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TEIPOUPEIKHI ANNYI
WORLD Journal of SURGERY @ 1996 by the Société Internationale de Chirurgie
Adrenal Surgery in the Elderly: Too Risky?
Chung Yau Lo, M.D.,1 Jon A. van Heerden, M.D.,1 Clive S. Grant, M.D.,1 Jon Arne Söreide, M.D., Ph.D.,1 Mark A. Warner, M.D.,2 Duane M. Ilstrup, M.S.3
1Department Surgery, Mayo Clinic and Mayo Foundation, 200 First Street SW, Rochester, Minnesota 55905, U.S.A.
2Department of Anesthesiology, Mayo Clinic and Mayo Foundation, 200 First Street SW, Rochester, Minnesota 55905, U.S.A.
3Section of Biostatistics, Mayo Clinic and Mayo Foundation, 200 First Street SW, Rochester, Minnesota 55905, U.S.A.
Abstract. Surgical treatment for adrenal disease may be withheld from elderly patients because of concern about prohibitive operative morbidity and mortality. To obtain objective data in our practice, we analyzed the results of adrenalectomy for patients aged 65 years and older. From 1984 to 1993 there were 85 patients (41 men, 44 women) with ages ranging from 65 to 84 years (median 69 years) who underwent adrenalectomy for Cushing syndrome (n = 19), pheochromocytoma (n = 16), adrenocortical carcinoma (n = 7), benign adenoma (n = 26), or primary hyperaldoste- ronism (n = 17) at our institution. Median follow-up was 26 months (range 1 month to 9.1 years). A retrospective review with respect to preoperative risks and postoperative morbidity and mortality was per- formed utilizing the American Society of Anesthesiologists (ASA) physical status classification and the modified Goldman multifactorial cardiac risk scheme. Survival was estimated by the Kaplan-Meier methods. Operative mortality was 7% (six patients). No patients with pheochromo- cytoma or primary hyperaldosteronism died during the postoperative period. Patients undergoing adrenalectomy for adrenocortical carcinoma had a significantly higher operative mortality (43%) (p = 0.006). Postop- erative complications developed in 19 patients (22%), and there was a reoperation rate of 6% (5 patients). Nineteen percent of patients required postoperative intensive care admission and had a median stay of 2 days (range, 1-38 days). Median hospital stay was 7 days (range 3-47 days). Seventy-three patients (86%) remained alive at study completion. Two- and five-year survivals were 86% and 84%, respectively. Goldman class II or greater was an excellent predictor of increased morbidity (p = 0.032) and mortality (p = 0.036). With the exception of adrenocortical carcinoma, adrenal surgery for elderly patients can be performed with acceptable morbidity and mortality. The Goldman multifactorial cardiac risk scheme reliably predicts postoperative outcome in this elderly group of patients.
Whereas 12% of the population (29 million) was 64 years or older in the United States in 1987, it is anticipated that this figure will rise to 22% by the year 2031 [1]. The life expectancy of this elderly population has changed. Approximately 90% of those 60 to 64 years of age, 75% of those between 70 and 74, and 50% of the population 80 years of age or older will live for another 5 years [2]. As the mean age of the population increases, more surgical procedures are anticipated to be performed in the elderly.
The incidence of adrenal hyper- and hypofunction is low in the elderly population. Postoperative complications and operative mor- tality associated with adrenal surgery (with the possible exception of patients with Cushing syndrome) are rare. Although operative
morbidity and mortality depend on the type and extent of the adrenal disease, the corresponding incidences could be expected to be higher in this group of elderly patients because of associated chronic illnesses, including atherosclerosis, cardiovascular heart disease, hy- pertension, diabetes mellitus, and renal failure. The following report summarizes our experience and results of adrenal surgery in this elderly group of patients over the most recent decade.
Patients and Methods
From 1984 to 1993 a total of 396 patients underwent primary adrenalectomy for varying adrenal pathology at the Mayo Clinic. Eighty-five patients (21%) who were 65 years of age or older at the time of operation were selected for review. Patients with adrenalectomy performed for metastatic disease or during con- comitant primary cancer operations were excluded from the study. There were 41 men and 44 women with a median age of 69 years (range 65-84 years). On the basis of clinical and pathologic findings, patients were divided into the following groups: Cushing syndrome (n = 19); pheochromocytoma (n = 16); adrenocortical carcinoma (ACC) (n = 7); benign adenoma (n = 26); and primary hyperaldosteronism (n = 17). Of the 19 patients with Cushing syndrome, 12 had diffuse adrenocortical hyperplasia [Cushing’s disease (n = 3); ectopic adrenocorticotropin (ACTH) syndrome (n = 6); and primary non-ACTH-dependent adrenocortical nod- ular hyperplasia (n = 3)]; seven had benign adenomas. The frequency of malignant pheochromocytomas was 13%. Among the patients with ACC, three had clinically nonfunctioning tu- mors, but four of the tumors produced various clinical syndromes (hyperaldosteronism, hypercortisolism, virilizing and feminizing syndromes). Except in two patients with cortical hyperplasia (12%), all patients operated on for primary hyperaldosteronism had a unilateral benign aldosterone-producing adenoma.
We assessed the combined operative risk by using the American Society of Anesthesiologists (ASA) physical status classification [3] (Table 1) and the modified Goldman multifactorial cardiac risk scheme [4] (Tables 2, 3) in our review. The charts of patients were retrospectively reviewed with respect to concomitant medi- cal problems, preoperative risk factors, operative details, postop- erative outcome, and long-term survival. Concomitant medical
| Class | Patients (no.) | Physical Status |
|---|---|---|
| 1 | 0 | Normal healthy patient |
| 2 | 30 | Patient with mild to moderate systemic disease |
| 3 | 51 | Patient with severe systemic disease that limits activity but is not incapacitating |
| 4 | 4 | Patient with incapacitating systemic disease that is a constant threat to life |
| 5 | 0 | Moribund patient not expected to survive 24 hours with or without the operation |
| Preoperative factor | Points |
|---|---|
| S3 gallop | 11 |
| Myocardial infarction < 6 months | 10 |
| Abnormal ECG rhythm other than atrial premature contractions | 7 |
| ≥ 5 Premature ventricular | 7 |
| contractions per minute | |
| Age > 70 years | 5 |
| Intraperitoneal operation | 5 |
| Important valvular stenosis | 3 |
| Poor general medical conditions (e.g., abnormal electrolytes, renal failure, chronic liver disease) | 3 |
problems were divided into eight groups: cardiovascular disease, pulmonary conditions, diabetes mellitus, cerebrovascular acci- dents, chronic renal failure or abnormal electrolyte balance, hepatic cirrhosis, active malignancy, and exogenous steroid ad- ministration. These problems were considered to be present if they were noted in a Mayo Clinic medical record. At our institution internists and surgeons routinely noted the presence of these conditions during the study period [5]. Risk factors for morbidity and mortality were evaluated, and the anterior and posterior surgical approaches were compared. Operative mortal- ity was defined as death occurring within 30 days after operation or during the same hospitalization. Morbidity was defined as any complication occurring within the same interval. Follow-up was obtained by clinic examinations, correspondence with patients or their primary physicians, or both. Survival was calculated by the Kaplan-Meier methods [6], and comparison of expected survival of age and sex-matched population of the upper Midwest states was performed with log-rank tests [7]. The endpoint for survival analysis was death due to any cause. Statistical analysis was performed using Fisher’s exact test (nominal variables) or Stu- dent’s paired t-test (continuous variables). A value of p < 0.05 was regarded statistically significant.
Results
Concomitant Medical Problems
Seventy-six patients (89%) had one to seven concomitant medical problems (median two) at the time of operation (Table 4).
| Class | Points | Patients (no.) | Predicted life- threatening complications (5%) | Predicted risk of cardiac deaths (%) |
|---|---|---|---|---|
| I | 0-5 | 51 | 0.2 | 0.2 |
| II | 6-12 | 28 | 5 | 2 |
| III | 13-25 | 6 | 11 | 2 |
| IV | ≥ 26 | 0 | 22 | 56 |
| Medical problem | No. of patients | % |
|---|---|---|
| Hypertension | 60 | 71 |
| Diabetes mellitus | 22 | 26 |
| Arrhythmia | 17 | 20 |
| Ischemic heart disease | 16 | 19 |
| Abnormal electrolytes | 15 | 18 |
| Cerebrovascular accident | 11 | 13 |
| Steroid intake | 9 | 11 |
| Congestive heart failure | 8 | 10 |
| Valvular heart disease | 8 | 10 |
| Chronic obstructive pulmonary disease | 6 | 7 |
| Myocardial infarct ≥ 6 months | 5 | 6 |
| Chronic renal failure | 5 | 6 |
| Active malignancy | 4 | 5 |
| Cirrhosis | 2 | 2 |
| Pulmonary embolism | 1 | 1 |
| Asthma | 1 | 1 |
A large number of patients had several concomitant medical prob- lems.
Cardiovascular disease was present in 68 patients (80%), pulmo- nary conditions in 22 (26%), and chronic renal failure or abnor- mal electrolytes in 18 (21%). Nine patients had a history of steroid consumption at the time of operation.
Preoperative Risk Assessment
Combined ASA class 2 (35%) and class 3 (60%) accounted for most of the patients; there were no patients in class 1 or 5 (Table 1). Categorized by the modified Goldman multifactorial risk scheme, there were 51 patients (60%) in class I, 28 (33%) in class II, and 6 (7%) in class III. There were no class IV patients (Table 3). Elective operations were performed in all instances, except for one emergency procedure performed on a patient with malignant pheochromocytoma who presented with a life-threatening hyper- tensive crisis that responded poorly to medical therapy. Invasive preoperative investigations were, in general, not employed in the overall assessment of these elderly patients.
Operative Details
Anesthetic Management. All patients underwent general anesthe- sia, with most receiving intravenous thiopental for induction and inhaled isoflurane for maintenance of anesthesia. Intraoperative hemodynamic surveillance included the use of standard noninva- sive monitors and, in selected patients with either an elevated risk for intraoperative hemorrhage or significant cardiac disease, arterial catheters for direct systemic blood pressure monitoring. In most cases, central venous hemodynamic monitoring was not
| Detail | Cushing (n = 19) | Pheochromocytoma (n = 16) | Carcinoma (n = 7) | Adenoma (n = 26) | Aldosteronism (n = 17) |
|---|---|---|---|---|---|
| Anterior approach | 4 (21%) | 15 (94%) | 7 (100%) | 14 (54%) | 1 (6%) |
| Concomitant procedures | 2 (11%) | 2 (13%) | 4 (57%) | 7 (27%) | 0 |
| Tumor size (cm), mean ± SD | 3.3 ± 1.2 | 6.4 ± 5.5 | 8.2 ± 2.5 | 5.1 ± 1.9 | 1.3 ±0.5 |
| Blood loss (ml), mean ± SD | 127 ± 179 | 328 ± 411 | 771 ± 610 | 133 ± 171 | 63 ± 29 |
| Operative time (hours), mean ± SD | 2.3 ± 0.8 | 2.1 ± 0.7 | 2.5 ±0.6 | 1.9 ±0.5 | 1.6 ± 0.3 |
| Hospital stay (days), mean ± SD | 10 ± 12 | 9±3 | 10 ±4 | 9 ±5 | 5 ±1 |
| Diagnosis | Sex/age (years) | ASA class | Goldman class | Cause of death | Time of death (days) |
|---|---|---|---|---|---|
| Ectopic ACTH syndrome | M/67 | 4 | II | Sepsis | 14 |
| Ectopic ACTH syndrome | F/71 | 3 | II | Suspected addisonian | 26 |
| Adrenocortical carcinoma | M/66 | 3 | II | Myocardial infarct | 9 |
| Adrenocortical carcinoma | F/77 | 3 | II | Sepsis | 19 |
| Adrenocortical carcinoma | F/71 | 2 | III | Pulmonary embolism | 22 |
| Adenoma | F/80 | 2 | I | Pulmonary embolism | 26 |
utilized in these patients. Intraoperative management of patient positioning, hemodynamics, muscular relaxation, and fluid admin- istration was determined collaboratively by anesthesiologists and surgeons.
Approach. Ninety-six adrenalectomies were performed in 85 pa- tients. Bilateral adrenalectomies were performed in 11 patients (17%); the pathologies in these patients included Cushing’s disease (n = 3), ectopic ACTH-secreting tumors (n = 6), and primary adrenocortical hyperplasia (n = 2). The ratio of right- sided/left sided procedures was 29:45 in those undergoing unilat- eral adrenalectomy. Adrenalectomy was performed via the ante- rior transperitoneal approach in 41 patients (48%), the posterior lumbar approach in 42 (49%), and the flank approach and laparoscopic transabdominal approach in 1 patient each. With the exception of a patient with a 3 cm pheochromocytoma who was operated on via the posterior approach, the anterior approach was employed in all patients with pheochromocytoma or adrenocorti- cal carcinoma. In contrast, adrenalectomy via the posterior ap- proach was selected in all but two patients with primary hyperal- dosteronism [anterior (n = 1), laparoscopic (n = 1)]. Unless other concomitant procedures were planned or technical considerations existed, the posterior approach was preferred in patients with Cushing syndrome (79%) and benign adenomas (42%).
Concomitant Operative Procedures. Twenty-one concomitant op- erative procedures were performed in 15 patients (18%) via the same laparotomy incision. The most common additional proce- dures included splenectomy (n = 5), cholecystectomy (n = 5), and liver biopsy (n = 4). Two patients underwent concomitant cervical exploration for primary hyperparathyroidism.
Duration of Operations and Hospital Stay. The duration of the operation ranged from 1.0 to 3.8 hours (median 1.8 hours), with a median estimated blood loss of 50 ml (range 20-1600 ml). Six patients (7%) required blood transfusions (range 2-5 units). Twelve patients (19%) were admitted to the intensive care unit postoperatively for a median period of 2 days (range 1-38 days).
Median hospitalization was 7 days (range 3-47 days). Table 5 shows the breakdown of the operative details with reference to adrenalectomy for the different pathology encountered.
Outcome. Operative mortality was 7% (six patients). Three deaths occurred in patients with ACC (43%), two with Cushing syndrome (11%), and one with a benign adenoma (4%). The cause of death included sepsis and multiorgan failure in two patients, pulmonary embolism in two, myocardial infarction in one, and suspected addisonian crisis in one (Table 6). No patient died as a result of adrenalectomy for pheochromocytoma or primary hyperaldosteronism. Nineteen patients (22%) developed postoperative complications, with five patients (6%) requiring operative intervention. The indications included hemostasis for intraabdominal hemorrhage (n = 2), truncal vagotomy and pylo- roplasty for a bleeding duodenal ulcer (n = 1), enterolysis for adhesive small bowel obstruction (n = 1), and transurethral resection of the prostate for urinary retention (n = 1) (Table 7).
Risk Factors for Morbidity and Mortality. Factors including gender, preoperative risk group assessment, concomitant medical prob- lems, surgical approach, size of tumors, and pathologic groups were compared for morbidity and mortality. There was no statis- tically significant relation between ASA class and operative mortality. Goldman class II and III patients had a significantly higher operative mortality (p = 0.036) than class I patients. The operative mortality in class I patients was 2% compared to 15% in class II and III patients. The mortality for ACC (43%) was significantly higher when compared with that for other conditions (4%) (p = 0.006).
In addition, the Goldman classification was shown to be a predictor for operative morbidity. Among 51 class I patients, 7 (14%) developed postoperative complications compared with 12 of 34 (35%) class II and III patients (p = 0.032). No such relation was found between ASA class and operative morbidity (Table 8). The postoperative complication rate was higher in patients un- dergoing adrenalectomy via the anterior approach than in those with the posterior approach, although this difference did not reach
| Complication | Patients (no.) | Associated mortality (no.) |
|---|---|---|
| Surgical | ||
| Intraabdominal | 2 | 0 |
| hemorrhage | ||
| Cardiac | ||
| Arrhythmia | 4 | 0 |
| Heart failure | 4 | 0 |
| Myocardial infarct | 1 | 1 |
| Pulmonary | ||
| Pneumonia | 6 | 0 |
| Respiratory distress | 3 | 0 |
| syndrome | ||
| Pulmonary embolism | 3 | 2 |
| Pleural effusion | 2 | 0 |
| Others | ||
| Adrenal insufficiency | 4 | 1 |
| Sepsis | 2 | 2 |
| Urinary retention | 2 | 0 |
| Miscellaneousª | 6 | 0 |
“Miscellaneous complications included small bowel obstruction, gas- trointestinal bleeding, pneumothorax, deep vein thrombosis, paralytic ileus, and ischemic toes. Some patients had more than one complication.
statistical significance (32% versus 14%, p = 0.07). Figure 1 shows the breakdown of postoperative morbidity and mortality rates in the various pathologic groups.
Follow-up and Survival. An additional six patients died (long- term) during the median follow-up of 26 months (range 1 month to 9.1 years). At the completion of the study, three patients had succumbed to malignancy: one each of a myocardial infarct, pneumonia, and unknown cause. Seventy-three patients (86%) remained alive. One patient with Cushing syndrome secondary to an adrenocortical adenoma underwent two uneventful reopera- tions at 53 and 87 months after initial operation for local recurrence, presumptively due to tumor spillage at the initial operation. For patients with primary hyperaldosteronism, all became normotensive, although 82% (14 of 17) required contin- ued antihypertensive medications.
The 2- and 5-year survivals for all patients were 86% (95% confidence interval, 78-94%) and 84% (95% confidence interval, 78-93%), respectively. The 3-year survival in patients with ACC was 25% (p < 0.0001), which was significantly lower than the expected survival in a matched population and in patients oper- ated on for other adrenal pathology. The number of patients in each pathologic subgroup was too small to make any meaningful individual statistical comparisons of survival.
Discussion
Although the incidence of hypo- and hyperadrenalism in elderly patients is low, 21% of our adrenal surgery during the past decade was performed for patients in this age group. Mortality as high as 26% for adrenalectomy has been reported in the past [8]. This high mortality rate can be attributed to the poor understanding of the pathophysiology of adrenal disease and the failure to prepare patients optimally before operation in order to avoid subsequent hormonal dysfunction. In general, the mortality today is approx-
| Class | With complications (n = 19) | Without complications (n = 66) pº | |
|---|---|---|---|
| ASA | |||
| 1 | 0 | 0 | |
| 2 | 9 | 21 | |
| 0.45 | |||
| 3 | 8 | 43 | |
| 4 | 2 | 2 | |
| Goldman | |||
| I | 7 | 44 | |
| II | 9 | 19 | |
| 0.018 | |||
| III | 3 | 3 | |
| IV | 0 | 0 | |
“Exact Wilcoxon rank sum test.
Cushing’s
(19)
(5)
Mortality
(2)
Morbidity
Carcinoma (7)
(3)
(3)
Pheochromocytoma
)4)
(16)
(0)
Adenoma
(6)
(26)
(1)
Aldosteronism (17)
(1)
(0)
0
20
40
60
%
mayo
CA-170922X-43
imately 2% to 4%, although the morbidity can be as high as 40% [9]. Undoubtedly, the outcome of adrenal surgery depends on multiple factors, including the type and extent of the adrenal disease in conjunction with the physiologic state of the patient and the expertise of the surgical and medical teams.
Our overall operative mortality was 7%, and it is striking that in our series patients with ACC accounted for 50% of the mortality, although only 8% of adrenalectomies were performed for this condition. For our elderly patients specifically and adrenal surgery in general, operative treatment for ACC is disappointing. An operative mortality of 9.7% for this pathology was reported in a previous study [10]. In elderly patients with ACC the high operative mortality rate is probably related to a combination of factors including the debilitating effect of the hormonal syndrome and the malignancy plus the extensive nature of the operation due to the large size of the tumors. In patients with this pathology who survive an operation, the 5-year survival ranges from 16% to 35% [10, 11]. These survival rates are comparable to the 3-year survival of 25% in this small series of elderly patients with ACC.
It is generally agreed that patients with hypercortisolism are more susceptible to postoperative complications, including wound infection, thromboembolism, addisonian crisis, and gastrointesti- nal bleeding [9, 12]. Complication rates as high as 40% have been reported [9, 12, 13]. Reported operative mortality ranges from 0% to 14% and occurs mostly in patients with hypercortisolism due to
ACC, ectopic ACTH syndrome, and Cushing’s disease. The overall mortality was 11% in our patients with hypercortisolism. Although it is comparable to that in other reported series [14-17] and is in keeping with the increased operative risk for this condition, it is notably high compared with the 5.6% in our overall experience of patients with Cushing syndrome [13, 18]. The two postoperative deaths of patients with hypercortisolism occurred in those undergoing bilateral adrenalectomy for ectopic ACTH- secreting malignant tumors. The only patient with a benign lesion who died had a massive pulmonary embolism 26 days after the initial operation. This 80-year-old woman had a history of deep vein thrombosis and underwent a posterior approach for removal of a 5 cm benign adenoma. Her postoperative course was com- plicated by small bowel obstruction secondary to adhesions from a previous appendectomy, which necessitated laparotomy 10 days after the initial operation. Despite this death, adrenalectomy in our elderly patients appears to be a safe procedure, especially in patients with benign conditions.
In the elderly, the essential clinical features of surgical diseases of the adrenal glands do not basically differ from those found in younger patients. However, it is anticipated that the risk of operation is higher in these patients. The chronologic and, more importantly, physiologic ages of patients are clearly recognized as determinants of operative risk. Other objective assessments of operative risk accounting for age and physiologic status usually utilize preoperative invasive monitoring techniques to develop a more precise preoperative risk-staging system [19]. Although such staging seems to help identify specific physiologic defects and may correlate well with risk in these patients, these invasive techniques are associated with complications and added costs and should not be undertaken without careful consideration. For many years, the ASA classification has been widely used by anesthesiologists in the United States for objective assessment of preoperative risk, whereas the Goldman multifactorial assessment of cardiac risk scheme has been shown to correlate with operative risk associated with noncardiac operations. Both of these preoperative calculated risk assessments are simple, noninvasive, and cost-effective. For example, the ASA classification was shown to correlate well with postoperative outcome in a group of elderly patients (≥ 80 years) undergoing major gastrointestinal surgery [20]. The results of our study showed that the Goldman multifactorial cardiac risk scheme is an excellent prognostic indicator for operative morbidity and mortality independent of other factors. Patients classified as Goldman class II and above have higher morbidity and mortality rates after adrenal surgery. This finding may be attributable to the frequent occurrence of cardiovascular disease (80%) in this age group and the importance of cardiorespiratory complications as a determinant of operative morbidity and mortality.
It is commonly accepted that the anterior approach be adopted exclusively for resection of adrenocortical carcinoma or pheochro- mocytoma [9, 12, 21-25]. However, the posterior approach has been shown to be better tolerated by the patient in terms of less perioperative blood loss, shorter operative duration, shorter hos- pital stay, and the need for analgesia during the postoperative period [25, 26]. We prefer the posterior approach for aldoster- onomas and most other nonmalignant adrenal resections unless the presence of technical difficulties due to large tumor size (> 5 cm) or the need to perform concomitant intraabdominal proce- dure exists. Our results once again confirmed the advances of adrenalectomy via the posterior approach in an uncontrolled
group of elderly patients. Laparoscopic adrenalectomy seems to be an appealing [27] approach that has generated a great deal of interest recently, although its role in various types of adrenal diseases is still being evaluated and refined.
This study has reemphasized the vital importance of the cooperative, multidisciplinary approach to a group of patients who present special challenges to all involved in their care. For the future, it behooves us to assign this group of elderly patients to the appropriate ASA and Goldman class when seen initially. If this assignment raises any red flags (advanced class assignment), we should make every endeavor to move the patient to a more favorable class by meticulous preoperative preparation. If it is not possible, even more careful attention needs to be placed on intraoperative monitoring, expeditious, safe surgery, and scrupu- lous attention to all details of postoperative care.
Résumé
On a tendance à récuser le traitement chirurgical des affections de la surrénale chez le sujet âgé en raison d’une certaine mortalité et morbidité opératoire. Pour obtenir des informations précises à ce sujet, nous avons analysé nos résultats de surrénalectomie chez les patients âgés 65 ans ou plus. Entre 1984 et 1993, nous avons opéré 85 patients (41 hommes, 44 femmes) âgés entre 65 et 84 ans: médiane: 69 ans) pour syndrome de Cushing (n = 19), phéochro- mocytome (n = 16), cancer de la surrénale (n = 7), adénome bénin (n = 26) et hyperaldosteronisme primaire (n = 16). La médiane de suivi a été de 26 mois (extrêmes un mois à 9.1 ans). Une revue rétrospective des risques préopératoires, de la mor- bidité et de la mortalité a été réalisée selon le score de l’ASA et le schéma multifactoriel de risque cardiaque de Goldman. La survie a été analysée selon la méthode de Kaplan-Meier. La mortalité opératoire a été de 7% (six patients). Aucun patient ayant une phéochromocytome ou un hyperaldosteronisme pri- maire n’est décédé dans la période postopératoire immédiate. Les patients ayant eu une surrénalectomie pour cancer avait une mortalité supérieure (43%) (p = 0.006). Des complications post- opératoires se sont développées chez 19 (22%) patients et il y a eu un taux de réintervention de 6% (5 patients). Dix-neuf patients sont restés pendant deux jours (médiane) avec des extrêmes de l à 38 jours en soins intensifs en période postopératoire. La médiane de séjour hospitalier a été de 7 (extrêmes: 3 à 47) jours. Soixante-treize (86%) patients sont en vie à la fin de cette étude. Les survies à 2 et à 5 ans étaient de 86% et de 84%, respective- ment. Etre classé Goldman II ou plus était un facteur prédictif de morbidité (p = 0.032) ou de mortalité supérieure (p = 0.036). A l’exception des cancers, la chirurgie de la surrénale chez le sujet âgé peut être accomplie avec une morbidité et une mortalité acceptables. Le schéma de risque cardiaque de Goldman prédit avec fiabilité l’évolution postopératoire dans ce groupe de pa- tients âgés.
Resumen
El tratamiento quirúrgico de la enfermedad suprarrenal puede ser evitado en pacientes de edad avanzada en atención a las prohibi- tivas morbilidad y mortalidad operatorias. Con miras a lograr una información objetiva en nuestra propia práctica, hemos hecho el análisis de los resultados de la adrenalectomía en pacientes de 65 años y mayores. Ochenta y cinco pacientes (41 hombres, 44
mujeres) con edades entre 65 y 84 años (media, 69) fueron sometidos a adrenalectomía por síndrome de Cushing (n = 19), feocromocitoma (n = 16), carcinoma adrenocortical (n = 7), adenoma benigno (n = 26) e hiperaldosteronismo primario (n = 17) en nuestra institución. El seguimiento medio fue de 26 meses (rango 1 mes a 91 años), se realizó una revisión retrospectiva con respecto a los riesgos preoperatorios utilizando la clasificación del estado físico de la American Society of Anesthesiology (ASA) y el esquema multifactorial modificado de Goldman de riesgo car- díaco. La sobrevida fue estimada por los métodos de Kaplan- Meier. La mortalidad operatoria fue de 7% (6 pacientes). Ningún paciente con feocromocitoma o con aldosteronismo primario murió en el período postoperatorio. Los pacientes sometidos a adrenalectomía por carcinoma adrenocortical exhibieron una mortalidad operatoria significativamente más alta (43%) (p = 0.006). Se desarrollaron complicaciones postoperatorias en 19 pacientes (22%) y se registró una tasa de reoperación de 6% (5 pacientes). 19% de los pacientes requirió cuidado intensivo postoperatorio, con una estancia media de 2 días (rango 1 a 38). La estancia hospitalaria media fue de 7 días (rango 3 a 47). 73 pacientes (86%) permanecían vivos al término del estudio. Las tasas de sobrevida a dos y a cinco años fueron de 86% y 84%, respectivamente. Una clase II de Goldman o mayor, constituyó un excelente factor de predicción de aumento de la morbilidad (p = 0.032) y de la mortalidad (p > 0.036). Con la excepción del carcinoma adrenocortical, la cirugía adrenal en pacientes de edad avanzada puede ser realizada con aceptable morbilidad y mortali- dad. El esquema multifactorial de riesgo cardíaco de Goldman puede predecir en forma confiable el resultado final en este grupo de pacientes.
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Invited Commentary
Malcolm H. Wheeler, M.D.
Department of Surgery, Cardiff Royal Infirmary, Newport Road, Cardiff, U.K.
The title of this paper asks a simple, important question that is of relevance to all endocrine surgeons treating the elderly patient with adrenal gland pathology. Although the study is a retrospec- tive review, it has been possible to carefully assess clinical data from no fewer than 85 elderly patients undergoing adrenalectomy. The overall operative mortality of 7% compares favorably with other series of patients undergoing adrenalectomy for a similar range of pathologic conditions, and it is no surprise that operative mortality was essentially confined to those patients suffering from either Cushing syndrome or adrenocortical carcinoma. The mor- tality rate for patients with adrenocortical carcinoma was 43%, constituting 50% of the total mortality. The size of this patient group was small (n = 7), and therefore caution must be applied when interpreting the mortality figures. It is well accepted, however, that significant operative mortality is seen among debil- itated patients with large malignant tumors that require an extensive, perhaps prolonged surgical procedure. The overall picture of adrenocortical carcinoma is indeed a depressing one even when evaluating series that include both young and old subjects.
There is no doubt that the elderly patients in the present study not only suffered from their adrenal disease but had a high incidence of associated disease, 90% having one to seven concom- itant medical problems. It has been shown that preoperative calculated risk assessment, particularly in the case of patients classified as Goldman class II and III, can be valuable for identifying the subjects at risk who require the utmost care during preoperative, operative, and postoperative management. Under which precise circumstances should a patient be rejected for
surgery on the basis of such risk scoring, however, remains speculative. Although 85 patients 65 years of age or greater were operated on from a total group of 396 patients undergoing primary adrenalectomy during 1984-1993, the authors do not indicate how many elderly patients in this period were rejected for surgery, being deemed unfit because of the primary disease or associated risk factors. This information would help to put some aspects of the reported results into clearer perspective.
With regard to the operative approach, the authors have shown that the posterior approach for adrenalectomy is associated with a lower complication rate than the anterior approach, a fact well known, particularly when considering patients with Cushing syn- drome and all the attendant problems of hypercortisolism.
We are seeing an ever-increasing application of laparoscopic adrenalectomy for certain selected types of adrenal disease [1, 2]. Early results indicate that the laparoscopic approach may take longer to perform than conventional open adrenalectomy but has distinct advantages with respect to postoperative pain and length of hospitalization [3]. It is hoped that this less invasive technique will have particular application in the elderly. The results of prospective studies are awaited with great interest.
This report is a valuable and interesting study, highlighting the problems of adrenalectomy in a particular patient group and reemphasizing the importance of a skilled multidisciplinary ap- proach. Indeed, the authors have clearly answered their own question posed in the title, showing that adrenal surgery can be safely performed in the elderly.
References
1. Gagner, M., Lacroix, A., Bolte, E .: Laparoscopic adrenalectomy in Cushing’s syndrome and phaeochromocytoma. N. Engl. J. Med. 327: 1033, 1992
2. Gagner, M., Lacroix, A., Prinz, R.A., et al .: Early experience with laparoscopic approach for adrenalectomy. Surgery 114:1120, 1993
3. Prinz, R.A .: A comparison of laparoscopic and open adrenalectomies. Arch. Surg. 130:489, 1995