Etienne Hamoir

Hemodynamic changes and catecholamine release during laparoscopic adrenalectomy for pheochromocytoma

UNLABELLED We investigated hemodynamics and plasma catecholamine concentrations in eight consecutive patients undergoing laparoscopic adrenalectomy for suspected pheochromocytoma. The same anesthesia protocol was used in all patients: a continuous infusion of sufentanil 0.5 microg x kg(-1) x h(-1) and isoflurane 0.4% (end-tidal) in 50% N2O/O2. Systolic arterial pressure was maintained between 120 and 160 mm Hg by adjusting an infusion of nicardipine, a calcium-channel blocker, while tachycardia (>100 bpm) was treated by 1-mg boluses of atenolol. Hemodynamics (thermodilution technique) and plasma catecholamine concentrations were measured before surgery, after the induction of anesthesia, after turning the patient to the lateral position, during pneumoperitoneum, during tumor manipulation, after adrenalectomy, and at the end of surgery. Two events resulted in significant catecholamine release: creation of the pneumoperitoneum and adrenal gland manipulation. As a consequence, a twofold increase in cardiac output was recorded. Adjustments of nicardipine infusion (2-6 microg x kg(-1) x min(-1)) minimized changes in mean arterial pressure. Beta-adrenergic blockade was necessary in six patients. In conclusion, laparoscopic adrenalectomy for pheochromocytoma results in marked catecholamine release during pneumoperitoneum and tumor manipulation. Titration of a nicardipine infusion allowed easy and quick control of the hemodynamic aberrancies related to these processes. IMPLICATIONS Pneumoperitoneum during laparoscopy, now used for adrenalectomy, may complicate anesthetic management of patients with pheochromocytoma. In this study, laparoscopic adrenalectomy was associated with catecholamine release during the creation of pneumoperitoneum and tumor manipulation. Adjustments of a nicardipine infusion readily attenuated the subsequent hemodynamic aberrancies.

Breast cancer and serum organochlorine residues

Background: Controversy still exists about the breast carcinogenic properties in humans of environmental xenoestrogens (organochlorines), justifying new investigations. Aims: To compare the blood levels of total dichlorodiphenyltrichloroethane (DDT) and hexachlorobenzene (HCB) in samples collected at the time of breast cancer discovery, in order to avoid the potential consequences of body weight change (after chemotherapy or radiotherapy) on the pesticide residue levels. Methods: Blood levels of HCB and total DDT (we calculated total DDT concentrations by adding all DDT and DDE isomers) were compared in 159 women with breast cancer and 250 presumably healthy controls. Risk of breast cancer associated with organochlorine concentration was evaluated. Results: Mean levels of total DDT and HCB were significantly higher for breast cancer patients than for controls. No differences in serum levels of total DDT or HCB were found between oestrogen receptor positive and oestrogen receptor negative patients with breast cancer. Conclusions: These results add to the growing evidence that certain persistent pollutants may occur in higher concentrations in blood samples from breast cancer patients than controls.

Bilateral neck exploration under hypnosedation : A new standard of care in primary hyperparathyroidism?

OBJECTIVE The authors review their experience with initial bilateral neck exploration under local anesthesia and hypnosedation for primary hyperparathyroidism. Efficacy, safety, and cost effectiveness of this new approach are examined. BACKGROUND Standard bilateral parathyroid exploration under general anesthesia is associated with significant risk, especially in an elderly population. Image-guided unilateral approaches, although theoretically less invasive, expose patients to the potential risk of missing multiple adenomas or asymmetric hyperplasia. Initial bilateral neck exploration under hypnosedation may maximize the strengths of both approaches while minimizing their weaknesses. METHODS In a consecutive series of 121 initial cervicotomies for primary hyperparathyroidism performed between 1995 and 1997, 31 patients were selected on the basis of their own request to undergo a conventional bilateral neck exploration under local anesthesia and hypnosedation. Neither preoperative testing of hypnotic susceptibility nor expensive localization studies were done. A hypnotic state (immobility, subjective well-being, and increased pain thresholds) was induced within 10 minutes; restoration of a fully conscious state was obtained within several seconds. Patient comfort and quiet surgical conditions were ensured by local anesthesia of the collar incision and minimal intravenous sedation titrated throughout surgery. Both peri- and postoperative records were examined to assess the safety and efficacy of this new approach. RESULTS No conversion to general anesthesia was needed. No complications were observed. All the patients were cured with a mean follow-up of 18 +/- 12 months. Mean operating time was <1 hour. Four glands were identified in 84% of cases, three glands in 9.7%. Adenomas were found in 26 cases; among these, 6 were ectopic. Hyperplasia, requiring subtotal parathyroidectomy and transcervical thymectomy, was found in five cases (16.1%), all of which had gone undetected by localization studies when requested by the referring physicians. Concomitant thyroid lobectomy was performed in four cases. Patient comfort and recovery and surgical conditions were evaluated on visual analog scales as excellent. Postoperative analgesic consumption was minimal. Mean length of hospital stay was 1.5 +/- 0.5 days. CONCLUSIONS Initial bilateral neck exploration for primary hyperparathyroidism can be performed safely, efficiently, and cost-effectively under hypnosedation, which may therefore be proposed as a new standard of care.

Surgical Management of Amiodarone-associated Thyrotoxicosis: Too Risky or Too Effective?

Abstract. Amiodarone-associated thyrotoxicosis, often clinically mild and resolutive after amiodarone discontinuation or under medical therapy, is sometimes drug unresponsive and not uncommonly follows a dramatic, even fatal course. Therefore, we considered a surgical solution in 15 severely amiodarone-associated thyrotoxic patients. Twelve men and three women (mean age 68 years, range 50–84 years) underwent radical thyroidectomy for clinical and biologically proved amiodarone-associated thyrotoxicosis. In six surgery was the first-line therapeutic option. In the other nine thyroidectomy seemed unavoidable considering the unresponsiveness to medical therapy and rapid deterioration of the patients’ clinical condition, with life-threatening cardiac failure in three. In every patient surgery was conducted without immediate or delayed complications. Total thyroidectomy proved uniformly, definitively, and rapidly effective in controlling thyrotoxicosis in all patients, with a spectacular reversal of cardiac failure in the three most critical cases. Surgery was beneficial to our 15 patients and undoubtedly life-saving in the three most worrying cases. These results suggest that thyroidectomy should be more liberally regarded as an interesting alternative to conventional, but unpredictably effective, medical therapies.

Fluorine-18-fluorodeoxyglucose positron emission tomography for preoperative parathyroid imaging in primary hyperparathyroidism

Fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) imaging was performed in seven consecutive patients with primary hyperparathyroidism to preoperatively locate parathyroid adenomas. Foci of FDG accumulation corresponding to abnormal parathyroid tissue were observed in two out of nine surgically excised parathyroid adenomas. It was concluded that FDG PET imaging demonstrated a too low sensitivity for systematic preoperative detection and localization of parathyroid glands causing primary hyperparathyroidism.

Laparoscopic removal of pheochromocytoma Why? When? and Who? (Reflections on one case report)

Until now, the need for wide exposure and nonmanipulative dissection of pheochromocytoma has dictated the use of a large intraperitoneal transabdominal approach, which unfortunately results in a significant incidence of morbidity. A unilateral retroperitoneal approach guided by the refinements of new imaging techniques is less invasive but is associated with a small risk of incomplete cure. In one case report, we tested the hypothesis that laparoscopic surgery could combine the beneficial effects of both operative strategies without their respective side effects. We concluded that a laparoscopic approach combined with exclusive intraoperative infusion of nicardipine, a calcium-channel blocker, can be used to surgically remove pheochromocytoma under stable hemodynamic conditions. This provides better exposure of the anatomical structures than open surgery and allows a visual exploration of the entire abdominal cavity to exclude tumor multicentricity or ectopic sites in the case of inconclusive preoperative imaging investigations. Moreover, conversion to open surgery is always possible if needed.

Iatrogenic thyrotoxicosis. Causal circumstances, pathophysiology and principles of treatment. Review of the literature

Thyrotoxicosis is the clinical syndrome that results when tissues are exposed to high levels of circulating thyroid hormones. In most instances thyrotoxicosis is due to hyperthyroidism, a term reserved for disorders characterized by overproduction of thyroid hormones by the thyroid gland. Nevertheless, thyrotoxicosis may also result from a variety of conditions other than thyroid hyperfunction. The present report focuses on the etiologies, pathophysiology, and treatment of iatrogenic thyrotoxicosis. Iatrogenic thyrotoxicosis may be caused by (1) subacute thyroiditis (a result of lymphocytic infiltration, cellular injury, trauma, irradiation) with release of preformed hormones into circulation; (2) excessive ingestion of thyroid hormones (“thyrotoxicosis factitia”); (3) iodine-induced hyperthyroidism (radiologic contrast agents, topical antiseptics, other medications). Among these causes of iatrogenic thyrotoxicosis, that induced by the iodine overload and cytotoxicity associated with amiodarone represents a significant challenge. Successful management of amiodarone-induced thyrotoxicosis requires close cooperation between endocrinologists and endocrine surgeons. Surgical treatment may have a leading yet often underestimated role in view of the potential life-threatening severity of this disease, whereas others kinds of iatrogenic thyrotoxicosis are usually treated conservatively.

Tolerance of Liver Transplant Patients to Strenuous Physical Activity in High-Altitude

Physical functioning is improved after liver transplantation but studies comparing liver transplant recipients with normal healthy people are lacking. How liver (and other organ) transplant recipients tolerate strenuous physical activities is unknown. There are no data on the tolerance of transplant patients at high altitude. Six liver transplant subjects were selected to participate in a trek up Mount Kilimanjaro 5895m, Tanzania. Physical performance and susceptibility to acute mountain sickness were prospectively compared with fifteen control subjects with similar profiles and matched for age and body mass index. The Borg‐scale (a rating of perceived exertion) and cardiopulmonary parameters at rest were prospectively compared with six control subjects also matched for gender and VO2max. Immunosuppression in transplant subjects was based on tacrolimus. No difference was seen in physical performance, Borg‐scales and acute mountain sickness scores between transplant and control subjects. Eight‐three percent of transplant subjects and 84.6% of control subjects reached the summit (p = 0.7). Oxygen saturation decreased whereas arterial blood pressure and heart rate increased with altitude in both groups. The only difference was the development of arterial hypertension in transplant subjects at 3950 m (p = 0.036). Selected and well‐prepared liver transplant recipients can perform strenuous physical activities and tolerate exposure to high altitude similar to normal healthy people.

Pylephlebitis of the portal vein complicating intragastric migration of an adjustable gastric band.

Pylephlebitis, or septic thrombophlebitis of the portal vein, is an infrequent but life-threatening complication of abdominal septic events. The authors report the occurrence of pylephlebitis and multiple liver abscesses induced by a neglected intra-gastric migration of an adjustable silicone gastric band. The patient was successfully treated by broad-spectrum antibiotics and total gastrectomy with Roux-en-Y esophago-jejunostomy. Postoperative recovery was marked by acute liver failure that was managed conservatively. The patient is alive and well at 1-year follow-up. This case emphasizes the interest in early removal of the band when intra-gastric migration is diagnosed.

Cardiac paraganglioma: diagnostic work up and review of the literature.

Abstract Paraganglioma of the heart are potentially invasive, highly vascularized tumors for which complete resection may be curative. Derived from the cardiac wall in most instances, resectability can be assessed after integration of the data provided by MRI in T2 sequence, and coronarography. A fully documented case of a large cardiac pheochromocy-toma of the left atrium and AV groove is reported and the pertinent literature on the subject is here presented.