Laparoscopic versus open adrenalectomy: another look at outcome using the Clavien classification system.

BACKGROUND: A laparoscopic approach to adrenalectomy has become the procedure of choice for most adrenal resections. We hypothesized that laparoscopic adrenalectomy is less likely to result in intensive care unit (ICU) level complications or death than open adrenalectomy, despite baseline comorbidity mix. METHODS: Using the National Surgical Quality Improvement Program (NSQIP) participant use files for 2005-2009, all laparoscopic and open adrenalectomies were identified by current procedural terminology. Adverse outcomes tracked in NSQIP were mapped to Clavien level based on need for ICU care or death. Univariate and multivariate analysis were used to compare groups. RESULTS: There were 1,980 laparoscopic and 592 open procedures. Clavien 4 and 5 complications occurred in 45 (7.6%) of open and 35 (1.8%) of laparoscopic operations. The univariate odds ratio showed a 4.6-fold greater likelihood that a patient would have an ICU level complication (P < .001), and 4.9 odds ratio of death (P < .001) if an open rather than laparoscopic operation was performed. Regression modeling showed persistence of the protective effect of laparoscopy after adjusting for comorbidities with a multivariate odds ratio of 3.3 (P < .001). CONCLUSION: The laparoscopic approach to adrenalectomy has an independent protective effect on ICU level complications and mortality when compared with open procedures. This correlation persists after correcting for multiple comorbidities.

Mild hypercalcemia: an indication to select 4-dimensional computed tomography scan for preoperative localization of parathyroid adenomas.

BACKGROUND: Technetium sestamibi scanning is the most accepted method of imaging used for preoperative localization of parathyroid adenomas. Four-dimensional computed tomography (4D-CT) scanning is a relatively new localization technique that has not been as rigorously evaluated. METHODS: One hundred thirty-five consecutive patients who underwent preoperative sestamibi scanning, 4D-CT scanning, and parathyroidectomy for primary hyperparathyroidism were evaluated. Patient characteristics, parathyroid gland weights, and the probability of having positive preoperative localization were examined. RESULTS: Four-dimensional computed tomography scanning was significantly more accurate than sestamibi (73% vs 62%, P = .016). In those with serum calcium levels less than 10.8 mg/dL, 4D-CT scanning was significantly more accurate than sestamibi scanning for the quadrant (45% vs 29%, P = .013) and hemisphere (66% vs 48%, P = .012). Also, 4D-CT scanning was more accurate among patients with parathyroid gland weights less than 500 mg (69% vs 45%, P < .001). CONCLUSIONS: Four-dimensional computed tomography scanning provides better preoperative localization than sestamibi scanning, particularly in patients with mild hypercalcemia and smaller parathyroid adenomas.