Adrenal surgery - time for change
John Newell-Price, John Wass, Wiebke Arlt & Fausto Palazzo | Features
How comfortable would you be performing a delicate and irreversible task just once a year? How much less comfortable would you be if you performed that task in isolation, and without the benefit of experts to help you make the right choices and to guide any necessary decisions? It is likely that the answers to these questions are ‘not very’ and ‘much less’.
What would you do if there was someone else available who could do this task and who did it regularly? It seems likely that you would consider, or insist on, getting them to do the task.
AN UNCOMFORTABLE TRUTH
This is not merely a hypothetical proposition. A recent audit of Hospital Episode Statistics (HES) data reveals that, for the 796 operations performed primarily for adrenal disease (excluding nephrectomies) in England during the tax year 2013–2014, the median number of adrenal operations performed per surgeon was … one.1
Yes, that is not a typo but a stark and uncomfortable fact. Would you refer yourself or your family to such a surgeon, or to a centre where such practice took place? Hopefully not, but that was the fate of nearly 200 individuals who were the only adrenal patient that their surgeon operated upon in that year. Instead, they might have been managed at UK centres that perform 20–30 or more adrenalectomies per annum.
Apart from the ‘feelings’ and ‘uncomfortable emotions’ alluded to above, does it matter that these very low volume surgeons are operating in this way? The HES data reveal a significantly longer length of stay and higher 30-day readmission rate for low volume surgeons compared with high volume surgeons, even though the latter are likely to be working in centres attracting more complex adrenal challenges.
The inference is clear: the current situation is causing harm to patients and costing the NHS more. This should come as no surprise to endocrinologists, as we have previously identified similar findings for pituitary and thyroid disease.2–4 Indeed, the recent clarion call in New England Journal of Medicine to ‘rid ourselves of low volume surgery’5 is particularly apposite with regard to these data.
THE VALUE OF TEAMWORK
As endocrinologists, we recognise that the surgeon is only one part of the jigsaw. From diagnosis through to pre-operative preparation, to choosing the right operation for the right person (for example, a transabdominal versus a retroperitoneal laparoscopic approach versus an open procedure), to managing peri-operative and post-operative care, high volume centres have the full range of clinicians, radiologists, clinical chemists, anaesthetists, pathologists, oncologists and nurse specialists working in organised multi-disciplinary teams (MDTs) to offer the best care. It works, as evidenced by the HES data.
Nevertheless, endocrinologists may often be the ‘gatekeepers’ who control access to adrenal surgery. As such, we have a duty of care to our patients to ensure that they are able to get the best care available, and a duty to the NHS for this to be done in the most time-efficient and cost-effective fashion. This is not the case currently. The number of patients undergoing adrenal operations is still relatively small. This means that to change what we do is achievable, and something where endocrinology truly can ‘put its own house in order’.
TAKING ACTION TO MAKE A DIFFERENCE
What then are we to do about this situation? Fuelled by these findings, a cross-disciplinary group has met, with representation from all the surgical specialities, endocrinology, radiology and anaesthetics, to draw up guidance for any patient being considered for adrenal surgery and for adrenal patients in general.
This guidance document has now had ‘multi-party’ endorsement, including that of the Society for Endocrinology, the Royal College of Physicians, the relevant surgical specialist associations, patient groups and all other parties involved, and is available online.6
The recommendations call for all patients being considered for adrenal surgery, all those with functioning adrenal tumours and all those in whom malignancy is suspected to be discussed and managed in centres where there is a formal MDT expert in the management of patients with adrenal disease. The recommendations are not controversial, are common sense, and are backed by evidence.
Moreover, European guidelines on the management of patients with adrenal incidentalomas will be published very soon by the European Society of Endocrinology. These have been drawn up with the involvement of several UK endocrinologists and have been endorsed by several international organisations including the Endocrine Society and the European Network for the Study of Adrenal Tumours.
The clinical endocrinology community needs to rise to this challenge and work together to make a difference to these patients and to the NHS.
Department of Oncology and Metabolism, University of Sheffield and Sheffield Teaching Hospitals NHS Foundation Trust
Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford
Institute of Metabolism and Systems Research, University of Birmingham, and Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners
Hammersmith Hospital and Imperial College London
- Palazzo F et al. 2016 Clinical Endocrinology doi:10.1111/cen.13021.
- Sosa JA et al. 1998 Annals of Surgery 228 320–330.
- Wass JA et al. 1999 Pituitary 2 51–54.
- Gittoes NJ et al. 1999 QJM 92 741–745.
- Urbach DR 2015 New England Journal of Medicine 373 1388–1389.
- Palazzo F et al. 2016 Adrenal Surgery Practice Guidance for the UK