title: Risk factors affecting operative approach, conversion, and morbidity for adrenalectomy: a single-institution series of 402 patients.
abstract: BACKGROUND
  Risk factors for selecting patients for open adrenalectomy (OA) and for conversion are limited in most series. This study aimed to investigate variables that are important in selecting patients for OA, predict risk of conversion from laparoscopic adrenalectomy (LA), and impact 30-day outcomes of OA and LA.
  
  
  METHODS
  A retrospective cohort study of prospectively collected data was conducted. Patients (≥ 16 years old) who underwent adrenalectomy in the Division of General Surgery at Barnes-Jewish Hospital (1993-2010) were grouped by operative approach (LA vs. OA) and compared using nonparametric tests and regression analyses (α < 0.05).
  
  
  RESULTS
  In total, 402 patients underwent 422 adrenalectomies. Compared to LA patients, those in the OA group were older (p = 0.02), had higher ASA scores (p = 0.04), larger tumor size (p < 0.01), and fewer functioning lesions (p < 0.01). OA patients more often required concurrent procedures (p < 0.01), had a longer operative time (p = 0.04), more intraoperative complications (p = 0.02), higher estimated blood loss (EBL), and larger transfusion requirement. Preoperative factors that predicted selection for OA were higher patient age (p = 0.01), higher ASA score (p = 0.03), larger tumor size (p < 0.01), nonfunctioning lesion (p < 0.01), diagnosis of adrenocortical carcinoma (p < 0.01), and the need for concomitant procedures (p < 0.01). Conversion to open or hand-assisted approach occurred in 6.2 % of LA patients. Preoperative risks for conversion included large tumor size (>8 cm) and need for concomitant procedures (p < 0.01). Multivariate analysis revealed that large indeterminate adrenal mass, adrenocortical carcinoma, tumor size (>6 cm), an open operation, conversion, concomitant procedures, operative time >180 min, and EBL >200 mL were predictors of 30-day morbidity.
  
  
  CONCLUSIONS
  Adrenal tumor size and need for concurrent procedures significantly impact the selection of patients for OA, the likelihood of conversion, and perioperative morbidity. These metrics should be considered when assessing operative approach and risks for adrenalectomy.
authors: Section of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8109, St. Louis, MO 63111, USA. jbittner4@gmail.com
authors: James G
authors: JG
authors: Bittner
authors: Victoria M
authors: VM
authors: Gershuni
authors: Brent D
authors: BD
authors: Matthews
authors: Jeffrey F
authors: JF
authors: Moley
authors: L Michael
authors: LM
authors: Brunt
mesh_terms: D000310:Adrenal Gland Neoplasms / Q000473:pathology / Q000601:surgery*; D000315:Adrenalectomy / Q000379:methods*; D018268:Adrenocortical Carcinoma / Q000473:pathology / Q000601:surgery; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical; D001803:Blood Transfusion / Q000706:statistics & numerical data; D015331:Cohort Studies; D061887:Conversion to Open Surgery; D005260:Female; D006801:Humans; D007431:Intraoperative Complications; D010535:Laparoscopy; D018208:Liposarcoma, Myxoid / Q000473:pathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D061646:Operative Time; D018579:Patient Selection; D010673:Pheochromocytoma / Q000473:pathology / Q000601:surgery; D011183:Postoperative Complications; D012189:Retrospective Studies; D012307:Risk Factors; D055815:Young Adult
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