C. Nomine-Criqui

Minimal impact of calcimimetics on the management of hyperparathyroidism in chronic dialysis

BACKGROUND The calcimimetic drug cinacalcet has changed the prescription patterns in patients with secondary hyperparathyroidism, despite the lack of randomized studies that compare cinacalcet with conventional treatment, including parathyroidectomy. The aim of this study was to evaluate current management of patients on chronic dialysis with incidental and parathyroid hormone (PTH) levels ≥ 500 ng/L. METHODS Prospective pharmacoepidemiologic study of chronic dialysis patients with PTH level ≥ 500 ng/L. RESULTS We studied 269 patients. Among the 186 patients who had 2-year follow-up, 125 (67%) were managed using cinacalcet. At 2 years, when comparing the cinacalet with the noncinacalet groups, we found that mean PTH values were 400 ± 318 versus 388 ± 251 ng/L (P = ns) and the percentage of patients following 2009 PTH Kidney Disease Improving Global Outcomes (KDIGO) guidelines were 79 versus 85% (P = ns). Eight patients (4%) underwent parathyroidectomy. On multivariate analysis, the use of cinacalcet was not a predictor for PTH within KDIGO guidelines at 2-year follow-up. CONCLUSION Cinacalcet was used in the majority (67%) of patients on chronic dialysis with secondary hyperparathyroidism, but the use of cinacalcet did not affect mean PTH values nor the proportion of patients following KDIGO guidelines compared with patients not using calcimimetics.

Robotic lateral transabdominal adrenalectomy.

Laparoscopic transabdominal adrenalectomy is considered to be the standard of care for adrnalectomy. Widespread adoption of robotic technology has positioned robotic adrenalectomy as an option in some medical centers. Many studies have compared laparoscopic versus robotic approaches to perform adrenalectomy and evaluated potential advantages to balance higher costs. This review summarizes current available data regarding the use of the robotic system to perform adrenalectomy (RA) and its comparison with laparoscopic adrenalectomy (LA). J. Surg. Oncol. 2015; 112:305–309.

Robot-assisted adrenalectomy: indications and drawbacks

Adrenal tumors can vary from a benign adrenocortical adenoma with no hormonal secretion to a secretory adrenocortical malignancy (adrenocortical carcinoma) or a hormone-secreting tumor of the adrenal medulla (pheochromocytoma). Currently, laparoscopic adrenalectomy is regarded as the preferred surgical approach for the management of most adrenal surgical disorders, although there are no prospective randomized trials comparing this technique with open adrenalectomy. However, widespread adoption of robotic technology has positioned robotic adrenalectomy as an option in some medical centers. Speculative advantages associated with the use of the robotic system have rarely been evaluated in clinical settings and cost increase remains an important drawback associated with robotic surgery. This review summarizes current available data regarding robotic transperitoneal adrenalectomy including its indications, advantages, limitations, and comparison with conventional laparoscopic adrenalectomy. We believe that the use of a robotic system seems to be useful especially in more difficult patients with larger tumors, truncal paragangliomas, and bilateral and/or partial adrenalectomies. Overall, we believe that overcosts due to robotic system use could be balanced by hospital stay decrease, patients’ referral increase, improved postoperative outcomes in more difficult patients and ergonomics for the surgeon. However, we also believe that the current surgical intuitive business model is counterproductive, because there are no available strong clinical data that could balance overcosts associated with the use of the robotic system.

Evaluation of risk factors for complications after bariatric surgery

The decision to perform a bariatric surgical procedure, the conclusion of a clinical pathway in which management is individually adapted to each patient, is taken after multidisciplinary consultation. Paradoxically, the patients who would most benefit from surgery are also those who have the highest operative risk. In practice, predictive factors of mortality and severe postoperative complications (Clavien-Dindo>III) must be used to evaluate the benefit/risk ratio most objectively. The main risk factors are age, male gender, body mass index, obstructive sleep apnea syndrome, insulin resistance and diabetes, tobacco abuse, cardiovascular disease, ability to lose weight before surgery, hypoalbuminemia and functional disability. Routine preoperative evaluation of high perioperative risk patients provides the attending physician with information to: (1) correct several of these risk factors before surgery and thereby limit the operative risk; (2) orient the patient to a less risky surgical procedure and/or to a facility with a more adapted technical capacity, as necessary; (3) contra-indicate the operation if the risks exceed the expected benefits. All in all, this preoperative evaluation combined with management of comorbidities contributes to decrease the risk of postoperative complications and to improve the overall management of obese patients.

Comments on: Clinical predictors of prolonged postresection hypotension after laparoscopic adrenalectomy for pheochromocytoma.

To the Editors: We read with interest the study by Namekawa et al. This interesting study aimed to identify clinical factors that predict postresection hypotension in patients after laparoscopic adrenalectomy for pheochromocytoma. We agree with the study’s authors that this issue is clinically relevant, because hypotensive episodes are affected by operative techniques and because the need for postoperative catecholamine support generally leads to increased mean duration of hospitalization and related costs. This study showed that about half of their patients required continuous catecholamine infusion to maintain a blood pressure >90 mmHg at the end of adrenalectomy. We commend the authors for having been able to show that a tumor size of >60 mm and greater preoperative levels of urinary epinephrine and norepinephrine were independent predictors of those hypotensive episodes. As reported in the Methods section, all patients included in this study were “treated fully with alphaadrenergic blockers for at least two weeks before the operation.” The use of this alpha-blockade, however, may have been an important potential bias, because it may be responsible for the greater incidence and severity of hypotensive episodes after pheochromocytoma resection. Mitmaker et al showed recently that postoperative episodes of hemodynamic instability (including hyperand hypotensive episodes) were more frequent after alpha-blockade in comparison with calcium channel blockade (95% vs 22%). In a comparative study, including 155 patients (110 receiving calcium channel blockers and 41 alphablockade), we showed that mean maximal systolic blood pressure intraoperatively was less after alpha-blockade, but severe hypotensive episodes (mean arterial pressure <60 mmHg) were more frequent and of greater duration with alpha-blockade (P < .001). Consequently, intraoperative vasoactive drugs were used more frequently, and mean fluid volume infused was greater (P < .001). While we acknowledge that this last comparative study focused only on the intraoperative period, it showed that the type of preoperative medical preparation had a significant impact on the incidence and severity of hypotensive episodes. Can we be sure that the postoperative hypotensive episodes reported in the Namekawa et al study were secondary to clinical criteria (size, secretion) and not due to preoperative medical preparation type? Also, we ask the authors: did they observe a correlation between their dosing of alpha-blockers and the incidence and severity of postoperative hypotensive episodes? Lastly, because alpha-blockade dosing is titrated according to preoperative blood pressure, it is likely that patients with larger pheochromocytomas (and greater mean levels of systemic catecholamines) received greater amounts of preoperative alpha-blockers during their preoperative medical preparation. In conclusion, we would like to thank the authors for their opinions about those issues.