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Surgical management of open versus laparoscopic adrenalectomy: Outcome analysis
Surgical Management of Open Versus Laparoscopic Adrenalectomy: Outcome Analysis By Ala Stanford, Jeffrey S. Upperman, Nam Nguyen, Edward Barksdale, Jr, and Eugene S. Wiener Pittsburgh, Pennsylvania
Purpose: The authors sought to compare the outcome of children undergoing open versus laparoscopic adrenalectomy for an adrenal tumor. Methods: Medical records of children that underwent an adrenalectomy from 1990 through 1999 were reviewed. Sixty-four adrenalectomies were performed: 27 pheochromocytomas, 36 neuroblastomas, and 1 virilizing tumor. Sixty adrenalectomies were performed open and 4 laparoscopically. The patient’s age, surgical length of stay, operative charge, hospital cost, operating time, blood loss, and outcome were examined. Results: Mean age for an open procedure was 8.9 ⫾ 0.9 years and 14 ⫾ 1.1 for laparoscopic (P ⫽ .019). Surgical length of stay for open was 5.4 ⫾ .38 days and 2.7 ⫾ .62 days for laparoscopic (P ⫽ .006). Patient operative charges were
L
APAROSCOPIC SURGERY has been popularized in the treatment of surgical diseases in the pediatric population. Dr. Gans first described laparoscopy in infants and children in the late 1970s.1 The main advantages to laparoscopic surgery are to provide equal to superior exposure to the viscera, diminish the soft tissue dissection required with an open procedure, and decrease postoperative pain, all with an improved cosmetic result.2 With the advent and ease of laparoscopic surgery in the 20th century, a laparoscopic adrenalectomy was proposed, because adrenal removal requires retroperitoneal exposure and dissection in a small area, which presents a challenge to the surgeon. We sought to compare the outcome of children undergoing open versus laparoscopic adrenalectomy for an adrenal tumor. We reviewed the medical records of all infants with a diagnosis of pheochromocytoma and neuroblastoma, managed surgically, from 1990 through 1999. We compared open and laparoscopic adrenalectomies and examined several variables including age, surgical length of stay, patient operative charge, patient hospital costs, operating time, blood loss, and overall patient outcome.
$12,941 ⫾ 676 for laparoscopic and $4,714 ⫾ 411 for open (P ⬍ .001). When total estimated patient cost, including hospital stay, were compared between groups there was no significant difference. Similar mean operating times and blood loss were noted. There were no deaths or complications in children with a pheochromocytoma. The mortality rate in children with neuroblastoma was 28%. Conclusions: Adrenalectomy for benign tumors can be performed safely. In selected children a laparoscopic procedure can be expected to decrease the surgical length of stay without increasing operating time or complications. J Pediatr Surg 37:1027-1029. Copyright 2002, Elsevier Science (USA). All rights reserved. INDEX WORDS: Laparoscopic adrenalectomy, pheochromocyotma, outcome analysis.
identified. There were a total of 64 adrenalectomies: 27 pheochromocytomas, 36 neuroblastomas, and 1 virilizing tumor. Sixty adrenalectomies were performed open and 4 laparoscopically. Patients with a diagnosis of Wilm’s tumor were excluded.
Methods This study was reviewed and approved by the Children’s Hospital of Pittsburgh Human Rights Committee. A retrospective review of all medical records examined the patient’s age, surgical length of stay, patient operative charge, patient hospital cost, operating time, blood loss, and overall patient outcome. Specifically, we compared these variables in children treated by an open or laparoscopic adrenalectomy. Statistical analyses were performed by Sigma Statistical software, version 2.0, with significance valued at P ⬍ .05. Values also are presented as the mean ⫾ SEM.
RESULTS
The mean age for an open adrenalectomy was 8.9 ⫾ 0.9 (range, 3 to 16 years) versus 14 ⫾ 1.1 (range, 12 to
All children who had undergone an adrenalectomy at the Children’s Hospital of Pittsburgh (Pittsburgh, PA) between 1990 and 1999 were
From the Department of Surgery, Children’s Hospital of Pittsburgh and the University of Pittsburgh School of Medicine, Pittsburgh, PA. Presented at the 53rd Annual Meeting of the Section of Surgery of the American Academy of Pediatrics, San Francisco, California, October 19-21, 2001. Address reprint requests to Eugene S. Wiener, MD, Children’s Hospital of Pittsburgh, 3705 Fifth Ave, Pittsburgh, PA 15213. Copyright 2002, Elsevier Science (USA). All rights reserved. 0022-3468/02/3707-0018$35.00/0 doi:10.1053/jpsu.2002.33835
Journal of Pediatric Surgery, Vol 37, No 7 (July), 2002: pp 1027-1029
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MATERIALS AND METHODS
Participants
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STANFORD ET AL
16 years); P ⬍ .05. Additionally, the surgical length of stay was determined to be significantly less for a laparoscopic adrenalectomy (2.7 ⫾ .62; range, 1 to 4 days) compared with an open adrenalectomy (5.4 ⫾ .38; range, 3 to 9 days). The open procedures were performed over the entire length of the review, whereas the laparoscopic procedures were performed from 1997 to 1999. Operative Factors The average operating time for a laparoscopic adrenalectomy (264 min; range, 217 to 307 min) was similar to that of an open procedure (235 min; range, 107 to 425 min). The estimated blood loss for the laparoscopic procedure was 100 mL versus open adrenalectomy at 284 mL. However, there was no significant statistical difference. Patient Operative Charge and Total Hospital Cost The patient operative charge was significantly higher in the laparoscopic group compared with the open patients (mean operative charges for a laparoscopic adrenalectomy, $12,941 ⫾ 676; range, $5,372 to $14,644). The mean operative charges for an open adrenalectomy were $4,714 ⫾ 411; range, $2,051 to $13,592. There was no significant difference in total hospital costs between the 2 procedures. Patient Outcome All patients with pheochromocytoma excised via an open or laparoscopic procedure survived. There were no associated operative complications or mortality. Three of the patients required a second operation for a metachronous contralateral adrenal pheochromocytoma. The mean time before a second operation was required was 2.9 years (range, 1.2 to 3.8 years). The long-term survival rate in the children with neuroblastoma was 72%. Most of the children who died had stage IV disease at the time of their death. In the laparoscopic group there was one conversion to an open procedure. This was done in a child with neuroblastoma. In this case, conversion did not lengthen the procedure (173 minutes). DISCUSSION
The age range in our patient population was 3 to 16 years. The older children were more likely to have a laparoscopic adrenalectomy, but the usual age of presentation of pheochromocytoma explains this finding.3 Initial concerns were that in the small or obese child laparoscopic surgery would be contraindicated.1 That has since been disproved because these procedures are performed safely in children with varying body habiti.2,4 Our data, showing a decrease in the surgical length of
stay with laparoscopic adrenalectomy, is comparable with what has been reported in the adult literature. It is probable that the surgical length of stay is decreased in children for several reasons, most notably a decrease in time to the return of bowel function, ease of pain control, and increased patient mobility, because they have less pain postoperatively. Despite the fact that laparoscopic adrenalectomy is a relatively new procedure, there was not a prolongation of operating time when compared with an open procedure. This probably is because of the ease of exposure of the adrenal tumor with a laparoscopic adrenalectomy compared with the open procedure. Also, a single surgeon performed all the laparoscopic adrenalectomies. Additionally, the estimated blood loss, which may be an indicator of operative difficulty, was not different between our 2 groups. Tumor size did not appear to adversely affect ease of a laparoscopic or open procedure. The largest pheochromocytoma removed laparoscopically was 5.5 ⫻ 5.8 ⫻ 2.1 cm. One laparoscopic adrenalectomy was converted to an open procedure in a child with neuroblastoma. This was primarily because of proximity and concern of involvement of surrounding structures. However, much of the dissection had been accomplished before conversion. Retrospectively, the surgeon felt that the operation could have been completed successfully laparoscopically. Although there is increasing experience with laparoscopic adrenalectomy for pheochromocytoma, careful analysis with a larger sample size would be required to determine its application for neuroblastoma. One major disadvantage to laparoscopic adrenalectomy may be the hospital charge. There clearly is a discrepancy in the hospital charge in those who receive a laparoscopic adrenalectomy. This is offset by a decrease in surgical length of stay in the laparoscopic group. Ideally, with more widespread use of the laparoscopic surgery and the availability of less expensive disposable equipment the charges should decrease.6 Preoperative localization is imperative with either approach of pheochromocytoma resection, but especially so with a laparoscopic adrenalectomy because complete and adequate exploration of all pheochromocytoma sites is likely inadequate. All patients underwent localization with computed tomography scan or magnetic resonance imaging and, recently, MIBG scanning. Although there has been metachronous development of a second pheochromocytoma, they were usually at a prolonged time interval in this series. Others have described similar results. Continued evaluation of this approach is necessary to determine whether preoperative localization is adequate.
LAPAROSCOPIC ADRENALECTOMY
1029
Our findings show that children undergoing a laparoscopic adrenalectomy for pheochromocytoma have a decreased surgical length of stay and faster return to function. These patients had no adverse sequelae with
excellent long-term results. A subset of patients with neuroblastoma with very localized disease also may be candidates for laparoscopic adrenalectomy. More data need to be accumulated to verify this recommendation.
REFERENCES 1. Gans SL, Johnson DG, Berci G: Laparoscopy in Infants and Children. New York, NY, Appleton-Century-Crofts, 1976 2. O’Neill JA, Rowe MI, Grosfeld JL, et al: Gastrointestinal endoscopy, laparoscopy, and other noninvasive surgical techniques, in Essentials of Pediatric Surgery (eds). St. Louis, MO, Mosby Year-Book, 1998, pp 1233-1251 3. Caty MG, Coran AG, Geagen M, et al: Current diagnosis and treatment of pheochromocytoma in children. Arch Surg 125:978, 1990 4. Shanberg AM, Sanderson K, Rajpoot D, et al: Laparoscopic
retroperitoneal renal and adrenal surgery in children. BJU Int 87:521524, 2001 5. Tanaka M, Tokuda N, Koga H, et al: Laparoscopic adrenalectomy for pheochromocytoma: Comparison with open adrenalectomy and comparison of laparoscopic surgery for pheochromocytoma versus other adrenal tumors. J Endourol 14:427-431, 2000 6. Yoshimura K, Yoshioka T, Miyake O, et al: Comparison of clinical outcomes of laparoscopic and conventional open adrenalectomy. J Endourol. 12:555-559, 1998
Purpose: The authors sought to compare the outcome of children undergoing open versus laparoscopic adrenalectomy for an adrenal tumor. Methods: Medical records of children that underwent an adrenalectomy from 1990 through 1999 were reviewed. Sixty-four adrenalectomies were performed: 27 pheochromocytomas, 36 neuroblastomas, and 1 virilizing tumor. Sixty adrenalectomies were performed open and 4 laparoscopically. The patient’s age, surgical length of stay, operative charge, hospital cost, operating time, blood loss, and outcome were examined. Results: Mean age for an open procedure was 8.9 ⫾ 0.9 years and 14 ⫾ 1.1 for laparoscopic (P ⫽ .019). Surgical length of stay for open was 5.4 ⫾ .38 days and 2.7 ⫾ .62 days for laparoscopic (P ⫽ .006). Patient operative charges were
L
APAROSCOPIC SURGERY has been popularized in the treatment of surgical diseases in the pediatric population. Dr. Gans first described laparoscopy in infants and children in the late 1970s.1 The main advantages to laparoscopic surgery are to provide equal to superior exposure to the viscera, diminish the soft tissue dissection required with an open procedure, and decrease postoperative pain, all with an improved cosmetic result.2 With the advent and ease of laparoscopic surgery in the 20th century, a laparoscopic adrenalectomy was proposed, because adrenal removal requires retroperitoneal exposure and dissection in a small area, which presents a challenge to the surgeon. We sought to compare the outcome of children undergoing open versus laparoscopic adrenalectomy for an adrenal tumor. We reviewed the medical records of all infants with a diagnosis of pheochromocytoma and neuroblastoma, managed surgically, from 1990 through 1999. We compared open and laparoscopic adrenalectomies and examined several variables including age, surgical length of stay, patient operative charge, patient hospital costs, operating time, blood loss, and overall patient outcome.
$12,941 ⫾ 676 for laparoscopic and $4,714 ⫾ 411 for open (P ⬍ .001). When total estimated patient cost, including hospital stay, were compared between groups there was no significant difference. Similar mean operating times and blood loss were noted. There were no deaths or complications in children with a pheochromocytoma. The mortality rate in children with neuroblastoma was 28%. Conclusions: Adrenalectomy for benign tumors can be performed safely. In selected children a laparoscopic procedure can be expected to decrease the surgical length of stay without increasing operating time or complications. J Pediatr Surg 37:1027-1029. Copyright 2002, Elsevier Science (USA). All rights reserved. INDEX WORDS: Laparoscopic adrenalectomy, pheochromocyotma, outcome analysis.
identified. There were a total of 64 adrenalectomies: 27 pheochromocytomas, 36 neuroblastomas, and 1 virilizing tumor. Sixty adrenalectomies were performed open and 4 laparoscopically. Patients with a diagnosis of Wilm’s tumor were excluded.
Methods This study was reviewed and approved by the Children’s Hospital of Pittsburgh Human Rights Committee. A retrospective review of all medical records examined the patient’s age, surgical length of stay, patient operative charge, patient hospital cost, operating time, blood loss, and overall patient outcome. Specifically, we compared these variables in children treated by an open or laparoscopic adrenalectomy. Statistical analyses were performed by Sigma Statistical software, version 2.0, with significance valued at P ⬍ .05. Values also are presented as the mean ⫾ SEM.
RESULTS
The mean age for an open adrenalectomy was 8.9 ⫾ 0.9 (range, 3 to 16 years) versus 14 ⫾ 1.1 (range, 12 to
All children who had undergone an adrenalectomy at the Children’s Hospital of Pittsburgh (Pittsburgh, PA) between 1990 and 1999 were
From the Department of Surgery, Children’s Hospital of Pittsburgh and the University of Pittsburgh School of Medicine, Pittsburgh, PA. Presented at the 53rd Annual Meeting of the Section of Surgery of the American Academy of Pediatrics, San Francisco, California, October 19-21, 2001. Address reprint requests to Eugene S. Wiener, MD, Children’s Hospital of Pittsburgh, 3705 Fifth Ave, Pittsburgh, PA 15213. Copyright 2002, Elsevier Science (USA). All rights reserved. 0022-3468/02/3707-0018$35.00/0 doi:10.1053/jpsu.2002.33835
Journal of Pediatric Surgery, Vol 37, No 7 (July), 2002: pp 1027-1029
1027
MATERIALS AND METHODS
Participants
1028
STANFORD ET AL
16 years); P ⬍ .05. Additionally, the surgical length of stay was determined to be significantly less for a laparoscopic adrenalectomy (2.7 ⫾ .62; range, 1 to 4 days) compared with an open adrenalectomy (5.4 ⫾ .38; range, 3 to 9 days). The open procedures were performed over the entire length of the review, whereas the laparoscopic procedures were performed from 1997 to 1999. Operative Factors The average operating time for a laparoscopic adrenalectomy (264 min; range, 217 to 307 min) was similar to that of an open procedure (235 min; range, 107 to 425 min). The estimated blood loss for the laparoscopic procedure was 100 mL versus open adrenalectomy at 284 mL. However, there was no significant statistical difference. Patient Operative Charge and Total Hospital Cost The patient operative charge was significantly higher in the laparoscopic group compared with the open patients (mean operative charges for a laparoscopic adrenalectomy, $12,941 ⫾ 676; range, $5,372 to $14,644). The mean operative charges for an open adrenalectomy were $4,714 ⫾ 411; range, $2,051 to $13,592. There was no significant difference in total hospital costs between the 2 procedures. Patient Outcome All patients with pheochromocytoma excised via an open or laparoscopic procedure survived. There were no associated operative complications or mortality. Three of the patients required a second operation for a metachronous contralateral adrenal pheochromocytoma. The mean time before a second operation was required was 2.9 years (range, 1.2 to 3.8 years). The long-term survival rate in the children with neuroblastoma was 72%. Most of the children who died had stage IV disease at the time of their death. In the laparoscopic group there was one conversion to an open procedure. This was done in a child with neuroblastoma. In this case, conversion did not lengthen the procedure (173 minutes). DISCUSSION
The age range in our patient population was 3 to 16 years. The older children were more likely to have a laparoscopic adrenalectomy, but the usual age of presentation of pheochromocytoma explains this finding.3 Initial concerns were that in the small or obese child laparoscopic surgery would be contraindicated.1 That has since been disproved because these procedures are performed safely in children with varying body habiti.2,4 Our data, showing a decrease in the surgical length of
stay with laparoscopic adrenalectomy, is comparable with what has been reported in the adult literature. It is probable that the surgical length of stay is decreased in children for several reasons, most notably a decrease in time to the return of bowel function, ease of pain control, and increased patient mobility, because they have less pain postoperatively. Despite the fact that laparoscopic adrenalectomy is a relatively new procedure, there was not a prolongation of operating time when compared with an open procedure. This probably is because of the ease of exposure of the adrenal tumor with a laparoscopic adrenalectomy compared with the open procedure. Also, a single surgeon performed all the laparoscopic adrenalectomies. Additionally, the estimated blood loss, which may be an indicator of operative difficulty, was not different between our 2 groups. Tumor size did not appear to adversely affect ease of a laparoscopic or open procedure. The largest pheochromocytoma removed laparoscopically was 5.5 ⫻ 5.8 ⫻ 2.1 cm. One laparoscopic adrenalectomy was converted to an open procedure in a child with neuroblastoma. This was primarily because of proximity and concern of involvement of surrounding structures. However, much of the dissection had been accomplished before conversion. Retrospectively, the surgeon felt that the operation could have been completed successfully laparoscopically. Although there is increasing experience with laparoscopic adrenalectomy for pheochromocytoma, careful analysis with a larger sample size would be required to determine its application for neuroblastoma. One major disadvantage to laparoscopic adrenalectomy may be the hospital charge. There clearly is a discrepancy in the hospital charge in those who receive a laparoscopic adrenalectomy. This is offset by a decrease in surgical length of stay in the laparoscopic group. Ideally, with more widespread use of the laparoscopic surgery and the availability of less expensive disposable equipment the charges should decrease.6 Preoperative localization is imperative with either approach of pheochromocytoma resection, but especially so with a laparoscopic adrenalectomy because complete and adequate exploration of all pheochromocytoma sites is likely inadequate. All patients underwent localization with computed tomography scan or magnetic resonance imaging and, recently, MIBG scanning. Although there has been metachronous development of a second pheochromocytoma, they were usually at a prolonged time interval in this series. Others have described similar results. Continued evaluation of this approach is necessary to determine whether preoperative localization is adequate.
LAPAROSCOPIC ADRENALECTOMY
1029
Our findings show that children undergoing a laparoscopic adrenalectomy for pheochromocytoma have a decreased surgical length of stay and faster return to function. These patients had no adverse sequelae with
excellent long-term results. A subset of patients with neuroblastoma with very localized disease also may be candidates for laparoscopic adrenalectomy. More data need to be accumulated to verify this recommendation.
REFERENCES 1. Gans SL, Johnson DG, Berci G: Laparoscopy in Infants and Children. New York, NY, Appleton-Century-Crofts, 1976 2. O’Neill JA, Rowe MI, Grosfeld JL, et al: Gastrointestinal endoscopy, laparoscopy, and other noninvasive surgical techniques, in Essentials of Pediatric Surgery (eds). St. Louis, MO, Mosby Year-Book, 1998, pp 1233-1251 3. Caty MG, Coran AG, Geagen M, et al: Current diagnosis and treatment of pheochromocytoma in children. Arch Surg 125:978, 1990 4. Shanberg AM, Sanderson K, Rajpoot D, et al: Laparoscopic
retroperitoneal renal and adrenal surgery in children. BJU Int 87:521524, 2001 5. Tanaka M, Tokuda N, Koga H, et al: Laparoscopic adrenalectomy for pheochromocytoma: Comparison with open adrenalectomy and comparison of laparoscopic surgery for pheochromocytoma versus other adrenal tumors. J Endourol 14:427-431, 2000 6. Yoshimura K, Yoshioka T, Miyake O, et al: Comparison of clinical outcomes of laparoscopic and conventional open adrenalectomy. J Endourol. 12:555-559, 1998