controversial indications for laparoscopic adrenalectomy 2006/adrenals/henry.pdf · • invasive...
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CONTROVERSIAL INDICATIONS FOR LAPAROSCOPIC ADRENALECTOMY
J. F. HENRY
Department of Endocrine SurgeryUniversity-Hospital La Timone
Marseilles - France
8th Postgraduate Course in Endocrine SurgerySeptember 21-24, 2006Heraklion, Crete-Greece
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CONTROVERSIAL INDICATIONS FOR LAPAROSCOPIC ADRENALECTOMY
Large tumors:- Pheochromocytomas- Cortical tumors
Metastases
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Background
• Laparoscopic adrenalectomy:– Less pain / blood loss1
– Less morbidity & shorter hospital stay2
– More rapid return to work3
• Procedure of choice:– Benign– Small secreting adrenal tumours
– ? Large adrenal tumours1Imai T. et al Am J Surg 1999; 178: 50-3.2Dudley NE, Harrison BJ. Br J Surg 1999; 86: 656-603Thompson GB et al. Surgery 1997; 122: 1132-6
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PRIMARY ADRENAL TUMORS
4 cm > > 6 cmBENIGN MALIGNANT
ENDOSCOPICAPPROACH
OPENAPPROACH
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LAPAROSCOPIC ADRENALECTOMYLAPAROSCOPIC ADRENALECTOMYTUMORS > 6 cmTUMORS > 6 cm
Nb :39* (7.9 %)
Pheochromocytoma 16Cortical tumors 23
* Tumors > 6 cm , solid .
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ADRENAL CARCINOMAS
Preoperative demonstration of invasive extra-adrenal carcinoma remains an
absolute contra-indication for laparoscopic adrenalectomy.
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LAPAROSCOPIC ADRENALECTOMY
Should laparoscopic approach be proposed for large and/or potentially malignant adrenal tumours ?
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TRANSPERITONEAL OR RETROPERITONEAL
ENDOSCOPIC APPROACH ?
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TRANSPERITONEAL OR RETROPERITONEAL
ENDOSCOPIC APPROACH ?Transperitoneal approachLateral position3-4 trocars - subcostal areaDissection : cautery hook, harmonic scapel, ligasure
clips (adrenal vein)Extraction in plastic bagDrainage : optionalVein thrombosis prophylaxis
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ENDOSCOPIC ADRENALECTOMY FOR LARGE PHEOCHROMOCYTOMAS
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LAPAROSCOPIC ADRENALECTOMYLAPAROSCOPIC ADRENALECTOMYFOR LARGE PHEOCHROMOCYTOMASFOR LARGE PHEOCHROMOCYTOMAS
Is endoscopic adrenalectomy a safe procedure ?
- with adequate preoperative blockers- CO2 pneumoperitoneum is well tolerated- laparoscopic versus open : no significant differences
in hemodynamic changes and catecholamine secretion
Fernandez-Cruz – World J. Surg. 20, 762-768, 1996
Inabnet – World J. Surg. 24, 574-578, 2000
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L.A. FOR LARGE PHEO > 60mm(16 cases)
• Mean size 76mm• Mortality 0• Conversion 0
• Hemodynamic complications 1• Capsular disruption 2• Malignancy 0• Recurrence 0
Dpt of Endocrine SurgeryHospital La Timone - Marseilles
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L.A. FOR LARGE CORTICAL TUMORS Predicting malignancy
• Clinical– Local symptoms– Virilization
• Biochemical– Mixed secretion– DHEA-S
• Radiological– Size– CT - low attenuation (?benign)– MRI - rapid gadolinium enhancement + washout (benign?)– NP59– PET
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L.A. FOR LARGE CORTICAL TUMORS
• Adrenalectomies 565• L.A. 489• Solid cortical > 6cm 23
11 non secreting tumors12 secreting tumors
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L.A. FOR LARGE CORTICAL TUMORSResults: Demographics/ Histology
• Mean age 49.9 (22-77) years• Mean tumour diameter 71mm (60-100) • Histology
– 8 cortical adenomas– 5 adrenocortical carcinomas– 10 indeterminate histology
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L.A. FOR LARGE CORTICAL TUMORSResults: Deaths
• 2 DNRD– 77 female
• 65mm non secreting tumour “cortical adenoma”– 71 female
• 65mm non secreting tumour “cortical adenoma”
• 2 DRD: 2o liver mets without local recurrence:– 44 female 10/12
• 80mm Cushings - “indeterminate histology”– 77 female 19/12
• 70mm Non secreting ACC
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L.A. FOR LARGE CORTICAL TUMORSResults
• 1 local recurrence:-43 woman, Recurrence at 54 months -60mm -Cushings, “Indeterminate histology”
• 1 local recurrence associated with distant metastases- 62 man, Recurrence at 12 months -75mm -Aldosteronoma-Malignant
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Conclusions
• Laparoscopic adrenalectomy produces acceptable medium term results in adrenal cortex tumours >6cm where there is no pre or intraoperative evidence of malignancy.
• Laparoscopy should be considered an assessment tool as well as therapeutic in the management of large adrenal tumours.
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Adrenal Cortex Tumour
Evidence of local invasion No evidence of local invasion
Signs of invasion
Laparoscopic Approach
No signs of local invasion
Complete LA - minimal touchtechnique, include surroundingperiadrenal fat
Open surgery - radical compartmental resection
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LAPAROSCOPIC ADRENALECTOMYLAPAROSCOPIC ADRENALECTOMYFOR METASTASESFOR METASTASES
Nb :25(5 %)
Lung 14Melanoma 4Mesothelioma 1Rhabdomyosarcoma 1Colon ADK 1Renal cell 4
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LA FOR METASTASES
•Synchronous AM (n=15), Metachronous AM (n=9)
• 13/16 patients presented other metastatic sites in their
history (controlled at the time of LA)
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• All patients : lateral, transperitoneal approach
• Conversion 6/25 (24%) (<5% conversion rate)
• Macroscopic complete resection : 75%
• Microscopic complete resection : 56%
• Minor Complications : 4/25
• Hospitalisation : 5 days (3-18)
LA FOR METASTASES
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Follow up (16 patients)• Observed FU 25 months (1-68 months)
• 5 years O. Survival : 42 % (24.4 months)(KM)
• 8 Patients alive with a mean FU of 35 months
– 3 without evidence of disease at 60, 24, 19 months after surgery
0
,2
,4
,6
,8
1
0 10 20 30 40 50 60 70Time
• We did not identify any prognostic factors such as primarytumour, meta/synchromous
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Conclusions (1)• Appropriate evaluation close before surgery :
– To avoid conversion : loss of the advantages of laparoscopycompared to open approach, and conversion often meansincomplete resection
– To avoid incomplete resection (AM incomplete resection or other uncontrolled metastatic sites)
⇒ Complete and appropriate evaluation using at least thin cut CT scan and PET scan performed close to the time of surgery
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Conclusions (2)
• When AM matches the « good criteria » for resection
(confined to the adrenal gland…), subsequently the AM
may be resected by LA in most cases.
• AM which match those criteria are rare…
• AM that would require open adrenalectomy with a
curative intent are probably rarer…
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Conclusions (3)
• Some factors are usually related to good prognosis…
• In our series, a majority of patients presentedsynchronous AM or others metastatic sites in theirhistory. Despite these characteristics, survival compared favourably…
• When “classical” favourable factors are absent, patient should not be excluded de facto from a surgical approach
• A patient specific multidisciplinary approach is required.
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Conclusions
• If all these conditions are respected, patients
may benefit from both surgical resection with
the comfort of laparoscopy.
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ENDOSCOPIC ADRENALECTOMY
• Invasive adrenal carcinoma is an absolute contra-indication for laparoscopic adrenalectomy
• Whether the laparoscopic approach should beconsidered for large-volume (>5-6 cm) and potentiallymalignant adrenal tumors remains debatable
• Endoscopic adrenalectomy may be considered for solitary adrenal metastases in patients in whom a primary carcinoma has been completely resected