Risk Factors for Perioperative Complications of Laparoscopic Adrenalectomy Including Single-Site Surgery

Abstract

Purpose:

To determine predictive factors for perioperative complications of laparoscopic adrenalectomy (LA) including single-site surgery performed or supervised by experienced laparoscopic surgeons.

Patients and Methods:

We retrospectively reviewed 265 consecutive unilateral LAs performed at a single institution from 2001 to 2011. All surgical procedures were performed or supervised by one of two experienced laparoscopic surgeons. The transabdominal approach was used in 248 patients, while a retroperitoneal approach was used in 17 patients. Laparoendoscopic single-site adrenalectomy was performed in 58 patients. Predictive factors for postoperative complications were analyzed.

Results:

There were no postoperative deaths. At least one postoperative complication occurred in 12 (4.6%) patients. No patient underwent reoperation for a complication. Only one (0.4%) patient's procedure was converted to open surgery, and only this patient needed a blood transfusion during the operation. One patient who underwent laparoendoscopic single-site adrenalectomy had the procedure converted to conventional laparoscopic adrenalectomy. Multivariable logistic regression analysis showed that an American Society of Anesthesiologists-physical status grade 3 or above was the only predictive factor for perioperative complications.

Conclusion:

American Society of Anesthesiologists-physical status grade 3 or above was a statistically significant factor for perioperative complications associated with laparoscopic adrenalectomy that involved laparoendoscopic single-site adrenalectomy, which was performed or supervised by an experienced laparoscopic surgeon. According to the findings of this retrospective study, single-site operation, obesity, adrenal tumor size, and tumor type may not be considered as risk factors for perioperative complications after LA performed or supervised by an experienced laparoscopic surgeon.

Introduction

S ince first described in 1992,¹ laparoscopic adrenalectomy (LA) has become the standard surgical procedure for the surgical management of most functioning and nonfunctioning adrenal tumors. This minimally invasive technique aims to achieve the same results as open surgical procedures with the same safety and less trauma for the patient, and several studies have suggested that LA decreases postoperative pain, duration of hospital stay, postoperative disability, the complication rate, and blood loss in comparison with open surgery.^2

–7 It has been reported that the perioperative complication rate and mortality rate were 6.7% to 8.5% and 0% to 0.5%, respectively.^8

–11

To decrease the complication rate of this minimally invasive technique, many studies have attempted to identify predictive factors for perioperative complications; however, the conclusions have been different and thus inconclusive.^{10

–18} We first used laparoendoscopic single-site adrenarectomy (LESS-A) at our institution in October 2009. LESS surgery was developed with the aim of preventing port-site complications, further decreasing discomfort associated with laparoscopic surgery, and improving the cosmetic outcome.^19
–21 This study was designed to establish the actual incidence of perioperative complications during LA (including LESS-A) at a single institution, with particular attention being paid to identifying predictive factors of perioperative complications.

Patients and Methods

A total of 265 consecutive patients who underwent unilateral LA at Keio University Hospital in Tokyo were recorded into the hospital database from January 2001 to November 2011. All surgical procedures were performed or supervised by one of two experienced laparoscopic surgeons (AM and KN). All patients were evaluated to analyze the diagnostic, therapeutic, and follow-up results of all cases with perioperative complications. Demographic data, surgical indications, American Society of Anesthesiologists-physical status (ASA-PS) grade, previous abdominal and/or retroperitoneal surgery, pathologic characteristics of adrenal tumors, perioperative variables, and perioperative complications were analyzed. Patients who underwent bilateral LA and had suspected primary adrenal malignant tumors as a result of clinical and radiologic evidence were excluded from the study.

All patients underwent multidetector CT and MRI. A complete endocrine evaluation was performed in all patients. Patients with subclinical disease or Cushing syndrome received postoperative glucocorticoid substitution. Patients with pheochromocytoma were routinely treated with alpha-beta-blockers. Surgical indications for incidentaloma were tumors greater than 4 cm in diameter. A postoperative complication was defined as an event that occurred within 30 days after surgery and was stratified according to the Clavien-Dindo classification.²²

Antibiotic prophylaxis was administered to all patients and consisted of a single administration of levofloxacin (0.5 g, internal use) just before induction of general anesthesia. The transabdominal approach was used in 248 patients, while the retroperitoneal approach was used in 17 patients.

Fifty-eight consecutive patients underwent LESS-A at our institution from December 2009 to October 2011. We did not make special exclusion criteria for LESS-A, and we decided the surgical type according to the patient's demand. In conventional left-sided LA, three trocars were placed beneath the costal margin. In the case of conventional right-sided LA, another 5-mm port was added to elevate the liver. In cases of LESS-A, the SILS^™ port was placed through a 2-cm incision located beside or at the inner edge of the umbilicus. In right LESS-A, we introduced an additional 2-mm needle port to slightly lift up the liver. All patients received prophylaxis for deep vein thrombosis, using intermittent pneumatic compression in all cases. Normal diet and full mobilization were initiated on the first or second postoperative day.

Demographic and perioperative data were analyzed statistically. Variables considered for the univariable analysis were sex, body mass index (BMI) of 25 kg/m² or higher, duration of operation, the side of the adrenalectomy, hormone oversecreting tumors (pheochromocytoma and functioning adrenocortical adenoma), age 60 years or above, ASA-PS grade 3 or above, an adrenal tumor at least 5 cm in diameter, previous abdominal surgery, conventional LA or LESS-A, transabdominal or transretroperitoneal approach, and conversion to laparotomy. Statistical analyses were performed using SPSS software version 19.0. Differences were considered to be significant at the 5% level.

Results

From May 2001 to November 2011, 265 patients underwent unilateral LA at our institution. The patient background characteristics are shown in Table 1. There were 153 women and 112 men, with a median age of 51.3 years (range 21–78 years). Median BMI was 22.9 (14.4–37.1) kg/m². Median ASA-PS grade was 1.77, and 25 patients were classified as ASA-PS grade 3. A total of 117 (44.1%) patients received a diagnosis of primary aldosteronism, 55 (20.8%) pheochromocytomas, and 59 (22.3%) Cushing syndrome. Previous upper abdominal and/or retroperitoneal surgery included three cholecystectomies, two duodenal ulcer procedures, one ureterolithotomy, and one gastric procedure. There were no statistically significant differences among the patient backgrounds or surgical indications for conventional adrenalectomy and LESS-A (data not shown).

Table 1.

Patient Characteristics

	Overall	Complicated	Noncomplicated	P value ^a
No. patients	265	12	253
Sex				0.080
Male	112	8	104
Female	153	4	149
Age (years)	51.3±12.2	55.0±13.9	51.2±12.0	0.240
BMI (kg/m²)	22.9±3.7	24.0±3.3	22.9±3.7	0.301
>35	2	0	2
>25	68	5	63	0.143
ASA-PS grade	1.77±0.59	2.17±0.65	1.76±0.58	0.003
3	25	5	20
2	158	6	152
1	82	1	81
Previous abdominal operation				0.360
Upper	7	1	6
Lower	62	1	61
Bilateral	3	0	3

t test and chi-square text.

BMI=body mass index; ASA-PS=American Society of Anesthesiologists-physical status.

The details of the surgical procedures are presented in Table 2. Intraoperative bleeding with conversion to open surgery was related to inferior vena cava injury. Caval injury was repaired by open conversion. We sutured caval laceration by 5-0 proline string. The total blood loss of the operation was 3160 mL, and we transfused packed red blood cells, 8U, during the operation. It was in the conventional LA patient. There were no postoperative deaths within the month after surgery.

Table 2.

Perioperative Parameters

	Overall	Complicated	Noncomplicated	P value ^a
Side of adrenalectomy				0.991
Left	155	7	148
Right	110	5	105
Duration of operation (min)	133±54	123±48	134±54	0.656
Intraoperative bleeding (mL)	50.6±52.6	40.1±36.1	298±902	0.342
Open conversion	1	1	0
Conversion to LA	1	1	0
Tumor type (= PA)	117	6	111	0.676
Tumor type (= pheo)	55	3	52	0.711
Tumor type (= Cushing)	59	2	57	0.633
Surgical type
LA	190	8	182
Retro LA	17	0	17
LESS-A	58	4	54	0.335
Tumor size (mm)	29.5±20.5	26.1±18.0	29.6±19.8	0.834

t test and chi-square test.

LA=laparoscopic adrenalectomy; PA=primary aldosteronism; pheo=pheochromocytoma; retro=retroperitoneal; LESS-A=laparoendoscopic single-site adrenalectomy.

Excluding minor complications (Clavien–Dindo grade I), 12 (4.6%) patients had at least one complication. No patient underwent reoperation for complications (Table 3). Overall, 12 patients had surgical complications. Retroperitoneal hematoma developed in a patient with a diagnosis of an endothelial cyst, but it resolved with conservative observation. Symptomatic partial renal infarction was observed in three patients. Two patients had wound complications, but they also resolved with antibiotic treatment.

Table 3.

Complications

Complication	Sex	Age	BMI (kg/m²)	Clavien-Dindo grade	Op. type	Size (mm)	Side	Tumor type	ASA-PS grade
Myocardial infarction	M	52	25.8	IVa	LA	10	R	PA	2
Cerebral infarction	M	42	29.0	IVa	LA	35	L	PA	2
Cerebral infarction	M	68	23.2	IVa	LA	6	R	PA	2
Acute heart failure	F	46	19.7	IVa	LESS	20	L	Pheochromocytoma	1
Pneumonia	F	48	26.3	II	LA	30	R	Cushing	3
Conversion to LA	F	59	20.8	IIIb	LESS	58	R	Pheochromocytoma	3
Open conversion, renal infarction	F	75	21.6	IIIb	LA	19	R	Pheochromocytoma	3
Renal infarction	M	39	20.8	II	LA	25	L	PA	2
Renal infarction	M	53	22.3	II	LA	7	R	PA	2
Retroperitoneal hematoma	M	40	27.3	II	LESS	43	L	Cystic tumor	2
Wound complication	F	67	23.3	II	LESS	25	L	PA	3
Wound complication	M	76	28.7	II	LA	68	L	Cushing	3

BMI=body mass index; op=operation; ASA-PS=American Society of Anesthesiologist-physical status; LA=laparoscopic adrenalectomy; LESS=laparoendoscopic single-site.

One LESS procedure was converted to conventional LA (Clavien grade IIIb). This was a 59-year-old woman with a history of hypertension and severe diabetes mellitus (HbA_1c=11.9%). Her BMI was 20.8, and there was no operative history. Tumor size was 58 mm, and adhesion around the tumor was severe. To perform the operation safely, we added two additional ports and finished the operation uneventfully.

Two patients had a cerebral infarction. Acute prostatitis developed in one patient, pneumonia in one patient, deep vein thrombosis in one patient despite prophylaxis; myocardial infarction developed in a patient with primary aldosteronism, and one patient with pheochromocytoma had acute heart failure.

Univariable analysis showed that an ASA-PS grade 3 or above was associated with a risk of complications (P=0.003) (Table 4). In multivariable logistic regression analysis, an ASA-PS grade 3 or above (risk ratio 5.58, 1.51 to 20.5; P=0.01) was the only independent predictive factor for overall complications.

Table 4.

Statistical Analysis—Complications

	Univariate P value	Multivariate P value	Risk ratio (95% CI)
Age≥	0.468
Sex	0.080
Side	0.991
Single port	0.335
ASA-PS grade ≥3	0.003	0.01	5.58 (1.51–20.5)
BMI ≥25	0.301
Tumor size >50 mm	0.873
Operative time >130 min	0.715
History of abdominal operation	0.360

CI=confidence interval; ASA-PS=American Society of Anesthesiologists-physical status; BMI=body mass index.

Discussion

LA is considered to be the ‘‘gold standard’’ treatment for most adrenal tumors because it is safe and feasible. The largest institutional studies have demonstrated a perioperative complication rate and mortality rate of 6.7% to 8.5% and 0% to 0.5%, respectively.^8
–10 In this single-center series of 265 patients who underwent LA, only one procedure was converted to open surgery, the overall perioperative complication rate was 4.6%, and no patient needed reoperation. There was no perioperative death. Major surgical complications were mainly retroperitoneal fluid collection and partial renal infarction. Conversion to open surgery was conducted in only one paient, and this was the only patient who needed transfusion.

According to previous reports, major intraoperative complications are mainly because of bleeding and retroperitoneal collections. Intraoperative bleeding that necessitated open conversion was mostly the result of vena cava injury during division of the right adrenal vein.^11,23,24 Retroperitoneal hematoma or symptomatic retroperitoneal fluid collections were caused by oozing from the adrenal space. In this series, segmental renal infarction was observed in three cases, and these may have been caused by accidental division of an upper segmental renal artery. The overall morbidity rate and open-conversion rate in our study were lower than major published reports. These results may be because all operations in this series were performed or supervised by experienced surgeons. Gupta and associates⁹ reported that the complication rate of LA is significantly lower in referral centers in which more than 30 adrenalectomies are performed annually. This most likely accounts for the comparatively lower morbidity in this study.

It has been reported that patient BMI is an independent risk factor of morbidity⁹; however, in our series, BMI did not affect total morbidity. This may be the result of the comparatively lower BMI of Japanese patients. In our series, the average BMI of 22.9±3.7 kg/m² was much lower than that reported by Gupta (31.8±7.9 kg/m²). This may be one of the reasons for our relatively low morbidity rate and conversion rate after LA.

Previous reports have demonstrated that the size of the mass and pheochromocytoma were independent risk factors of the perioperative complication rate for LA.^10,18 On the other hand, it has been reported that the size of the mass and pheochromocytoma did not affect morbidity in LA.^9,15
–17 Considering the surgical outcome of our series, the size of the mass did not appear to affect the morbidity of our patients. Also, there was no statistical difference between patients with pheochromocytomas and those with other adrenal diseases. We speculate that, while the size of the mass or pheochromocytoma might affect morbidity in LA, surgery performed or supervised by an experienced surgeon can prevent the occurrence of perioperative complications.

LESS-A was developed recently as a treatment option for adrenal tumors and has less postoperative pain and a greater cosmetic benefit than other procedures.^19
–21,25 Because LESS is a new and technically difficult procedure, however, few studies have examined this procedure in a large patient population. To our knowledge, the safety of LESS-A compared with conventional LA has not yet been determined. We analyzed cases that included conventional LA and LESS-A. There was no statistically significant difference with respect to the perioperative complication rate between the two surgical methods, even when combined with large tumor size or BMI. Even though LESS-A is a new method and requires a high level of technical skill, it does not affect the total perioperative complication rate, as we reported previously.^21,26

The ASA-PS is related to the risk of anesthesia and also reflects the health state of the patient. For example, the National Surgical Quality Improvement Program study reported that a high ASA-Ps grade (≥3) was an independent risk factor for complications.²⁷ This registry-based study is limited by data reliability and by analysis of only total morbidity (no differentiation between minor and major complications). Single-center studies have also shown that a high ASA-PS grade is a significant risk factor for the total perioperative complication rate.^28,29 In the urologic field, Permpongkosol and colleagues¹³ reported that ASA-PS grade 3 or above was a risk factor for perioperative complications in urologic procedures, a finding that is similar to that of the present study. On the other hand, a previous review described an increased risk of infectious complications in patients with a reduced general health status, especially an ASA-PS grade 3 or above.^30,31 These reviews showed the relative lack of systematic knowledge regarding the factors that might influence the development of infectious complications in conjunction with urologic procedures.

Although LESS-A is reported to have many merits compared with conventional LA, we should give high priority to safety. Because LESS is a new and technically difficult procedure, we strongly recommend the operator does not hesitate to add more ports in difficult cases if it is thought that the risk associated with performing LESS is unacceptably high. Although this study discusses operations performed or supervised by experienced surgeons, we believe this is applicable to inexperienced laparoscopic surgeons as well. A large prospective, randomized trial focusing not only on the safety of the operation but also on medical costs and patient quality of life should be conducted in the future.

Conclusion

This single-center retrospective series has confirmed good results after LA for various benign secreting or nonsecreting adrenal tumors. Based on the results, we believe careful consideration should be given to patients with an ASA-PS of grade 3 or above, with proper attention being paid to the prevention of perioperative complications. Single-site operation, obesity, adrenal tumor size, and tumor type may not need to be considered as risk factors for perioperative complications associated with an LA that is performed or supervised by an experienced laparoscopic surgeon.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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