authors review their experience with laparoscopic adrenalectomy in patients with benign adrenal neoplasms. Efficacy, safety, and cost effectiveness of the procedure are examined. BACKGROUND: Laparoscopic adrenalectomy is replacing open adrenalectomy in some medical centers as the standard surgical approach for uncomplicated tumors. However, laparoscopic adrenalectomy often is considered more difficult and more expensive than traditional "open" surgery. METHODS: Perioperative and postoperative records as well as hospital charges from the first 19 patients undergoing laparoscopic unilateral adrenalectomies at the authors' medical institutions were examined and compared with 19 patients who underwent open unilateral adrenalectomies. RESULTS: None of the 19 patients undergoing unilateral laparoscopic adrenalectomy required conversion to open adrenalectomy. Mean operative times as well as total hospital charges were similar in those patients undergoing either laparoscopic or open adrenalectomy. However, the morbidity and postoperative length of hospital stay were significantly less in those patients undergoing laparoscopic adrenalectomy. CONCLUSIONS: Laparoscopic adrenalectomy can be performed safety and with the benefits associated with minimally invasive surgery. In addition, the procedure is cost effective. These factors suggest that laparoscopic adrenalectomy should be the preferential surgical technique for benign adrenal disease.     

Multicentric experience of the Belgian Group for Endoscopic Surgery (BGES) with endoscopic adrenalectomy

BACKGROUND: Adrenalectomy is not a frequent operation. Therefore the newly developed laparoscopic approach is sporadically performed by surgeons dealing with endocrine disorders. METHODS: Some 54 videoendoscopic adrenalectomies performed on 52 patients by five surgical teams between October 1993 and December 1996 were prospectively evaluated. RESULTS: Indications for endoscopic adrenalectomy were pheochromocytoma (n = 17), primary hyperaldosteronism (n = 15), Cushing's adenoma or disease (n = 7), nonsecreting adenoma (n = 7), single metastasis from adenocarcinoma (n = 2), adenoma with dehydroepiandrostenedione (DHEAS) hypersecretion (n = 3), and ACTH-secreting metastases from a thymoma (n = 1). Of the 54 adrenalectomies performed, 31 were of the left gland, 19 of the right and two bilateral. Laparoscopic adrenalectomy was successful in 50 patients (96%). Median tumor size was 4 cm (range 1.5-12), median operation duration was 80 min (range 59-360), and median postoperative stay was 4 days (range 2-13). One patient required blood transfusion. CONCLUSIONS: Endoscopic adrenalectomy can safely be performed-even sporadically-by surgeons well versed in adrenalectomy techniques for endocrine disorders and trained in endoscopic surgery.     

Predictability of Gleason score and reduction time (tau) of prostatic volume after castration for the prognosis of prostatic cancer

BACKGROUND: After 3 years from the introduction of laparoscopic adrenalectomy in an endocrine surgery unit the results are retrospectively compared with those achieved by traditional techniques with the aim of comparing the respective advantages. METHODS: During this period 68 laparoscopic adrenalectomies have been performed. The main pre-, intra- e postoperative parameters of the adrenalectomies for benign neoplasm have been examined. Mean follow-up was 51 months (65.3 for open adrenalectomy and 18.8 for laparoscopic). RESULTS: Statistical studies were homogeneous between the two groups. The laparoscopic adrenalectomy--with the same effectiveness--thanks to less peritoneum and parietal stress, is followed by fewer postoperative complications, faster resumption of biological functions, earlier return to work and better cosmetic results. CONCLUSIONS: On the basis of our personal experience laparoscopic adrenalectomy is to be considered the treatment of choice in the majority of adrenal benign neoplasms.     

Influence of radiotherapy on long-term relapse in clinically non-secreting pituitary adenomas. A retrospective study (1970-1988)

OBJECTIVE: We wished to evaluate the influence of postoperative radiotherapy on the incidence of tumour regrowth in non-secreting pituitary adenomas. METHODS: The cases of 57 patients with clinically non-secreting pituitary adenomas were retained for a retrospective study of long-term disease-free survival out of a series of 66 patients treated between 1970 and 1988. Thirty-three patients were treated by surgery only (Group A), and twenty-four by surgery followed by external radiotherapy (Group B). Disease-free survival curves were calculated according to the Kaplan-Meyer method and compared by the Logrank test. The impact of some supposed prognostic parameters--such as tumoural volume, macroscopic features of invasiveness and quality of surgical resection--on the disease-free survival was analyzed according to the Logrank adjusted test. RESULTS: The mean follow-up duration was 7.1 +/- 6.2 years, and eleven patients relapsed: nine in group A (27.0%) and two in group B (8.3%), with respective free intervals of 6.1 +/- 5.0 years and 9.6 +/- 2.4 years. Statistical analysis of the disease-free survival curves confirmed that this difference was significant (p < 0.01). Further analysis of putative risk factors (the importance of extrasellar extension and the estimated quality of surgical resection) was attempted, but it did not reach statistical significance. CONCLUSIONS: Radiotherapy is effective in preventing post-operative regrowth of non-secreting pituitary adenomas. Whether it should be systematically proposed or reserved to selected cases remains to be evaluated.     

Laparoscopic adrenalectomy. An alternative to open surgery of minor adrenal tumors

In the period February 1994 to November 1995 11 laparoscopic adrenalectomies were performed at our institution (seven women, four men). A transperitoneal approach was used in both right- and left-sided operations. Results were collected retrospectively. Indications for surgery were: Conn's syndrome (four), Cushing's syndrome (two), phaecromocytoma (four), and incidentaloma (one). The operations took median 170 minutes (range 105-250 minutes). Median size of the tumour was 4 cm range 1(1/2)-5 cm). No significant peri- or postoperative complications were recorded. The patients were discharged from the surgical unit median two days after surgery. Laparoscopic operation emerges as an alternative to open operation when dealing with smaller adrenal tumours. Because of the small number of patients, these operations have to be restricted to a few centres where both internists, anaesthesiologists and surgeons with expertise in this field are found.     

Serum bilirubin distribution and its relation to cardiovascular risk in children and young adults

The discovery of an asymptomatic adrenal mass (incidentaloma) during the investigation of an unrelated condition is relatively common. In this study, we report the clinical, radiologic, and endocrine evaluation of 38 patients (22 women and 16 men aged 24 to 84 years) with adrenal incidentaloma (size, 1 to 12 cm). The patients underwent basal and dynamic evaluation of the hypothalamic-pituitary-adrenal (HPA) axis, renin-angiotensin-aldosterone system, and adrenomedullary function. Moreover, computed tomograpy (CT) scan and 131I-6beta-iodomethyl-19-norcholest-5(10)-en-3beta-ol(NP-59) and/or 131I-metaiodobenzylguanidine (MIBG) scintigraphy were performed. The endocrine evaluation indicated two cases of pheochromocytoma and four cases of preclinical Cushing's syndrome, three of which underwent surgery with histologic diagnosis of two adrenocortical adenomas and one carcinoma. Low levels of serum dehydroepiandrosterone sulfate (DHEA-S), associated with a markedly increased 17-hydroxyprogesterone (17-OHP) response to a corticotropin (ACTH) test, were found in patients with incidentaloma. On the basis of endocrine and morphologic data, 13 patients underwent surgical treatment: five adrenocortical adenomas (two functioning), two pheochromocytomas, two ganglioneuromas, one cortisol-secreting adrenal carcinoma, one lymphangiomatous cyst, one myelolipoma, and one hemorrhage were found. Careful diagnostic assessment of incidentally discovered adrenal masses must be performed to exclude the presence of malignant and/or functioning lesions and to verify the possibility that patients with incidentaloma have a genetic or acquired deficit of adrenal steroidogenic activity.     

Bacteriotherapy with Lactobacillus reuteri in rotavirus gastroenteritis

Laparoscopic transperitoneal and endoscopic extraperitoneal adrenalectomy are two safe options in minimally invasive surgery associated with very low morbidity. The anterior transperitoneal approach we prefer yields a better exposure of the anatomic structures and allows the surgeon to orient himself more easily. In addition, various other laparoscopic maneuvers may be performed synchronously. We report on our own experience with eight laparoscopic transperitoneal adrenalectomies performed in four cases unilaterally and in two additional cases bilaterally during April, 1996, and January, 1997, in six patients aged 20 to 56 years. The indications were in four cases pheochromocytoma (operated on bilaterally in two cases), and in the remaining two cases adrenal Cushing's syndrome. The duration of surgery was approximately 240 min for bilateral adrenalectomy and 166 min for unilateral adrenalectomy, respectively, with an intraoperative blood loss of about 50 to 400 ml. Except for haematoma of the abdominal wall there were no other postoperative complications. The serum levels of interleukin 6 and 10 underline the minimal invasiveness of this technique, since there were only small increases of interleukin 6 and interleukin 10.     

Intestinal permeability in cystic fibrosis in relation to genotype

To investigate the clinical significance of plasma dehydroepiandrosterone sulfate (DHEAS) measurements, 175 patients with histologically confirmed adrenal tumors, 10 cortisol-producing adenomas, 59 aldosterone-producing adenomas, 56 non-hyperfunctioning adenomas, 13 adrenocortical carcinomas, 13 adrenal cysts, and 24 adrenomedullary tumors were studied. Plasma DHEAS levels were expressed as percentage of the mean of sex- and age-matched groups of healthy, normal subjects (DHEAS %). We found that before adrenal surgery, DHEAS % values were significantly reduced in patients with cortisol-producing (mean, 15.2% of control; 95% confidence interval (CI), 9.4-24.7%), non-hyperfunctioning (28.4%; 22.4-36.0%) as well as aldosterone-producing adrenocortical adenomas (55.4%; 47.1-65.1%) compared with controls, while values were normal in patients with adrenal cysts and in those with adrenomedullary tumors. Plasma DHEAS % values exhibited a great variability in adrenocortical carcinomas (mean, 84.0%; 95% CI, 33.2-212.5%). Death from adrenocortical carcinoma was more frequent in patients with high plasma DHEAS % values compared with those with low DHEAS %. During long-term postoperative monitoring, we found that plasma DHEAS levels of patients with aldosterone-producing and non-hyperfunctioning adenomas returned to normal in the second and fourth postoperative year respectively. In patients with cortisol-producing adenomas, plasma DHEAS remained suppressed for as long as 8 years after the operation. These findings show that except in adrenocortical carcinomas and cysts, plasma DHEAS levels are significantly decreased in all groups of adrenocortical tumors, including non-hyperfunctioning and aldosterone-producing tumors. The extent of this decrease and the postoperative persistence of suppressed plasma DHEAS levels may be related to the glucocorticoid production of adrenocortical tumors.     

Pre-operative localization of aldosterone-secreting adrenal adenomas

Techniques for pro-operative localization of aldosterone-secreting adrenal adenomas were studied in thirty-seven patients, each with hypertension and biochemical evidence of primary hyperaldosteronism and each later having adrenal surgery (thirty-two adenomas, five bilateral hyperplasia). Bilateral adrenal vein catheterization was attempted in all cases; it was successful on the left side in all patients and in 92% of cases on the right. Adrenal vein plasma samples were obtained from the left side in 92% and from the right in 73% of cases. Adrenal vein plasma aldosterone measurements correctly indicated the presence of tumour in twenty-eight cases but falsely predicted unilateral adenoma in two cases of bilateral adrenal hyperplasia. Adrenal venography also correctly predicted unilateral adrenal adenomas in twenty-six cases but falsely suggested the presence of tumour in three cases of bilateral adrenal hyperplasia. Computed tomography (CT) was used in the last eight cases. In seven instances the predictions (six adenomas, one bilateral adrenal hyperplasia) were confirmed at surgery. However, the remaining patient harboured an adenoma 20 mm in diameter which was not detected by CT although diagnosed both by adrenal venography and adrenal vein aldosterone measurements. Ultrasound detected adenoma in only three of twenty-two cases examined. Although further comparative studies of the type described here are required, the results of computed tomography are promising and suggest that this non-invasive technique might well become the first choice procedure in localizing aldosterone-secreting adenomas.     

Colectomy: the role of laparoscopy

Laparoscopically assisted colonic surgery was performed in 23 patients in the last 12 months. In all cases, after an initial diagnostic laparoscopy, the colon was mobilized laparoscopically. The mesenteric and bowel division was performed extracorporeally, as was the anastomosis. No deaths occurred. There was a 13% complication rate; one patient suffered a late (10 days) anastomotic dehiscence at home, and two patients had postoperative upper respiratory chest infections. The mean number of lymph nodes excised for malignant cases was 12, and the total mean postoperative hospital stay was 7 days. The laparoscopic dissection required 40% of the operating time. Although this is our initial experience, we conclude that laparoscopically assisted bowel surgery replaces one operation with two, is more costly, requires a longer-lasting anaesthetic, and in our hands appears to offer little additional benefit to the patient compared with conventional surgery.     

Diagnostic value of hysterosalpingography and laparoscopy in infertile women

Tubal pathology with tubal blockage due to the pelvic inflammatory diseases is one of the most frequent causes of infertility in a woman [1]. The two most important diagnostic procedures which are used for evaluation of tubal patency are hysterosalpingography and laparoscopic hydrotubation [4]. SUBJECT: The aim of the study was the comparison of hysterosalpingographic and laparoscopic findings and determination of accuracy of these two procedures in the diagnosis of tubal patency. MATERIAL AND METHODS: We studied and compared the results of hysterosalpingography and laparoscopy in 102 infertile women who were operated on at the Narodni Front Hospital of Gynaecology and Obstetrics in Belgrade during 1993 and 1994. Of 102 operated women 47 women were with primary infertility and 55 with secondary infertility. The patients were from 20 to 41 years of age, the average 28 +/- 2.4 years. RESULTS: Of one hundred and two operated women tubal blockage was found in 94 (92.1%) patients. Unilateral hydrosalpinx was found by hysterosalpingography in 16 (15.7%) subjects and bilateral hydrosalpinx in 30 (29.4%) women. Unilateral hydrosalpinx was found by laparoscopy in 17 (16.1%) patients and bilateral hydrosalpinx in 32 (31.4%) subjects. The concordant findings by hysterosalpingography and laparoscopy in the diagnostics of unilateral hydrosalpinx were found in 76.5% of cases, and in bilateral hydrosalpinx in 70.4%. This difference was not statistically significant. Unilateral tubal blockage was identified by laparoscopy in 26 (25.5%) patients and bilateral in 27 (26.5%) subjects. The concordant findings by hysterosalpingography and laparoscopy in unilateral tubal blockage were found in 61.5% of cases, and in bilateral tubal blockage in 70.4% of women. The total concordant findings by hysterosalpingography and laparoscopy in tubal blockage were found in 65.7 of cases, and concordant findings after hysterosalpingography and surgery were noted in 61.7% cases. The findings by laparoscopy and surgery were in harmony in 86.3% patients. Ovarian abnormalities were found by laparoscopy and surgery in 22 (21.6%) women. Pelvic adhesions were found by laparoscopy in 42 women of 49 patients in whom pelvic adhesions were found during the operation. Uterine congenital anomalies were found by laparoscopy in 3 (2.9%), women and by hysterosalpingography in 6 (5.9%) patients. DISCUSSION: Of 102 operated women tubal blockage was found in 94 (92.2%) women. Unilateral tubal blockage was found in 38 (40.4%) patients, and bilateral tubal blockage in 56 (59.6%) subjects. Hysterosalpingographic and laparoscopic hydrotubation findings in the diagnosis of tubal patency were concordant in 65% of cases, hysterosalpingographic and operative findings in 61.7% of patients, and laparoscopic and operative findings in 86.3% of subjects. Although concordant findings of 65.7% were noted in this study, which were similar to findings of other authors, the percentage of 62.5% [4], and 76% was observed [5]. During the operation pelvic adhesions were found in 49 patients, and laparoscopic in 42 women only. Ovarian abnormalities were found by laparoscopy in 22 (21.6%) patients, while uterine fibroid was found in 10 (9.8%) subjects. Uterine congenital anomalies were found by hysterosalpingography in 6 (5.9%) cases and by laparoscopy only in 3 (2.9%) patients. The advantage of visual hysterosalpingography seems to be in identification of some congenital uterine anomalies. However, the advantage of laparoscopy is identified by the possibility of visualisation of some other pelvic abnormalities which may be the cause of infertility. CONCLUSION: There are some hysterosalpingographic and laparoscopic advantages and disadvantages in the diagnosis of infertility in women. Only by using both procedures accurate results can be achieved in the tubes, the uterus and the ovary, that can be a cause of infertility in women.     

Laparoscopic adrenalectomy

The authors performed three left and one right sided laparoscopic adrenalectomies between 3rd April and 8th August 1997. The indication of surgery was hormonally active cortical adenoma of about 2 cm size in three cases, a 6 cm large hormonally inactive tumour in one case respectively. For the operation on the left side three, on the right side four trocars with 11 mm diameter was used. The duration of the operations was between 115 and 220 min. The patients left one the second or third postoperative day, no complication was observed. The authors' opinion based on both literature data and their own experience is that laparoscopic approach to adrenalectomies is the method of choice today.     

Trends in rates of occupational fatal injuries in the United States (1983-92)

Recent advancements in laparoscopic surgery have made laparoscopic splenectomy possible. We retrospectively compared the outcomes of laparoscopic versus open splenectomy in patients with idiopathic thrombocytopenic purpura (ITP) or beta-thalassemia. From July 1993 to July 1997, 52 patients (ITP, 43 cases; beta-thalassemia, 9 cases) underwent either laparoscopic (30 patients, 9 men, 21 women; average age, 36.9 years) or conventional open splenectomy (22 patients, 5 men, 17 women; average age, 34.3 years). The two groups were similar in terms of sex, age, diagnosis, duration of disease, preoperative platelet count, and spleen size. The mean surgical time, estimated amount of blood loss, duration of postoperative recovery, analgesic usage, and complications were compared between the two groups. Laparoscopic splenectomy was successful in 29 (97%) of the 30 patients. The mean surgical time in the laparoscopy group was longer than in the open splenectomy group (190.6 vs 113.9 minutes, p < 0.01). The laparoscopy group had earlier postoperative oral intake (15.2 vs 52.6 hours, p < 0.01), less usage of analgesics (meperidine 50 mg/unit, 1.1 vs 2.8 units, p < 0.01) and a shorter postoperative hospital stay (4.1 vs 6.8 days, p < 0.01). The estimated blood loss, incidence of accessory spleen, surgical complication rate, and recurrence rate of thrombocytopenia were similar in the two groups. Our findings show that laparoscopic splenectomy in patients with ITP or beta-thalassemia is as safe as the open approach. While laparoscopy required a longer surgical time, the recovery period was shorter, analgesic use was less, and physical discomfort was less severe.     

Ipsilateral adrenalectomy in the surgical treatment of renal carcinoma

OBJECTIVES: To assess the value of ipsilateral adrenalectomy during radical nephrectomy for the treatment of renal cell carcinoma as a function of preoperative computed tomography findings. METHODS: Between May 1985 and June 1994, 194 patients underwent radical nephrectomy for renal cell carcinoma in our institution. Preoperative radiological reports and postoperative pathological reports were reviewed for 185 patients. RESULTS: 148 patients underwent abdominal computed tomography before surgery. 94 adrenalectomies were performed in this group of patients. None of the 77 patients in whom computed tomography showed a normal adrenal gland had adrenal metastasis on the definitive histological examination. 17 patients had an adrenal mass on computed tomography, 3 of which proved to be neoplastic. Preoperative CT had a sensitivity of 100%, a specificity of 82%, a positive predictive value of 18% and a negative predictive value of 100%. The 185 files reviewed included 114 adrenalectomies, including 4 adrenal glands invaded by renal cell carcinoma (3.5%). In these 4 cases, the smallest diameter of the renal tumour was 4 cm and the minimum pathological stage was T3. CONCLUSIONS: It therefore appears justified not to perform adrenalectomy during nephrectomy, in the presence of a renal tumour and negative adrenal computed tomography.     

Development of the cribriform plate and of the lamina mediana

From September 1992 to November 1996, 28 patients underwent laparoscopic adrenalectomy at Osaka University Medical Hospital. They were compared with 25 instances of conventional open surgery performed between May 1990 and April 1996 at the same institution. Laparoscopic adrenalectomy was performed via either a transperitoneal or a retroperitoneal approach. The mean operative time of 375 minutes for laparoscopic adrenalectomy was significantly longer than that of 133 minutes for open surgery. The average hospital stay for laparoscopic surgery was significantly shorter than that of conventional open adrenalectomy. The convalescent period was also significantly shorter in the patients who had laparoscopic adrenalectomy. There was no statistical difference in blood loss during the operation or the number of doses of analgesics administered after operation in the two groups. We conclude that laparoscopic adrenalectomy is one of the options to be selected in surgically managing adrenal tumors. Laparoscopic adrenalectomy could become a standard operative procedure as instruments and techniques of laparoscopy improve significantly.     

Cleveland Clinic experience with adrenal Cushing's syndrome

PURPOSE: Cushing's syndrome due to adrenal adenoma or adrenocortical carcinoma is rare. To understand better the clinical and biochemical presentation of this disorder, as well as therapy efficacy and patient survival, we conducted a retrospective review. MATERIALS AND METHODS: Between August 1971 and April 1994, 40 patients presented to our institution with adrenal Cushing's syndrome (27 adenomas and 13 carcinomas). These groups were analyzed with respect to clinical signs and symptoms preoperatively and postoperatively, biochemical analysis, length of postoperative steroid replacement therapy, disease recurrence and patient survival. Followup was obtained by chart review and telephone interviews and averaged 59.6 +/- 66.4 and 47.6 +/- 56.2 months for adenoma and carcinoma patients, respectively. RESULTS: Women predominated in both groups (26 of 27 adenomas, 11 of 13 carcinomas), and tumors affected the left adrenal gland more frequently (19 of 27 adenomas, 9 of 13 carcinomas). Adenoma patients were younger than carcinoma patients (39.6 +/- 14.4 versus 51.5 +/- 16.6 years, p = 0.026) and presented with smaller tumors (3.3 +/- 1.0 versus 8.6 +/- 4.5 cm., p = 0.001). There was a trend toward increased incidence of glucose intolerance among carcinoma patients but no significant differences in clinical signs or symptoms between adenoma and carcinoma patients could be made. Similarly, while there was no significant difference in biochemical evaluation of adenoma versus carcinoma patients, 24-hour urinary free cortisol and serum lactate dehydrogenase levels tended to be higher among carcinoma patients. In addition 17-ketosteroid and dehydroepiandrosterone sulfate levels were more elevated in carcinoma than in adenoma patients, and several adenoma patients actually had subnormal levels. Among adenoma patients mean length of steroid replacement therapy was 16.8 +/- 9.1 months. However, 7 adenoma patients (25.9%) required greater than 24 months of exogenous steroids, and only 1 of these patients was subsequently weaned off steroid replacement. There were no recurrences among adenoma patients, although there was 1 perioperative death due to hypoglycemia. Ten (76.9%) carcinoma patients had recurrences at a mean followup of 33 months. The 3 and 5-year survival rates were 41.5 and 31.2%, respectively. CONCLUSIONS: While presenting signs and symptoms and hormonal analysis may suggest benign or malignant disease, only tumor size and patient age are reliable preoperative indicators of adrenal adenoma versus adrenocortical carcinoma among patients with adrenal Cushing's syndrome. Surgery is curative for adenoma patients, but lifelong steroid replacement may be required. Survival remains poor among carcinoma patients.     

Breast implants. Evaluation of breast implants using magnetic resonance imaging (MRI)

Ureteral injury is a potential complication of any abdominal or pelvic surgery. Gynecological surgery has traditionally accounted for most injuries. In the last decade, there have been major advances in endoscopic surgery including ureteroscopy and laparoscopy, both of which may cause ureteral injury. Increased use of these procedures change the nature of ureteral injuries. From 1988 to 1997, 22 patients with 24 ureteral injuries were identified. The causes, diagnostic methods and treatments were reviewed. Ureteral injury was defined as any laceration, transection or ligation of the ureter that required an unexpected procedure for repair, stent or drainage. In 24 ureteral injuries, there were 20 unilateral cases and 2 bilateral cases eight men (33%) were 15 to 43 years old (mean age 30), and 14 women including 2 case of bilateral lesion (67%) were 30 to 75 years old (mean age of 46). The injuries were on the right side in 11 cases (46%), left side 13 cases (54%), and in the upper, and lower third of the ureter in 7 (29%) and 17 cases (71%), respectively. Bilateral injuries were all in the lower ureter and another 2 cases of lower ureteral injuries were combined with bladder injuries. In the cases of ureteral injuries, iatrogenic injuries accounted for 19 cases (79%). Of these, urological surgery, laparoscopic surgery, ureteroscopic procedures and gynecological surgery accounted for 1 (4%), 2(8%), 5(21%) and 11 cases (46%) respectively. Between 1988 and 1992, there were 7 cases, and after 1993, there were 17 cases of ureteral injuries. The injuries caused by trauma and gynecological surgery remained stable in the 2 period. The recent increases were caused by endoscopic procedures including ureteroscopy and laparoscopy. Of the 24 cases, 13 cases (54%) were managed by ureteroneocystostomy, 5 cases (21%) by nephrectomy, 4 cases (17%) by ureteroureterotomy, 1 case by PCN and 1 case by double-J catheter stenting only. The early recognition and repair at injury allow for better results with fewer complications. Delayed finding or commitant infection may lead to failure of reconstructive procedure and lead to nephrectomy.     

The role of staging laparoscopy for multimodal therapy of gastrointestinal cancer

BACKGROUND: This prospective study was conducted to evaluate the accuracy and the therapeutic relevance of staging laparoscopy. METHODS: Between June 1993 and February 1997 staging laparoscopy was performed in 389 patients with various neoplasms. Additionally, 144 selected patients of this group were examined with laparoscopic ultrasound using a semiflexible ultrasound probe (7.5 MHz). RESULTS: Compared to conventional imaging methods, laparoscopy and laparoscopic ultrasound improved the accuracy of staging in 158 of 389 patients (41%). Statistical subgroup analysis of 131 patients with gastric cancer showed that the accuracy of staging laparoscopy in the detection of distant metastases (68%) was significantly higher (p < 0.01) than that of ultrasound (63%) or computed tomography (58%). In the whole group, laparoscopy alone disclosed intraabdominal tumor dissemination or nonresectable disease in 111 patients. Laparoscopic ultrasound displayed additional metastases-i. e., liver metastases (n = 9), M1 lymph nodes (n = 15), or nonresectable tumors (n = 6) in 30 patients. Although metastastic disease was suggested by preoperative imaging, benign lesions were found in five patients with laparoscopy and in a further 12 patients with ultrasonography. The findings of staging laparoscopy changed the treatment strategy in 45% of the patients. Conversion to open surgery was necessary in 5% of the cases, and complications related to laparoscopy occured in 4% of the patients. CONCLUSIONS: Laparoscopy with laparoscopic ultrasound improves the staging of gastrointestinal tumors and has a significant impact on a stage-adapted surgical therapy.