L. Sabater

Laparoscopic Approach to Pheochromocytoma: Hemodynamic Changes and Catecholamine Secretion

Abstract. This study compares the outcome of laparoscopic adrenalectomy (LpA) in 23 patients using CO 2 insufflation with the outcome of this procedure in another 8 patients with pheochromocytoma (7 unilateral, 1 bilateral) using helium for pneumoperitoneum. The adrenal lesions in the first group included nonfunctional adenoma (n = 3), aldosterone adenoma (n = 11), Cushing’s adenoma (n = 6), and Cushing’s disease (n = 3). The latter patients were compared with a third group of 8 patients with pheochromocytoma undergoing conventional transabdominal adrenalectomy (CTA). With both procedures, intraoperative changes in plasma catecholamine levels were studied during pheochromocytoma removal and the changes correlated with intraoperative cardiovascular derangements. LpA was successfully performed in 95% of patients with adrenal lesions and in 100% of patients with pheochromocytoma. There was no significant difference in laparoscopic adrenalectomy for pheochromocytoma compared to that for other adrenal lesions in terms of operative time, blood loss, hospital stay, analgesic requirements, and return to normal activity. The outcome was less favorable in pheochromocytoma patients undergoing CTA. The largest increase of catecholamine levels in pheochromocytoma patients occurred during tumor manipulation with both LpA (17.4-fold for epinephrine and 8.6-fold for norepinephrine) and CTA (34.2-fold for epinephrine and 13.7-fold for norepinephrine), but cardiovascular instability was associated only with CTA. LpA may become the technique of choice for surgical removal of adrenal lesions and may also become the preferred method for removing pheochromocytoma.

Helium and Carbon Dioxide Pneumoperitoneum in Patients with Pheochromocytoma Undergoing Laparoscopic Adrenalectomy

Insufflation with helium is used to prevent respiratory acidosis, hypercapnia, and cardiovascular instability associated with carbon dioxide (CO2) pneumoperitoneum. The aim of this prospective study was to compare CO2 with helium pneumoperitoneum with special reference to respiratory and hemodynamic changes at different times during the operation. Altogether 22 pheochromocytoma patients undergoing laparoscopic adrenalectomy (LpA) were included using CO2 in 11 patients (CO2LpA) and helium in 11 patients (HeLpA). The insufflation pressure was 12 mmHg. The two groups were comparable with regard to demographic data and preoperative management. CO2 and helium insufflation were associated with similar catecholamine increase. The most striking significant increase compared with the baseline was observed during tumor isolation: The mean plasma epinephrine (EPI) and norepinephrine (NE) levels increased 32.86-fold and 25.92-fold, respectively, in the CO2LpA patients and 27.43-fold and 18.46-fold, respectively, in the HeLpA patients. HeLpA did not result in significant hypercarbia or acidosis at any measured intraoperative point; this was without any alteration in minute ventilation to maintain these normal PaCO2, excess base (EB), and pH values. Significant increases of mean arterial pressure, pulmonary arterial pressure, pulmonary vascular resistance index, PaCO2, EB, and acidosis were seen in the CO2LpA patients at the time of tumor isolation and tumor removal compared with those in HeLpA patients. No patient required conversion to open surgery. There were no significant differences between CO2LpA and HeLpA regarding mean operative time (117.50 ± 93.68 vs. 106.87 ± 16.60 minutes), mean blood loss (168.54 ± 78.63 vs. 142.02 ± 109.26 ml), hospital stay (4 days), the need for analgesics, or mean time required to return to normal activity (12 days). There was one wound infection in the HeLpA group and one wound hematoma and one case of atelectasis in the CO2LpA group. Helium may be the agent of choice for abdominal insufflation in patients undergoing LpA for pheochromocytoma, eliminating the adverse hemodynamic and respiratory changes associated with CO2 insufflation.

Retroperitoneal approach in laparoscopic adrenalectomy Is it advantageous

Abstract. Recently, the retroperitoneal laparoscopic approach has been described as advantageous in avoiding the respiratory and hemodynamic effects of CO2 pneumoperitoneum and giving direct access without the need to move abdominal organs. Forty-two laparoscopic adrenalectomies (LpA) were performed in 36 patients with a variety of adrenal disorders, including 9 patients with nonfunctioning tumors, 11 patients with aldosterone adenoma, 10 patients with Cushings adenoma, and 6 patients with Cushings disease. Twenty-two adrenalectomies were performed using the transperitoneal approach (TLpA), and 20 via the retroperitoneoscopic approach (RLpA). Arterial blood samples, mean arterial pressure, heart rate, and clinical parameters were evaluated. At the end of the operation, the PaCO2, PetCO2, and base deficit all increased significantly in both retroperitoneal and transperitoneal CO2 insufflation compared with basal values. Arterial pH decreased significantly in both TLpA and RLpA groups. All clinical parameters evaluated (operation time, analgesic dosing requirements, hospital stay, and the days until return to normal activity) were similar in the TLpA and RLpA approaches. Two patients in the TLpA (10.5%) group and two patients in the RLpA (10%) group needed conversion to open surgery. This study shows the safety and efficacy of laparoscopic adrenalectomy via the transperitoneal or retroperitoneal route in patients with a variety of adrenal disorders. The retroperitoneoscopic approach could be the primary choice in patients with previous abdominal surgery.

Prognostic factors in nonresectable pancreatic adenocarcinoma: a rationale to design therapeutic trials.

Objective:Most patients with pancreatic cancer show an advanced tumor at the time of diagnosis. In recent years, new therapies have been developed in such patients, thus forcing the analysis of factors that influence their survival. The present study was aimed at determining the prognostic factors in a series of 134 consecutive patients with pancreatic carcinoma not suitable for surgical resection, due to either locally advanced tumors or metastatic spread.Methods:First, 34 epidemiological, clinical, analytical, and tumor-related parameters recruited at admission were included in a univariate analysis of survival by using the Kaplan-Meier method. Those significant variables in the previous step were thereafter introduced in a Cox regression procedure. A prognostic index for calculating the relative risk of death of each patient was also proposed.Results:The median survival time in the whole series was 3.11 months, the 3, 6, and 12 months probability of survival being 51%, 28%, and 8%, respectively. Eight of 34 variables (jaundice and toxic syndrome at admission, serum cholesterol, iron and alanine aminotransferase concentrations, leukocyte count, baseline performance status, and the presence of distant metastases) were selected in the univariate analysis. Of these eight parameters, the Cox regression analysis identified a preserved baseline performance status (OR = 2.14, 95% CI = 1.49–3.04) and the absence of metastases (OR = 1.34, 95% CI = 1.03–1.73) as the only variables independently associated with a longer survival. Therefore, a prognostic index was constructed allowing the division of patients in three different groups according to their relative risk of death (RRD) = exp (performance status × 0.7589 + presence of metastases × 0.2891).Conclusions:The results of the present investigation suggest that baseline performance status and distant metastases should be considered in designing and evaluating any therapeutic trial in patients with nonresectable pancreatic carcinoma.

Does hormonal function of the tumor influence the outcome of laparoscopic adrenalectomy

AbstractBackground: Patients with hypertension, with catecholamine hypersecretion, and with cortisol excess may associate intraoperative cardiovascular instability and postoperative complications.n Methods: To compare the outcome of laparoscopic adrenalectomy (LpA) in patients with aldosterone adenoma (11), Cushings adenoma (six), Cushings disease (four), pheochromocytoma (Pheo) (11), and nonfunctioning tumor (five). Intra- and postoperative parameters were studied and in patients with Pheo intraoperative catecholamine plasma levels were correlated with cardiovascular derangements.n Results: Operative time, estimated blood loss, hospital stay, analgesic requirements, and time to return to normal activity were significantly higher in patients undergoing total bilateral adrenalectomy for Cushings syndrome compared with other groups undergoing unilateral adrenalectomy, but these latter groups showed no significant differences among themselves in all parameters analyzed. One patient with nonfunctioning tumor and another with Cushings adenoma were converted to open surgery, and two patients with Cushings disease had urinary infection. Isolation of Pheo was associated with significant release of catecholamines but not with hemodynamic changes.n Conclusion: LpA may be the most suitable method for removing functioning adrenal tumors.

Total bilateral laparoscopic adrenalectomy in patients with Cushing's syndrome and multiple endocrine neoplasia (IIa)

AbstractBackground: The benefit of simultaneous bilateral laparoscopic adrenalectomy in patients with Cushings syndrome and pheochromocytoma associated with multiple endocrine neoplasia (MEN) is unknown.nnMethods: Ten patients underwent laparoscopic adrenalectomy (LpA) with CO2 pneumoperitoneum for Cushings syndrome. One MEN patient underwent simultaneous bilateral laparoscopic adrenalectomy with helium pneumoperitoneum for bilateral pheochromocytoma. A comparison was made between unilateral LpA and simultaneous bilateral laparoscopic adrenalectomy in patients with Cushings syndrome. Plasma catecholamines were correlated with hemodynamic changes in the patient with pheochromocytoma.nnResults: Simultaneous bilateral laparoscopic adrenalectomy in the patient with pheochromocytoma lasted 330 min. The substantial increase in plasma catecholamines was not associated with cardiovascular instability. Operative time (270 ± 3 vs 120 ± 4 min), blood loss (365 ± 1 vs 210 ± 1 ml), hospital stay (7.6 ± 1.5 vs 4.6 ± 1 days), and normal activity (19.3 ± 2 vs 10.4 ± 4.4 days) were, in patients with Cushings syndrome, significantly (p < 0.05) higher after simultaneous bilateral laparoscopic adrenalectomy than after unilateral LpA; the differences were not significant in the analgesic requirements (7.6 ± 1 vs 4.6 ± 1 doses). One patient with unilateral LpA was converted to open surgery.nnConclusion: Simultaneous bilateral laparoscopic adrenalectomy is safe, and associated with short hospital stay and lessening of the time needed to achieve normal activity.n

Unusual intraoperative complication in laparoscopic sigmoidectomy

Abstract. The authors report a case of complete rotation of the left colon after laparoscopic sigmoidectomy. Such an uncommon complication in open colectomies has not been previously described with the laparoscopic approach. During the performance of laparoscopic-assisted colectomies the proximal segment of the colon can be rotated when removing the specimen through a small incision. Therefore we recommend inspecting the position of the colon before the stapler is fired.