Tomasz Wołoszko

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.

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).

Adrenal cysts – optimal laparoscopic treatment

Introduction Adrenal cysts develop in up to about 0.2% of the overall population. They may account for up to 11% of all pathologies of adrenal glands. Aim Is laparoscopic resection of adrenal cysts a method for the treatment of these pathologies? Material and methods In the years 2010–2017, a total of 27 patients underwent surgery due to adrenal cysts; those included 18 (66.7%) women and 9 (33.3%) men aged 29 to 84 years (mean age: 42.7). Cyst diameter ranged from 55 to 130 mm. After exclusion of hormonal hyperactivity, parasitic cysts, or, to the best possible extent, cancer lesions, patients were qualified for adrenal-sparing laparoscopic surgery. Results All patients were subjected to laparoscopic surgery. Cystic wall resection was performed in 15 (55.6%) patients while adrenalectomy was performed in the remaining 12 (44.4%) patients. The decision regarding the extent of the surgery was made intraoperatively. Histopathological assessment revealed pathological adrenal lesions in as few as 3 (11.1%) patients, with the rest of the study population, i.e. 24 (88.9%), presenting with normal adrenal tissue. Conclusions Laparoscopic resection of adrenal cysts appears to be recommendable as a method for the treatment of these pathologies. It is simpler than adrenalectomy and associated with low risk of any pathological lesion remaining within the adrenal gland following careful intraoperative assessment by an experienced surgeon.

Adrenal incidentaloma – diagnostic and treating problem – own experience

Abstract Introduction Incidentaloma is defined as an tumor diagnosed accidentally using imaging studies performed due to other indications. The aim of this paper was to describe the diagnostic and treatment problems experienced by patients with adrenal incidentaloma in a clinical practice. Material and methods In years 2009-2012 there were 33(16,5%) adrenal tumors diagnosed incidentally out of 200 cases treated due to adrenal pathology. The group consisted of 54 patients aged 27-77. In 15(45,5%) patients the diagnosis was made based on ultrasound examination, while in 18(54,5%) the tumor was visualized in CT/MRI. Results Only after the diagnostics was finalized, in which in all cases no signs of hormonal activity were detected, 26(78,8%) patients were qualified for the surgery. In 7(21,2%) cases no indications for such a management were found. The latter group was followed-up and in all patients the indications for the surgery arose due to enlargement of the tumor or/and the existence of hormonal activity. Our observations suggest that the incident finding of adrenal tumor is an indication of long-term observation. The analysis of our material shows that all patients observed needed surgical treatment. Conclusions The small adrenal tumors under follow-up have a tendency to enlarge and acquire hormonal activity. Long-term observation significantly increases the costs of treatment in that group, which eventually results in surgical management.

Effectiveness of unilateral laparoscopic adrenalectomy in ACTH-independent hypercortisolaemia and subclinical Cushing’s syndrome — a retrospective study on a large cohort

INTRODUCTION To assess the effectiveness of early unilateral laparoscopic adrenalectomy in ACTH-independent and subclinical hypercor-tisolaemia. MATERIAL AND METHODS We conducted a unicentric, retrospective study. Between 2010 and 2015, 356 laparoscopic adrenalectomies were performed in the Department of General and Endocrine Surgery of the MUW. Hypercortisolaemia was found in 50 (14%) patients, while overt hypercortisolaemia was found in 31 patients. In the hypercortisolaemia group, ACTH-dependent hypercortisolaemia was diagnosed in five (10%) and ACTH-independent hypercortisolaemia in 25 patients (50%). One patient with overt hypercortisolaemia had cancer of the adrenal cortex. The remaining 19 (38%) patients had subclinical Cushings syndrome. For our study, we compared patients with ACTH-independent hypercortisolaemia (n = 25) with those with Cushings syndrome (n = 19). Patients with ACTH-dependent hyper-cortisolaemia (n = 5) and the patient with cancer of the adrenal cortex (n = 1) were excluded. RESULTS Patients from both groups (n = 44) underwent a unilateral transperitoneal adrenalectomy. Good early outcomes were observed in 42 patients (93.3%). In one patient, an additional laparoscopic surgery was necessary on postoperative day 0 due to bleeding. In another patient, on day 22 post-surgery, we found an abscess in the site of the excised adrenal gland, which was drained under laparoscopic guid-ance. In three patients (6.8%) with substantial obesity, temporary respiratory insufficiency of varying degrees occurred. We did not observe any thromboembolic complications. All patients with overt hypercortisolaemia and nine patients with subclinical hypercortisolaemia had secondary adrenal insufficiency postoperatively. CONCLUSIONS Transperitoneal unilateral laparoscopic adrenalectomy is an efficient and safe treatment option in patients with ACTH- -independent hypercortisolaemia, both overt and subclinical.

Intravascular treatment of left subclavian artery aneurysm coexisting with aortic coarctation in an adult patient

Abstract Coexistence of aortic coarctation with aneurysm of subclavian artery is a uncommon situation and may require unusual treatment in patients. A 40-year-old patient diagnosed incidentally with left subclavian artery aneurysm coexisting with aortic coarctation. Patient was initially referred for hybrid treatment. Initially ostium of the left subclavian artery was covered with a stent-graft. Over a 30-month follow-up period aneurysm became thrombosed all the way up to the ostium of internal mammary artery. The patient did not present with neurological symptoms or signs of upper limb ischemia. Taking into consideration good blood supply to the axillary artery via reversed blood flow in the thyreocervical trunk, hence we decided not to proceed with cervicoaxillary bypass grafting. Implantation stent-graft into aorta coarctation with covering axillary artery is proper way of treatment and may need no other surgical procedures.

The usefulness of laparoscopic adrenalectomy in the treatment of adrenal neoplasms — a single-centre experience

INTRODUCTION Adrenal neoplasms comprise about 10% of all tumours affecting this organ and constitute a significant, at first diagnostic and subsequently therapeutic, problem, especially since a relatively high proportion of neoplastic lesions are asymptomatic. The number of diagnosed metastases to adrenal glands is increasing. Surgical treatment involves both open surgery as well as laparoscopy. MATERIAL AND METHODS There were 245 adrenalectomies performed at our centre due to various indications over the past four years. In 27 (11.5%) cases neoplasms were diagnosed in the final histopahtological examination. In 11 (40.7%) cases primary adrenal cortex tumours were diagnosed, metastases from other solid organ tumours were identified in another 12 (44.4%) patients, and rarer neoplasms were diagnosed in the remaning 4 (14.8%) subjects. Cases of malignant pheochromocytoma were not included in this report. RESULTS Laparoscopic adrenalectomy was performed in 23 (85.2%) subjects, while the ramaining 4 (12.9%) patients were subject to open adrenalectomy (conversion to open procedure in one case). There were no deaths or significant complications in the perioperative period. Comparing mean duration of open (140 minutes) and laparoscopic (190 minutes) procedures yielded a statistically significant difference (p = 0.02). There was no statistically significant difference found in the duration of operation with regard to laparoscopic adrenalectomies of tumours less than 50 mm and over 55 mm in diameter (p = 0.16). CONCLUSIONS Laparoscopic adrenalectomy is a safe and effective method of treatment of adrenal tumours. Its oncological completeness is comparable (to open surgery) when performed by experienced surgical teams. Laparoscopy is the reason for the smooth postoperative course observed in most patients.