Adrenalectomy in regional Australia: a balance of benefits and potential harms

Internationally, centralization of surgical care in higher volume centres for complex and oncological surgery has led to improved clinical outcomes.^{1, 2} The challenges of the vast geography and comparative low density of the Australian population require this model of care to be tested in an Australian context. Approximately 29% of the Australian population lives in regional Australia and is comparatively under-resourced by surgical care.^{3, 4} Patients in regional areas deserve high quality care in their local vicinity. It is imperative to ensure surgeons servicing these areas develop and maintain an adequate skill mix, and as such can enjoy a viable and rewarding career path in their local community.⁴ Whilst increased surgical volume may improve clinical outcomes, this can be offset by distress cause by travel and psychosocial and financial harm associated with care distant to home. With this in mind, patients in regional areas may preference procedures undertaken closer to home and their support networks, even if informed of associated higher morbidity and mortality.⁵

In this edition, Tree et al. have published their case series of 31 adrenalectomy cases performed by two surgeons in Lismore NSW, over a 16-year period.⁶ The majority were laparoscopic (90%), 52% were admitted to ICU/HDU post-operatively and the mean length of stay was 3.1 days. Similarly, in 2023, Cui et al. published a single surgeon series from Dubbo NSW, of 13 cases of adrenalectomy over 9 years.⁷ In both series, the hospital volume was <2 cases per year and there were no mortalities. The authors are to be congratulated on documenting their case series and challenging the paradigm of centralisation.

Adrenalectomy is an infrequent procedure within scope of practice both general surgeons (endocrine, upper GI and HPB subspecialities) as well as urologists. International data suggest that surgeon thresholds of ≥6–12 adrenal resections annually are associated with improved clinical outcomes.^8-10 Higher annual volumes again (>12 adrenal resections annually) may be associated with improved outcomes (completeness of resection, decrease in complications, more comprehensive pre-operative work-up) in open adrenal surgery and adrenocortical cancer care.^11-13 International guidelines also stress the importance of thorough pre-operative work-up and the multidisciplinary team in the care of patients undergoing adrenal surgery.^{10, 14} Yet, surgical volume remains a crude marker of either the skill of the surgeon themselves or of their team.

For surgeons wishing to undertake adrenalectomy, or any other uncommon procedure, it is unlikely that a fellowship (FRACS) of any surgical speciality will provide adequate skills and experience. Thus, both surgeons and health services need to address issues of skills acquisition and maintenance not just of the surgeon but for the whole peri-operative team. For adrenalectomy, additional training is required to ensure adequate pre-operative work-up (with respect to functional status) and peri-operative care (particularly of functional lesions). By anatomical nature, catastrophic bleeding can occur in adrenal surgery and vascular surgery (or similar skill set) back-up should be available if required. In a study examining mortality in endocrine surgery in Australia, the mortality rate was highest for adrenalectomy (risk of mortality estimated at 0.15%–0.33%), 27% of deaths in endocrine surgery were deemed preventable, most due to systems issues.¹⁵ Failure to rescue, or death after a serious (and possibly preventable) complication, is becoming a metric of regional health care and is of particular reference to adrenalectomy.¹⁶

The data would strongly suggest that centralisation of adrenalectomy within a few metropolitan centres be encouraged. Perhaps not every hospital in every state capital city needs to perform this operation. For those in regional centres, links to tertiary centres with access to specialized pathology, genetic services and multi-disciplinary teams are essential.

In Hunter New England, an adrenal specific multidisciplinary team has run since 2016. The team is run out of Newcastle, a metropolitan (non-capital city), high volume adrenal surgery centre and NSW Cancer Institute adrenocortical cancer centre.¹⁷ Although most members of the team are geographically based in Newcastle, many patients live in regional areas. All patients considered for adrenalectomy are presented pre-operatively and there is active involvement from anaesthetics, endocrinology, surgeons (endocrine, HPB and urology), radiology, pathology and radiation and medical oncology as necessary. Although initially a face-to-face meeting, the meeting transitioned online in 2020 and has continued in this virtual format. This format encourages and allows the involvement of surgeons and endocrinologists in regional centres (in this case Port Macquarie and Tamworth). In our centre, this meeting has optimized the perioperative preparation of patients (particularly those with functional tumours), minimizing intensive care admissions and hospital length of stay in our very resourced constrained environment.^{18, 19} For regional centres, this meeting can provide the tertiary hospital back-up and virtual multi-disciplinary care to patients to have their procedures safely undertaken in regional centres. Where needed, transfer to tertiary care, is facilitated but patients receive much of their pre- and post-operative care closer to home.

Whilst the two surgical series of regional adrenalectomy published in this journal document safe surgery, they do not address the multidisciplinary care of the patient with regards to pre-operative functional testing, tumour genetics and follow-up care. It is unlikely that every regional centre (or every metropolitan centre) will be able to safely offer high quality adrenalectomy services. Where adrenalectomy is offered, surgeons and health services should ensure they have the requisite training and experience, audit outcomes and develop ties with larger centres where multidisciplinary services can be provided, often without the need for travel of the patient.