International multicentre review of perioperative management and outcome for catecholamine-producing tumours.

BACKGROUND: Surgery for catecholamine-producing tumours can be complicated by intraoperative and postoperative haemodynamic instability. Several perioperative management strategies have emerged but none has been evaluated in randomized trials. To assess this issue, contemporary perioperative management and outcome data from 21 centres were collected. METHODS: Twenty-one centres contributed outcome data from patients who had surgery for phaeochromocytoma and paraganglioma between 2000 and 2017. The data included the number of patients with and without α-receptor blockade, surgical and anaesthetic techniques, complications and perioperative mortality. RESULTS: Across all centres, data were reported on 1860 patients with phaeochromocytoma or paraganglioma, of whom 343 underwent surgery without α-receptor blockade. The majority of operations (78·9 per cent) were performed using minimally invasive techniques, including 16·1 per cent adrenal cortex-sparing procedures. The cardiovascular complication rate was 5·0 per cent overall: 5·9 per cent (90 of 1517) in patients with preoperative α-receptor blockade and 0·9 per cent (3 of 343) among patients without α-receptor blockade. The mortality rate was 0·5 per cent overall (9 of 1860): 0·5 per cent (8 of 517) in pretreated and 0·3 per cent (1 of 343) in non-pretreated patients. CONCLUSION: There is substantial variability in the perioperative management of catecholamine-producing tumours, yet the overall complication rate is low. Further studies are needed to better define the optimal management approach, and reappraisal of international perioperative guidelines appears desirable.

ANTECEDENTES: La cirugía de los tumores productores de catecolaminas puede complicarse por la inestabilidad hemodinámica intraoperatoria y postoperatoria. Se han propuesto distintas estrategias de manejo perioperatorio, pero ninguna ha sido evaluada en ensayos aleatorizados. Para evaluar este tema, se han recogido los datos de los resultados y del manejo perioperatorio contemporáneo de 21 centros. MÉTODOS: Veintiún centros aportaron datos de los resultados de los pacientes operados por feocromocitoma y paraganglioma entre 2000-2017. Los datos incluyeron el número de pacientes con y sin bloqueo del receptor α, las técnicas quirúrgicas y anestésicas, las complicaciones y la mortalidad perioperatoria. RESULTADOS: Los centros en su conjunto aportaron datos de 1.860 pacientes con feocromocitoma y paraganglioma, de los cuales 343 pacientes fueron intervenidos sin bloqueo del receptor α. La gran mayoría (79%) de las cirugías se realizaron utilizando técnicas mínimamente invasivas, incluido un 17% de procedimientos con preservación de la corteza suprarrenal. La tasa de complicaciones cardiovasculares fue de 5,0% en total; 5,9% (90/1517) en pacientes con bloqueo preoperatorio de los receptores α y 0,9% (3/343) en pacientes no pretratados. La mortalidad global fue del 0,5% (9/1860); 0,5% (8/1517) en pacientes pretratados y 0,3% (1/343) en pacientes no tratados previamente. CONCLUSIÓN: Existe una variabilidad sustancial en el manejo perioperatorio de los tumores productores de catecolaminas, aunque la tasa global de complicaciones es baja. Este estudio brinda la oportunidad para efectuar comparaciones sistemáticas entre estrategias de prácticas terapéuticas variables. Se necesitan más estudios para definir mejor el enfoque de manejo óptimo y parece conveniente volver a evaluar las guías internacionales perioperatorias.

[Management of anesthesia in endovascular interventions]. / Anästhesiologisches Management bei endovaskulären Gefäßeingriffen.

Cardiovascular diseases are one of the leading causes of morbidity and mortality in Germany. In these patients, the high-risk profile necessitates an interdisciplinary and multimodal approach to treatment. Endovascular interventions and vascular surgery have become established as an important element of this strategy in the past; however, the different anatomical localizations of pathological vascular alterations make it necessary to use a wide spectrum of procedural options and methods; therefore, the requirements for management of anesthesia are variable and necessitate a differentiated approach. Endovascular procedures can be carried out with the patient under general or regional anesthesia (RA); however, in the currently available literature there is no evidence for an advantage of RA over general anesthesia regarding morbidity and mortality, although a reduction in pulmonary complications could be found for some endovascular interventions. Epidural and spinal RA procedures should be carefully considered with respect to the risk-benefit ratio and consideration of the recent guidelines on anesthesia against the background of the current study situation and the regular use of therapy with anticoagulants. The following article elucidates the specific characteristics of anesthesia management as exemplified by some selected endovascular interventions.

Isolated aneurysm of the internal jugular vein.

True venous aneurysms are rare. We report the case of a 70-year-old male with the extremely uncommon finding of an aneurysm of the internal jugular vein. Due to their rarity, no general guidelines for the treatment of these aneurysms have been established. Upon surgical exclusion of the aneurysm, a progressive swelling of the right side of the face was noted in this patient leading to the decision to interpose a thin-walled ePTFE prosthesis for want of a suitable vein graft. Upon follow-up three years later, the patient is completely asymptomatic and the prosthesis is patent in Doppler sonography.

[Anesthesia for carotid artery surgery. Is there a gold standard?]. / Anästhesie zur Karotischirurgie. Gibt es einen Goldstandard?

Carotid endarterectomy (CEA) has remained the first choice of treatment in preventing ischemic stroke due to symptomatic stenosis of the internal carotid artery despite other new available options. During CEA patients are first and foremost at risk of cerebral as well as myocardial ischemia, therefore, maintenance of the oxygen supply to the brain and the myocardium is of outstanding importance requiring reliable monitoring of cerebral and cardiac function. The regional versus general anesthesia debate is an age-old one that has brought few definite answers regarding the impact on postoperative outcome of either anesthetic technique. Up to now, there is little evidence from only a few randomized clinical trials to demonstrate the superiority of either anesthetic technique with respect to outcome parameters. Because the level of evidence in favor of regional anesthesia during CEA can at least be rated between 1(-) and 2(+) the resulting recommendation is grade C. The purpose of the review is to highlight the characteristics and goals of anesthetic management during CEA.

Spatial pulmonary flow distribution in rabbit isolated lungs is a poor representation of the situation in vivo.

1. Isolated lung preparations are established to investigate effects on pulmonary vascular tone and spatial pulmonary flow (Q (rel)) distribution. In the present study, we hypothesized that Q (rel) distribution in isolated lungs is only poorly correlated with the in vivo situation. 2. Fourteen rabbits were anaesthetized and mechanically ventilated with room air. Animals were held in an upright position for 15 min and Q (rel) was assessed using fluorescent microspheres (Q (rel-in vivo)). A second injection of microspheres was made after isolation of the lungs (Q (rel-ex vivo)). Lungs were dried, cut into 1 cm(3) cubes and spatial Q (rel) distributions were analysed. 3. The mean correlation of Q (rel-in vivo) and Q (rel-ex vivo) was 0.592 +/- 0.188 (95% confidence interval 0.493-0.690). The Q (rel) was redistributed to more ventral (the mean slope of Q (rel) vs the dorsal-ventral axis changed from -0.289 +/- 0.227 to -0.147 +/- 0.114; P = 0.03), cranial (mean slope of Q (rel) vs the caudal-cranial axis changed from -0.386 +/- 0.193 to -0.176 +/- 0.142; P < 0.001) and central (mean slope of Q (rel) vs the hilus-peripheral axis changed from 0.436 +/- 0.133 to -0.236 +/- 0.159; P = 0.003) lung areas. 4. The results obtained from studies investigating Q (rel) distributions in isolated lung models must be interpreted cautiously because the isolated lung set-up significantly affects the spatial distribution of pulmonary flow.

Impact of n-3 fatty acid supplemented parenteral nutrition on haemostasis patterns after major abdominal surgery.

In various diseases n-3 fatty acids exert anti-inflammatory properties. These effects seem to be related to the uptake and incorporation of eicosapentaenoic acid (EPA) into the cellular substrate pool after dietary intake of EPA, which is contained in fish oils (FO). In the state of inflammation EPA is released to compete with arachidonic acid (AA) for metabolism at the cyclo-oxygenase and the 5-lipoxygenase level. The metabolites of EPA have less inflammatory and chemotactic potency than the substances derived from AA. In addition to positive effects, early studies pointed towards prolonged bleeding times after dietary intake of n-3 fatty acids. This study was undertaken to address the issue of potential coagulation disturbances associated with postoperative parenteral FO administration. This was a prospective, randomised, double blinded clinical trial, carried out in two operative intensive care units (13 and 16 beds) in a university hospital. Forty-four patients undergoing elective major abdominal surgery participated in the trial. Patients were randomly assigned to receive total parenteral nutrition (TPN) supplemented with either soybean oil (SO, Lipovenoess 10% PLR; 1.0 g/kgBW per day; n = 20) for five days or with a combination of FO and SO (FO, Omegaven; 0.2 g/kgBW per day plus SO, Lipovenoes 10% PLR; 0.8 g/kgBW per day, n = 24), respectively. Blood samples were taken preoperatively (day -1), prior to (day 1) during (days 2-5) and after TPN (day 6). The coagulation parameters thromboplastin time (Quick), activated partial thromboplastin time (aPTT), fibrinogen and antithrombin III were measured. To differentially assess activation levels of extrinsic and intrinsic coagulation pathway, factors VIIa and XIIa were quantified. Moreover platelet function was determined by resonance thrombography. Baseline values of coagulation and platelet function were comparable in both groups, but coagulation activity dropped after surgery. Over the observation period of 6 days, however, physiological levels were regained. No clinically significant differences were observed between the SO- and SO + FO- group. These findings suggest that infusion of fish oil in doses up to 0.2 g/kgBW per day is safe regarding coagulation and platelet function.

Gemelar monoamniotico: una rareza

Se presenta un caso clínico de gestación gemelar monocorial, monoamniótica, la resolución del parto y breve revisión bibliográfica.

Espatulas de thierry versus forceps de kjelland

Presentamos la experiencia y evolución del parto instrumentado en nuestro Servicio de Obstetricia y Ginecología, en los últimos once años 1992-2002. La evidencia demostró que respecto de las lesiones maternas y fetales, las Espátulas (ET), o instrumento no articulado de la clasificación general de los fórceps (F), son significativamente menores cuando se las compara con el fórceps articulado y fenestrado de Kjelland o Kielland (FK), por lo que se sugiere su conocimiento y adiestramiento en los Servicios de la especialidad, y cambiar el concepto de la presa del cráneo-fetal o biparieto malar por la toma libre facio malar.

¿Es la tricotomía necesaria en la práctica neuroquirúrgica habitual?: experiencia preliminar del Hospital Dr. Sótero del Río, Santiago - Chile / Is the tricotomy needed in the usual neurosurgical practice?: preliminary experience of Hospital Dr. Sótero del Río, Santiago - Chile

El corte del cabello en la preparación del paciente es frecuentemente usado en la mayorìa de los centros neuroquirúrgicos de Chile. Los fundamentos que lo avalan son el arraigo cultural, en la creencia de muchos neurocirujanos, que una herida limpia es una herida sin pelos, más que en el rigor cientìfico y en la medicina basada en la evidencia. Apoyados en que no existe un consenso en nuestro servicio respecto a este tema, es que pudimos tener dos grupos de pacientes y realizar un estudio prospectivo a contar del mes de Enero del año 2006. Se consideraron los primeros 25 pacientes de cada equipo para el trabajo. Concluimos que, pese a que la técnica no es aceptada por todos, no existe un mayor riesgo de infección de herida operatoria en aquellos sin corte de cabello respecto de aquellos tricotomizados y si una mejor calidad para el paciente en el postoperatorio y mayor aceptación del tratamiento quirúrgico. Sin embargo nuestro universo de pacientes aún es demasiado pequeño para tener conclusiones definitivas por lo que se presenta sólo como un trabajo preliminar. Describimos la técnica en el manejo de la herida operatoria sin corte de cabello, sus ventajas y desventajas.

Hair removal in elective cranial surgery is frequently used in most neurosurgical centers in Chile. The main reason of this procedure is the general belief that a wound is clean when it has no hair on it rather than a decision taken on the evidence based medicine. In our department there was not a single view on this issue so it was possible to make two groups of patients, one with hair removal and another one without it, and start prospective study from January 2006. For this report were included the first 25 patients of each group. We conclude that even though the tecnique is not worldwide accepted, there is no more risk of wound infection in the group without hair removal than in the other. However our sample is still samll to obtain definitive conclusions, so we present this as a preliminary report. The technique of wound management without hair removal is described.

Lipomas del ángulo pontocerebeloso: caso clínico y revisión de la literatura / Cerebellopontine angle lipoma: case report and review of the literature

Los lipomas del ángulo pontocerebeloso son tumores extremadamente raros, se describe un caso clínico y se realiza una revisión bibliográfica dando énfasis a su diagnóstico y tratamiento.

Lipomas of the cerebellopontine angle are extremely rare tumors, we described a case report and review of the literature with emphasis on management and diagnostic.