Aims: Given that the vast majority of surgeons who undertake adrenal surgery in UK have a median workload of 1 case/year there is increasing awareness that the care of such patients should be centralised. This case series illustrates the benefits of multidisciplinary input from surgeons with various expertise involved in the care of complex adrenal cases.
Methods: Retrospective review of cases in which endocrine, hepatobiliary and cardiac surgeons collaborated.
Results: During 20082017 the median annual workload for adrenal surgery in our unit was 65 cases/year (range 5275). Veno-venous cardiac bypass was used in seven patients with tumour thrombus extending in the supradiaphragmatic inferior vena cava (IVC). A patient operated in 2007 remains disease free (32yrs, Cushing syndrome, left adrenal tumour with thrombus into the atrium). Median survival was 3 years. There was one in-hospital death (day 11 postop due to hypoxic brain injury and multi-organ failure. Hypothermic cardiorespiratory arrest was used for two patients: i. 12-cm right-sided non-secreting adrenocortical carcinoma excised in continuity with a 5-cm segment of IVC followed by IVC reconstruction; ii. 16-cm malignant right phaeochromocytoma extending into right atrium. Both patients are alive at over 5 years after operation. Patients with infrahepatic IVC tumours extension (n=11) were operated without establishing cardiac bypass. Support from the cardiac team was provided during adrenalectomy of five patients with phaeochromocytomas and severe catecholaminergic-induced heart-failure. Similar multidisciplinary approach was used for two patients with IVC sarcoma and Ewings sarcoma of the adrenal gland in whom a complete en-block resection of tumour and segment of IVC was achieved.
Conclusion: Multidisciplinary surgical collaboration is needed for a minority of patients with locally-advanced adrenal tumours who can achieve favourable oncological outcomes.