Andrea Valeri

Adrenal masses in neoplastic patients: The role of laparoscopic procedure

BackgroundThe incidence of complications resulting from fine-needle biopsy of adrenal masses in patients already treated by radical procedures for primitive neoplasms of the lungs and kidneys substantiates our opinion concerning laparoscopy as both a diagnostic and therapeutic procedure.MethodsWe performed 70 laparoscopic adrenalectomies from April 1995 to December 1999. In five patients, the adrenal mass appeared at follow-up evaluation in patients submitted to surgery for a spinocellular lung cancer. One patient underwent surgery for renal adenocarcinoma. In two patients, the adrenal mass was present already at the time primitive lung tumor was diagnosed, so adrenalectomy was performed at the first lung surgery in one patients were placed in a lateral position for a transperitoneal approach. Right adrenal masses were present in seven patients, whereas one patient had an adrenal mass in a left location.ResultsNo laparotomy was required. The average surgical time was 160 min. (range, 115–120 min). No morbility or mortality occurred, and the average hospital stay was 4 days (range, 3–11 days). All the patients had a complete removal of their masses, which averaged 4.5 cm (range, 2.5–6 cm) in size. Histology confirmed the metastatic origin of the mass in five of seven patients with primary lung cancer, and in one patient with previous kidney cancer. At this writing, three patients were disease free and still alive respectively at 3, 5, and 18 months. Three patients died of brain metastases respectively at 16, 36, and 36 months. An adenoma was proved in the other two cases.ConclusionsLaparoscopic adrenalectomy allows us to propose a much more aggressive approach to adrenal masses demonstrated at follow-up evaluation or in patients with primary lung or kidney cancer and no masses at other locations. Nevertheless a much larger study is required for definitive conclusions on a survival rate. We believe that a mini-invasive procedure such as laparoscopy may allow us to replace a rational surgical approach with a more certain pathologic diagnosis.

Vacuum-assisted closure device enhances recovery of critically ill patients following emergency surgical procedures

IntroductionCritically ill surgical patients frequently develop intra-abdominal hypertension (IAH) leading to abdominal compartment syndrome (ACS) with subsequent high mortality. We compared two temporary abdominal closure systems (Bogota bag and vacuum-assisted closure (VAC) device) in intra-abdominal pressure (IAP) control.MethodsThis prospective study with a historical control included 66 patients admitted to a medical and surgical intensive care unit (ICU) of a tertiary care referral center (Careggi Hospital, Florence, Italy) from January 2006 to April 2009. The control group included patients consecutively treated with the Bogota bag (Jan 2006-Oct 2007), whereas the prospective group was comprised of patients treated with a VAC. All patients underwent abdominal decompressive surgery. Groups were compared based upon their IAP, SOFA score, serial arterial lactates, the duration of having their abdomen open, the need for mechanical ventilation (MV) along with length of ICU and hospital stay and mortality. Data were collected from the time of abdominal decompression until the end of pressure monitoring.ResultsThe Bogota and VAC groups were similar with regards to demography, admission diagnosis, severity of illness, and IAH grading. The VAC system was more effective in controlling IAP (P < 0.01) and normalizing serum lactates (P < 0.001) as compared to the Bogota bag during the first 24 hours after surgical decompression. There was no significant difference between the SOFA scores. When compared to the Bogota, the VAC group had a faster abdominal closure time (4.4 vs 6.6 days, P = 0.025), shorter duration of MV (7.1 vs 9.9 days, P = 0.039), decreased ICU length of stay (LOS) (13.3 vs 19.2 days, P = 0.024) and hospital LOS (28.5 vs 34.9 days; P = 0.019). Mortality rate did not differ significantly between the two groups.ConclusionsPatients with abdominal compartment syndrome who were treated with VAC decompression had a faster abdominal closure rate and earlier discharge from the ICU as compared to similar patients treated with the Bogota bag.

The influence of new technologies on laparoscopic adrenalectomy

BackgroundLaparoscopic adrenalectomy has proved to be the technique of choice for managing benign pathologies of the adrenals and isolated adrenal metastases, especially those arising from lung tumor, but the procedure should not be performed for primitive adrenal carcinoma. The Authors wanted to test the advantages of the Harmonic Scalpel in laparoscopic adrenalectomy.MethodsFrom April 1995 to April 2001, the authors investigated their series of laparoscopic adrenalectomies performed at the Careggi General Hospital, Division of General and Vascular Surgery, Florence, Italy. This study enrolled 91 patients with various adrenal pathologies. The transperitoneal approach was used, with the patient in a lateral position, as suggested by Gagner. Special care was taken to improve the surgical approach to the adrenals by the use of new technological devices such as the Harmonic Scalpel. The operative time required by the surgical procedure was computed by dividing the study into thee periods: 1995–1997, 1998–1999, 2000–2001. The first period was necessary to complete the learning curve. In the second period, a steady state in surgical time was reached. During the third period, the Harmonic Scalpel was introduced. The differences between the three periods were tested using a nonparametric analysis (Mann-Whitney U test or Kruskal-Wallis test) as appropriate. A two-tailed p value of 0.05 or less was considered statistically significant. The authors investigated the cost of the operation performed in each of the two groups using, respectively, the conventional laparoscopic device (1998–1999) and the Harmonic Scalpel (2000–2001). The following expenses were considered: Harmonic Scalpel impulse generator and disposable shears, operating room cost per hour, and endoclip applier.ResultsThe 91 laparoscopic adrenalectomies were performed with these indications: 31 incidentalomas (26 adenomas and 5 cysts), 25 cases of Conn’s disease, 18 cases of Cushing’s disease, 9 pheochromocytomas, 2 myelolipomas, 5 metastases (from lung, kidney, and breast) and 1 primitive carcinoma diagnosed preoperatively. Considering the whole series (1995–2001), there was a significant trend of reduction in operative time (p =0.0001). Moreover looking at the first period (1995–1997), in which the learning curve was completed, the mean surgical time was 148 min, as compared with 125 mm. For the second period (1998–1999) (p=0.0002). This represents a significant reduction in operative time. The authors notes a further reduction in the operative time when surgery was performed with the Harmonic Scalpel (2000–2001) (92 min; p=0.001). The reduction in operative time attributable to the Harmonic Scalpel was confirmed also by a multivariate analysis of covariance general linear models procedure (GLM), which accounts for several confounders: age, gender, site and size of tumors, and histology (p=0.0001). The rate was 3.3% for morbidity, 1.1% for mortality, and 2.2% for conversion. There was no difference in complications between patients treated with conventional devices and those treated with the Harmonic Scalpel.ConclusionsThe laparoscopic approach has proved to be an extremely reliable procedure for benign pathologies and isolated metastases. There may yet be doubts about its use for the treatment of adrenal carcinomas preoperatively diagnosed. When surgery is performed using Harmonic Scalpel, operative time is significantly reduced and surgery is easier and less expensive. Infact use of the Harmonic Scalpel allowed the cost per operation to be reduced

Portal thrombosis. A rare complication of laparoscopic splenectomy.

70. Moreover, if surgery is performed using the nondisposable clip applier, the expences are reduced

Complications in laparoscopic adrenalectomy: the value of experience.

105.

Expectations and outcomes when moving from open to laparoscopic adrenalectomy: Multivariate analysis

Abstract. Portal thrombosis is a rare complication of splenectomy. We performed 12 laparoscopic splenectomies and observed this complication only in one patient with idiopathic thrombocytopenia (ITP). The right branch of the portal vein presented a partial thrombosis, while the left branch was completely obstructed by thrombi. Abdominal ultrasonography and an ultrasound doppler exam allowed us to diagnose this event and a retrograde angiography performed afterward confirmed our diagnosis. A 48-h intravenous heparin treatment was promptly begun, followed by anticoagulant drugs (dicumarol). The patient was dismissed 5 days afterward, presenting a steady-state ultrasound doppler pattern and a complete normalization of liver parameters. An ultrasound doppler exam performed 1 month after anticoagulant therapy showed a complete resolution of portal thrombosis. We believe that early diagnosis of this rare complication, prompt beginning of anticoagulant therapy, and care in surgical procedures may reduce patient life-threatening risks and assure complete remission.

Uncommon clinical presentations of pheochromocytoma and paraganglioma in two different patients affected by two distinct novel VHL germline mutations

BackgroundWith the increased diffusion of laparoscopic adrenalectomy (LA), surgeons from nonreferral surgical departments are beginning to approach this procedure, even if they are less experienced than surgeons from centers with a larger workflow. This study was designed to establish the real incidence of perioperative complications, in LA, in both major and minor surgical departments.MethodsPatients were prospectively recorded into the Italian Registry of Endoscopic Surgery-Adrenalectomy (IRES-A) database since January 2000. Surgical Centers were divided in to referral centers (RC) with >30 adrenalectomies and nonreferral centers (NRC) with <30 adrenalectomies performed. Peri- and postoperative complications were evaluated.ResultsOf the 833 patients included in the IRES-A, 66 patients (7.9%) had complications (33 females; mean age 48xa0±xa08xa0years). Mean age and body mass index were significantly lower in noncomplicated patients. Pheochromocytoma histotype and large mass dimension were associated with a higher complication rate. The whole number of complications, conversion rate, and nonsurgery-related complications were statistically lower in the RC groups than the NRC groups.ConclusionsThe main risk factors for the occurrence of complications during laparoscopic adrenalectomy appear to be surgical inexperience, age, and body mass index of the patient, the dimension of the mass, and pheochromocytoma. Therefore, laparoscopic adrenalectomy, especially for tumors that are potentially more complicated, should only be undertaken in high-volume specialist centers by surgeons with the appropriate training and experience.

Long-term results of treatment of acute diverticulitis: still lessons to be learned?

Various authors have suggested that laparoscopic adrenalectomy (LA) leads to better surgical outcomes than open surgery. The debate is still open, however, and indications and limitations of minimally invasive surgery have not been completely established. The objective of our study was to compare surgical outcomes of LA and open adrenalectomy (OA), using multivariate analysis to adjust for potential confounding factors (e.g., size of the lesion, histology). Between 1995 and June 2000 at “Careggi” Hospital in Florence, Italy patients with an indication for adrenalectomy were treated laparoscopically if the lesion was < 10 cm and there was no clinical evidence of malignancy. All 79 patients who underwent LA have been included in this study. Among 152 patients who underwent OA at “La Sapienza” University in Rome, 93 had an adrenal lesion < 10 cm and no clinical evidence of malignancy; they were selected for comparison. Multivariate analysis has been used to analyze the effect of the surgical approach (OA vs. LA) on the surgical outcome, controlling for potential confounders. Multiple logistic regression showed that there is no significant difference in intraoperative outcomes (i.e., surgical time > 2 hours, blood loss ≥ 500 ml) between patients operated on through a traditional approach and those who underwent LA. On the other hand, patients operated on laparoscopically have a significantly higher probability than the OA group of experiencing a better recovery from surgery (i.e., require less postoperative analgesics and return to normal activities earlier). The results of the present study show that, although LA does not add much benefit in terms of expected intraoperative outcomes, it dramatically speeds patients’ recovery from surgery. The two approaches are complementary and should both be integrated into the technical background of all endocrine surgeons.

Mitochondrial function and content in pheochromocytoma/paraganglioma of succinate dehydrogenase mutation carriers

Contextu2002 The von Hippel‐Lindau (VHL) syndrome is an inherited multitumour disorder characterized by clinical heterogeneity and high penetrance. Pheochromocytoma (Pheo) is present in 10%–15% of cases and can be isolated or associated with other lesions such as haemangioblastomas, kidney cysts or cancer and pancreatic lesions. In VHL patients, Pheos generally secrete norepinephrine and are located in the adrenals. Extra‐adrenal Pheos (paragangliomas, PGLs) are rare.

A multi-center study on the surgical management of metastatic disease to adrenal glands†

The aim of the present study was to evaluate the long-term results in patients treated for diverticular disease (DD), mainly considering indication for surgery, outcome of the treatment modalities and quality of life. All consecutive patients who underwent treatment for diverticular disease since January 2003 to June 2007 were analyzed. Patients were divided into three groups: medical treatment, elective surgery and emergency surgery. The patients responded to the questions of the Cleveland Global Quality of Life (CGQL) questionnaire and to a symptoms questionnaire during a telephone interview. The long-term outcome parameters such as readmission to the hospital, further surgery for DD, current health status, and quality of life were analyzed according to possible predictors. 146 patients (72.2xa0%) agreed to submit to the telephone interview and were enrolled in the study. The median follow-up was 99xa0months. Fifty-two patients were managed with medical therapy, 36 patients received elective operations, and 58 patients underwent acute surgery. Twelve patients (12.7xa0%) complained episodes of persistent abdominal pain after surgical resection, compared with 6 non-surgical patients (11.5xa0%). No possible predictors of recurrence, reoperation or readmission were found. The CGQL total scores were found to be similar in the three groups. DD affected bowel function and quality of life of patients in the long-term follow-up regardless of the type of therapy adopted. No long-term advantages of colonic resection were found which should be considered only in patients presenting complicated DD.