A. D. Shahait1, 2, K. Girten2, K. J. Saleh2, D. Weaver1, G. Mostafa1, 2 1Wayne State University, Surgery, Detroit, MI, USA 2John D. Dingell VA Medical Center, Surgery, Detroit, MI, USA
Introduction:
Since the introduction of laparoscopic adrenalectomy in 1992, it became the standard of care for most of adrenal pathologies. This study aims to compare the outcomes and trends of open (OA) vs. laparoscopic adrenalectomy (LA) in veterans.
Methods:
VASQIP was queried for adrenalectomies performed for benign pathologies during the period 2000-2019. Data collection included demographics, comorbidities, operative details, and postoperative outcomes. Univariate and multivariate regression analyses were performed, and a p-value of ≤0.05 was considered significant.
Results:
A total of 1,683 patients were included (91.4% males, mean age 59.6, mean BMI 31.2, and 87.2% with ASA class ≥III). Overall, mean operative time (OT) was 3.2 hr, majority performed by general surgeons (71.4%), 5.7% required at least one-unit PRBC intraoperatively, and mean length of stay (LOS) 4.1 days. There were 12 (0.7%) 30-day mortalities, and 162 patients (8.8%) developed ≥1 complication. LA was performed in 70.9% (1,306), with conversion rate of 0.85% (10). When compared with OA, patients with laparoscopic approach were likely independent (98.5% vs. 96.8%, p=0.028), shorter OT (3.1 hr vs. 3.4 hr, p<0.001), less intraoperative blood transfusion (1.5% vs. 15.7%, p<0.001), shorter LOS (3.3 day vs. 6.2 day, p<0.001), and lower mortality (0.4% vs. 1.3%, p=0.025). LA was associated with lower morbidity rate (6.25 vs. 15.1%, p<0.001), including lower superficial surgical site infection (0.9% vs. 2.9%, p<0.001), reoperation (1.6% vs. 3.9%, p=0.003), and UTI (0.9% vs. 2.4%, p=0.011). Dependent functional status (OR 29, p<0001), CHF (OR 3.5, p=0.046), ASA class ≥III (OR 3.3, p=0.046), and smoking (OR 2.6, p=0.029) were independent predictors of mortality, while intraoperative transfusions (OR 5.9, p<0.001), COPD (OR 2.8, p<0.001), and dependent functional status (OR 2.8, p<0.001) were predictors of morbidity. Laparoscopic approach has a protective effect with a reduction in morbidity rate (OR 0.56, p=0.004). Trend analysis showed eight-fold increase in use of LA [0.8% (2000) to 6.4% (2019)] (p<0.001). Moreover, trend analysis for morbidity and mortality rates showed a significant reduction in the OA group (C statistics 0.48, p<0.001; 0.47, p<0.001, respectively), while for LA no significant change with overall lower rates.
Conclusion:
Laparoscopic adrenalectomy is being well adopted in the VA system with an 8-fold increase over 20 years, with lower morbidity and mortality compared to the open approach for benign adrenal pathologies.