Comment on “Outpatient Versus Inpatient Minimally Invasive Adrenalectomy: A Systematic Review and Meta‐Analysis”

Dear Editor, We read with great interest the study by Martin et al. [1] examining postoperative outcomes in outpatient versus inpatient minimally Invasive adrenalectomy. The authors' efforts to synthesize the available evidence across diverse settings provide valuable data for surgeons considering ambulatory pathways for adrenal surgery. The inclusion of both prospective and retrospective cohorts and adjustment for confounders in most analyses strengthen the external applicability of their findings. A key contribution of this review is the pooled evaluation of 30-day readmission and complication rates, suggesting no significant differences between the discharge pathways. However, high statistical heterogeneity persisted in the adjusted readmission analyses (I2 = 67%–81%), largely due to variations in patient selection and perioperative protocols. From a clinical standpoint, this degree of heterogeneity limits the certainty with which surgeons can counsel patients regarding the safety equivalence of outpatient discharge, especially in health systems lacking standardized criteria [2]. Inconsistent thresholds for selecting patients with higher American Society of Anesthesiologists (ASA) scores, inclusion of pheochromocytoma in some but not all series, and varying restrictions on body mass index create overlapping but clinically distinct populations that could influence unplanned care after discharge. Additionally, three of the five included studies retrospectively defined “outpatient” status based on the final discharge date rather than the preoperative intent. This methodological choice introduces classification bias with direct clinical consequences; patients initially intended for same-day discharge but requiring overnight observation for postoperative hypertension, nausea, or bleeding were recategorized as inpatients [3]. This practice may underestimate the true incidence of early adverse events in the outpatient pathway, potentially affecting perioperative safety protocols and informed consent. The authors appropriately acknowledged the inability to account for the surgeon or institutional case volumes. From a clinical quality perspective, volume–outcome relationships are well documented in endocrine surgery, and omitting this factor may obscure differential complication risks in lower-volume centers seeking to adopt ambulatory adrenalectomy [4]. Without this granularity, extrapolating the reported safety profile to all practice environments may be considered premature. Finally, the review highlighted that a substantial proportion of complications occur after typical inpatient discharge windows. Although this finding supports the feasibility of same-day discharge, it also underscores the importance of robust post-discharge surveillance systems. Implementing structured follow-ups, such as next-day telehealth check-ins or early postoperative clinic visits, could mitigate delays in recognizing complications such as hemorrhage, adrenal insufficiency, or infection, where timely intervention influences morbidity. In summary, Martin et al. presented a comprehensive synthesis supporting the selective use of outpatient minimally invasive adrenalectomy. Future prospective multicenter studies using standardized eligibility criteria, preoperative assignment of discharge pathways, and stratified reporting by surgical volume would further clarify safety and implementation strategies. Constructive discourse on these methodological and clinical considerations will help refine patient selection and optimize perioperative care in this evolving field of surgery. A.K. conceived the study and developed the methodology. A.K. and P.S.R. wrote the original draft of the manuscript and contributed to reviewing and editing. K.R. validated the findings, supervised the project, and was involved in project administration. All authors contributed to writing, reviewing, and editing the manuscript, and approved the final version for submission. Generative AI tools, including ChatGPT-5, were utilized solely for language refinement, grammar enhancement, and stylistic refinement. These tools had no role in the conceptualization, data analysis, interpretation of results, or substantive content development of this manuscript. All intellectual contributions, data analysis, and scientific interpretations remain the sole work of the authors. The final content was critically reviewed and edited to ensure accuracy and originality. The authors take full responsibility for the accuracy, originality, and integrity of the work presented. The authors have nothing to report. The authors declare no conflicts of interest. The authors have nothing to report.