Ryszard Pogorzelski

Laparoscopic treatment of Cushing’s syndrome in a woman in late pregnancy – a case presentation

Hypercortisolaemia during pregnancy constitutes a serious threat to life of the mother and fetus and may be associated with adrenocortical carcinoma. The objective of this study is to present the usefulness of laparoscopic procedures in treating adrenal tumours in such cases. One 21-year-old woman, 24 weeks pregnant, with hypertension and Cushings syndrome due to a left adrenal tumour, underwent laparoscopic adrenalectomy followed by hydrocortisone replacement. Spontaneous delivery occurred at the 37/38th week of gestation. At 3 months postpartum the function of the remaining adrenal gland was found to be normal. Similarly, imaging tests, abdominal CT scan and chest X-ray revealed no abnormalities. Pregnancy is not a contraindication for performing complicated laparoscopic procedures unless they are planned in advance and done by an experienced team.

The effect of surgical treatment of phaeochromocytoma on concomitant arterial hypertension and diabetes mellitus in a single–centre retrospective study

Introduction Phaeochromocytoma is one of the numerous causes of secondary hypertension. Furthermore, phaeochromocytoma may first present with type 2 diabetes mellitus. The objective of our study was to evaluate the effects of adrenalectomy on patient recovery with regards to normotension and well–controlled glycaemia. Material and methods The retrospective analysis involved 67 patients with phaeochromocytoma operated between 2006 and mid-2012. The pre–operative diagnoses were made in the departments of internal medicine and endocrinology. Based on laboratory tests and diagnostic imaging, we were able to confirm the diagnosis of phaeochromocytoma in 42 (62.7%) patients. We verified the influence of adrenalectomy on the level of patient recovery, with regards to normotension and glycaemic control: arterial pressure and fasting glycaemia levels were obtained on the day of hospital discharge, at follow–up 3 months post–operatively and 1 year after surgical intervention. Results Of the 67 patients operated for phaeochromocytoma, 48 (71.6%) were treated laparoscopically, whereas 19 (28.4%) underwent open adrenalectomy. Arterial hypertension was recorded in 53 (79.1%) cases. Furthermore, among this group, diabetes mellitus coexisted in 21 (31.3%) cases. Postoperatively, 70% of cases of arterial hypertension and 90% of type 2 diabetes mellitus were cured. Additionally, a high rate of patients reported a quantitative reduced use of antihypertensive medicines. Conclusions In the majority of patients, surgical treatment of symptomatic phaeochromocytoma leads to a regression of arterial hypertension, or a reduction of the number or doses of medicines taken in ones treatment, and glucose–intolerance symptoms.

Is tumour size a contraindication to laparoscopic adrenalectomy? Case report

The authors present a case report of a patient with a large, hormonally silent tumour of the right adrenal gland. Due to the patients numerous strains, the necessity of two gynaecological operations, and treatment of broken bones, adrenalectomy was contraindicated for 2 years. After that time, the size of the tumour reached 18 cm × 12 cm. The patient was selected for laparoscopic adrenalectomy, which was successful. The size of the tumour and performed abdominal surgery did not constitute substantial obstacles, and the less invasive procedure was additionally justified by computed tomography and magnetic resonance imaging results, which demonstrated a benign lesion.

Anastomotic aneurysms- 20-years of experience from one center

UNLABELLED Anastomotic aneurysms may develop after any type of vascular surgery, in different areas of the arterial system, and require reoperation. The frequency of occurrence of the above-mentioned is estimated at 1-5%. MATERIAL AND METHODS During the period between 1989 and 2010, 180 patients with 230 anastomotic aneurysms were subject to surgical intervention at the Department of General and Thoracic Surgery, Warsaw Medical University. The study group comprised 21 (11.7%) female and 159 (88.3%) male patients, aged between 30 and 87 years (mean age - 62.8 years). In relation to the number of anastomoses aneurysms were diagnosed in 2.1% of cases. Twenty-four (10.4%) patients were diagnosed with recurrent aneurysms. RESULTS Surgical procedures performed were as follows: artificial prosthesis implantation (119), reanastomosis (40), patch plasty (25), graftectomy (19), prosthesis replacement (9), and stent-graft (7) implantation. 195 (84.8%) aneurysms were subject to planned surgery, while 35 (15.2%) required emergency intervention. 77.8% of patients were diagnosed with aseptic aneurysms, while the remaining 22.2% with infected perioperative aneurysms. Good treatment results were obtained in 149 (82.8%) patients. Limb amputations were performed in 19 (10.5%) cases. Twelve (6.7%) patients died as a consequence of infection and general complications. CONCLUSIONS Vascular reoperations are a difficult clinical problem and are burdened with a high rate of complications. The above-mentioned often require complex treatment, in order to improve therapeutic results.

A spontaneous paraganglioma-pheochromocytoma syndrome

We present a case of a 40–year old woman diagnosed with a four–place spontaneous paraganglioma–pheochromocytoma syndrome, which was treated surgically. The presence of the succinate dehydrogenase complex subunit D (SDHD) mutation that causes the pheochromocytoma was confirmed but no mutations in the family members were found. After the excision of the paragangliomas located in the areas of the division of carotid arteries, and mediastinum, as well as a tumor on the left site of the celiac trunk, the patient remains asymptomatic and is regularly followed–up.

Long-term results of endovascular treatment for May-Thurner syndrome

May-Thurner syndrome is a rare condition caused by compression of the left common iliac vein (LCIV) by the overlying right common iliac artery. This syndrome was shown to occur most frequently between the second and fourth decade of life, more often in women, with a prevalence of 2–5% in the general population. The syndrome was first described by R. May and J. Thurner in 1957. Compression of the LCIV causes disability of blood outflow from the left lower extremity, which results in unilateral LCIV thrombosis, chronic venous insufficiency, and the creation of multiple collaterals crossing the pelvis. Seven women, aged from 22 to 60 (mean 38) years were operated in our Department, and the consecutive mean follow-up period was 25.7 (12–36) months. In the preoperative period, in four cases a critical stenosis of LCIV (from 2 to 3 mm) was diagnosed, while in three other patients the stenosis was accompanied by a distal iliac vein thrombosis. In all cases endovascular therapy was performed. Access to the left common femoral vein or popliteal vein — in the case of iliac deep vein thrombosis — was achieved. After initial predilatation and catheter-based aspiration (in patients with iliac vein thrombosis), intravenous stent placement was performed. For this procedure four Veniti, two Zilver Vena, and one Sinus Venous stent/s (14–18 mm × 60–140 mm) was/were used. Three months after stent implantation duplex Doppler ultrasound revealed stent stenosis in the proximal part of LCIV in three patients. In all those cases re-interventions were conducted. Because of the poor radial strength of previously implanted stents, which was insufficient to compensate for the compression by LCIV, additionally 12–20-mm diameter Wallstents were used. This allowed restoration of blood through LCIV in further observations. Directly after the angioplasty procedure, all patients were given clopidogrel 1 × 75 mg and rivaroxaban (initially 2 × 15 mg, thereafter 1 × 20 mg). Such therapy was advocated for six months, and after that period only antiplatelet drugs were used. The follow-up ultrasound examination, to evaluate stent patency, was performed after three months and subsequently every six months. In four cases angio-computed tomography examinations were done from 18 to 24 months after angioplasty, which confirmed the patency of all implanted stents and good blood flow (Figs. 1–3). Endovascular therapy should be considered as a good method of treatment for May-Thurner syndrome, which prevents severe disablement in the patient — left leg chronic venous insufficiency with all its consequences. In addition, the development of collateral circulation may lead to pelvic congestion syndrome, which should be treated as well. We observed such a necessity in one patient after left iliac vein recanalisation, in whom wide pelvic veins were closed by embolisation coils during endovascular procedure.

Influence of Selective Biochemical and Morphological Agents on Natural History of Aneurysm of Abdominal Aorta Development.

Background The development of abdominal aortic aneurysm (AAA) is probably influenced by many factors. The role of some of these factors, such as intraluminal thrombus (ILT) or cystatin C serum levels, remains controversial. Proving their influence could have therapeutic implications for some patients with AAA. Associations between the rate of increase in diameter of an aneurysm and ILT, as well as other factors, including biochemical factors (C-Reactive Protein – CRP, cystatin C), age, sex, and comorbidities, could predict disease progression in individual patients. Material/Methods Seventy patients with small AAA were included into the study. The patients were followed using ultrasound and CT imaging. We evaluated aneurysm dimensions and aneurysm wall thickness, as well as ILT and its dimensions, aneurysm wall morphology, CRP, and cystatin C. Results We observed significant growth of AAA and thinning of aneurysmal wall. Aneurysms over 4 cm grew significantly faster in the second year of observation. ILT grew together with AAA size. Age, sex, smoking, dyslipidemias, or controlled arterial hypertension had no influence on aneurysm progression rate. Changes in serum of CRP concentration did not reach statistical significance, but cystatin C levels did. Conclusions Presence and size of ILT, wall thickness, and cystatin C levels may be considered in prediction of AAA progression. ILT might exert a protective influence on the risk of aneurysm rupture. However, larger aneurysms containing larger thrombi grow faster and their walls undergo more rapid degradation, which in turn increases the risk of rupture. This matter requires further studies.

Location and Incidence Rate of Anastomotic Aneurysms – own Clinical Material and Literature Review

UNLABELLED Anastomotic aneurysms occurs at various levels of arterial system. Determining their location and incidence rate required investigation of large patient clinical material. MATERIAL AND METHODS In the years 1989-2010 in local centre 230 anastomotic aneurysms were operated in 180 patients. RESULTS For 187 (81.3%) patients anastomotic aneurysms were localised in the groin, while for remaining 43 (18.7%) they occurred in other localisations. In aortic arch branch they occurred four times (1.7), in descending aorta--three times (1.3%), in abdominal aorta--14 (6.1%) and in iliac arteries--6 (2.6%). While for anastomosis with popliteal artery they were diagnosed in 16 (7%) patients. Own clinical material was compared with literature data. CONCLUSIONS Anastomotic aneurysms in over 80% of cases occur in the groin, remaining percentage corresponds to other localisations.

Regressive changes in phaeochromocytomas and paroxysmal hypertension

IntroductionPheochromocytomas may cause life-threatening episodes of arterial hypertension and surgical treatment is obligatory following proper general medical preparation.Material and methodsThere were 63 patients in years 2006–2011 operated in the department due to pheochromocytoma. The group comprised 38 women and 25 men of the age range 16–80, mean 44,7. All the specimen were analyzed in pathological examination. The regressive changes that were found were subsequently compared with the clinical course of the pheochromocytoma both in the preoperative period and at the time of the surgery.ResultsThere were 44 laparoscopic adrenalectomies performed, out of which 5 resulted in conversions to open surgery, while 19 patients were operated primarily via open access. The indications for the open procedures: extraadrenal tumors, fibrotic-infiltrative lesions suggestive of malignancy, vast intratumoral extravasation, and respiratory failure. In all the postoperative specimens pheochromocytomas were found. In 29 cases intratumoral haemorrhages were observed, in 17 — tumoral necrosis at different stages, and in 3 cases posthaemorrhagic cystis. In 6 cases the lesions were accompanied by major fibrosis and hyalinization.ConclusionsThere is a statistically significant relationship between regressive changes observed within phaeochromocytomas and a reduction of paroxysmal hypertension at the time of adrenalectomy (p=0,012).

Laparoscopic adrenalectomy in a patient with situs inversus levocardia.

The article presents a case of an adrenal adenoma (Conns syndrome) in a 50-year-old man with situs inversus with levocardia. Laparoscopic adrenalectomy was performed and the patient made a full recovery. It has been concluded that diagnostic assessment by means of imaging techniques providing details of the organ anatomy and the experience of the medical team are the key factors determining the outcome of such surgery.