Dr. James Lee Answers Five Questions About Adrenal Surgery in 2024

This conversation has been adapted from a comprehensive interview on thyroid, parathyroid, and endocrine surgery with James Lee, MD, Chief of Endocrine Surgery.

What’s new in the treatment of adrenal diseases?

For adrenal cancer, which is one of the deadliest cancers known to man, there are new chemotherapeutics and new directed therapies that are out there. Some of these take into account the genetic profile of the patient and can target therapeutics to their particular mutations.

For us, one of the big things we focus on is the technique for taking out adrenals. The standard way to do a run-of-the-mill adrenal operation nowadays is to do a laparoscopic operation where you go through the belly. We are one of the few institutions I think in the country, or in the world, that actually go through the back. It's called retroperitoneal laparoscopic adrenalectomy.

And the reason we do that approach is that the operative times are faster, usually half as long. When you think about it, the adrenal gland is sitting way in the back, right on the top of the kidney. If you go through the belly you have to move a lot of stuff out of the way to get there. You have to move the intestines, the spleen, and the pancreas. But if you go through the back it's really just the kidney and the adrenal back there, so it's a much more direct shot. And so again, faster operative times, there are fewer complications because you're just interacting with fewer things, and patients recover faster.

Wow. Why isn’t this approach more common?

This approach started to gain popularity probably about seven or eight years ago. Like any new innovation, it takes a while to spread. The other thing for adrenal surgery, in particular, is that it's just not that common. We do probably 50 to 60 adrenalectomies a year here, and that’s for a high-volume center.

The statistics are that the average general surgery resident does 0.7 adrenalectomies during their training period. Most people will never do an adrenal operation—for us from a surgical side that's the big thing, our experience with that approach.

Are there any other methods for adrenal surgery being developed?

We actually have a robotic adrenalectomy program. With a robot, we can offer the same techniques through the belly or through the back, but we use robot assistance. And the robotic adrenalectomy has some advantages to it. What our robotic surgeons tell us is that it's actually easier to do patients who have higher BMIs because the robot helps eliminate some of the physical limitations when you're doing it laparoscopically. Jen, Eric, and Katie McManus run one of the handful of robot adrenal programs in the country.

How important is early detection of adrenal disease? How much does it factor into treatment options?

Early detection is important, but especially early detection done in a thoughtful way. From a screening standpoint, for adrenal, the problem that we have is sort of the inverse—the rate of adrenal incidentaloma, which is an adrenal tumor that's found incidentally on a scan that's being done for some other reason, is driving a lot of the diagnosis of new cases of adrenal disease. And most of those patients who have adrenal incidentalomas don’t need an operation.

The thought is the same across the board—don't have a knee-jerk reaction and just take those things out because most of those patients don't need an operation. So, they'll get repeat blood tests and hormonal testing, and imaging every six months, that kind of thing. If it's non-changing, then you leave them alone.

My last question is about goals. What are you looking forward to in the next 5 to 10 years?

At the end of the day, I think what I'm most excited about is that we are no longer hammers looking for nails. We have this whole toolkit that we can apply and make the treatment very appropriate to the individual patient. It's not just one size fits all. At Columbia, you are an individual patient with an individual set of concerns and we have a tool that can fit your lifestyle.

Our goal is to grow intelligently. When we talk about being a multidisciplinary center, it’s about having all of the experts and all the tools necessary to take care of patients. But part of that is also having it all in one place, and we're getting there. We have our endocrinologists here with us, but we want our radiologists here too. We don’t want you to have to leave this floor to get a CT scan.

Ultimately, it’s really about making the patient experience as good as possible, as comfortable as possible, and making it completely focused on the patients themselves. It sucks to be diagnosed with thyroid, endocrine issues, and our goal is to make it as nice as possible while you’re here.