Fouad Atallah

Retroperitoneoscopic Adrenalectomy: Comparison of Retrograde and Antegrade Approach Among a Series of 279 Cases

OBJECTIVE To compare the results of retroperitoneal laparoscopic adrenalectomy using the antegrade and retrograde approach. MATERIALS AND METHODS We performed an analysis of a single-center series of 279 retroperitoneal laparoscopic adrenalectomies from 1996 to 2010. We compared 172 cases performed with an antegrade approach and 107 with a retrograde approach without dissection of the renal hilum and initial control of the adrenal vein in comparable populations. RESULTS The operative time was shorter in the group treated with the retrograde technique, 101±51 vs 140±40 minutes, respectively (Students t test, P<.001). Blood loss was similar in both groups, 85±224 vs 80±126 mL, respectively (P=NS). Hemodynamic instability was defined as the maximal systolic blood pressure minus the minimal systolic blood pressure divided the maximal systolic blood pressure. It was lower in the group who underwent the retrograde technique (32.7 vs 37.6 mL; Students t test, P=.005) with a lower perioperative consumption of ephedrine (2.2 vs 5.1 mg, P=.004) and atropine (0.09 vs 0.22 mg, P=.026). No difference was found between the 2 groups in the frequency of perioperative complications or postoperative mortality (1 death in each group of causes unrelated to the surgery). CONCLUSION Retroperitoneal laparoscopic adrenalectomy using a retrograde approach is a safe and reproducible technique. It makes it possible to perform adrenalectomy without dissection of the renal hilum, with a reduction in the operative time. The good hemodynamic stability observed with this technique makes it very attractive for the treatment of pheochromocytoma.

Obesity May Be Protective against Severe Perineal Lacerations.

Objective. To determine if there is an association between BMI and 3rd- or 4th-degree perineal lacerations in normal spontaneous and operative vaginal deliveries. Study Design. We performed a retrospective case control study using a large obstetric quality improvement database over a six-year period. Cases were identified as singleton gestations with third- and fourth-degree lacerations. Controls were obtained randomly from the database of patients without third- or fourth-degree lacerations in a 1 : 1 ratio. Univariate and multivariate logistic regression analyses were performed. Results. Of 32,607 deliveries, 22,011 (67.5%) charts with BMI documented were identified. Third- or fourth-degree lacerations occurred in 2.74% (n = 605) of patients. 37% (n = 223) were identified in operative vaginal deliveries. In the univariate analysis, obesity, older maternal age, non-Asian race, and birth weight <4000 g were all protective against 3rd- and 4th-degree lacerations. After controlling for age, race, mode of vaginal delivery, and birth weight, obesity remained significant. Conclusion. Being obese may protect against third- and fourth-degree lacerations independent of parity, race, birth weight, and mode of delivery.

Nefopam analgesia as a substitute of neurolept analgesia for extracorporeal shock wave lithotripsy.

Pain is an important side effect of extracorporeal shock wave lithotripsy (ESWL). It causes patient discomfort, movements, and tachypnea. We evaluated the efficiency of nefopam hydrochloride, a centrally acting nonnarcotic analgesic, in 197 consecutive patients (mean age 53 yr, range 23–86 yr) treated for renal stones by ESWL, using the piezoelectric EDAP LT-02 lithotriptor (EDAP, Lyon, France). Nefopam (20 mg) was administered IV over 30 min before ESWL. At the end of the session, patients were asked to assess their satisfaction with pain control using a four-point verbal scale. A total of 26.9% of patients reported no pain, 36.5% reported minimal pain, 30.5% moderate but tolerated pain, and 6.1% severe or untolerated pain necessitating interruption of the session. Nefopam was efficient in 94% of cases, ESWL session being conducted with the power and duration planned by the urologist (mean 44 min, range 25–62 min). No hemodynamic changes or oxygen desaturation were noted. The following minor side effects occurred in 14.7% of patients: nausea (8.6%), sedation (5.1%), and vomiting, hypotension, and drowsiness (0.5%). Nefopam is not structurally correlated to nonsteroidal antiinflammatory drugs or morphine-like drugs and so it is free of their serious side effects and contraindications. It inhibits the neuronal uptake of dopamine, serotonin, and noradrenaline in supraspinal and spinal levels, and increases neurotransmission in pain inhibitory serotoninergic descending pathways (1,2). As analgesic requirements during ESWL are difficult to predict, we recommend routine nefopam administration to reduce the incidence of treatment failure and avoid stressful pain experience.