Protocol for presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas: a multidisciplinary approach.

OBJECTIVE: To offer a practical guide for the presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas (PGLs). METHODS: This protocol was based on a comprehensive review of the literature and on our own multidisciplinary team's experience from managing pheochromocytoma and sympathetic PGLs at a referral center. RESULTS: Patients with pheochromocytomas and sympathetic paragangliomas (PGLs) may develop potentially life-threatening complications, especially during surgical procedures. A complete biochemical, radiological, genetic, and cardiological assessment is recommended in the preoperative stage as it provides an evaluation of the risk of surgical complications and malignancy, allowing individualization of the presurgical treatment. Treatment with α-blockade and proper volume expansion in the preoperative stage significantly reduces the perioperative morbidity. During surgery, the anesthesiologist should look for a deep anesthetic level that inhibits the cardiovascular effects of catecholamines to minimize the risk of intraoperative complications. CONCLUSIONS: An optimal presurgical evaluation of pheochromocytomas/ sympathetic PGL requires a multidisciplinary approach, including a complete hormonal, radiological, cardiac, genetic, and functioning evaluation in most cases. A proper preoperative evaluation in combination with strict blood pressure and heart rate control, and blood volume status optimization, will significantly reduce the risk of intraoperative and perioperative complications. In those patients who unfortunately develop intraoperative complications, the role of the anesthesiologist is essential since the selection of the appropriate management has a direct impact on morbimortality reduction.

Atypical carcinoid tumours of the lung: prognostic factors and patterns of recurrence.

BACKGROUND: Atypical carcinoids (AC) of the lung are rare intermediate-grade neuroendocrine neoplasms. Prognostic factors for these tumours are undefined. METHODS: Our cooperative group retrieved data on 127 patients operated between 1980 and 2009 because of an AC. Several clinical and pathological features were studied. RESULTS: In a univariable analysis, T-status (p=0.005), N-status (p=0.021), preoperative M-status (previously treated) (p=0.04), and distant recurrence developed during the outcome (p<0.001) presented statistically significant differences related to survival of these patients. In a multivariable analysis, only distant recurrence was demonstrated to be an independent risk factor for survival (p<0.001; HR: 13.1). During the monitoring, 25.2% of the patients presented some kind of recurrence. When we studied recurrence factors in a univariable manner, sublobar resections presented significant relationship with locoregional recurrence (p<0.001). In the case of distant recurrence, T and N status presented significant differences. Patients with preoperative M1 status presented higher frequencies of locoregional and distant recurrence (p=0.004 and p<0.001, respectively). In a multivariable analysis, sublobar resection was an independent prognostic factor to predict locoregional recurrence (p=0.002; HR: 18.1). CONCLUSIONS: Complete standard surgical resection with radical lymphadenectomy is essential for AC. Sublobar resections are related to locoregional recurrence, so they should be avoided except for carefully selected patients. Nodal status is an important prognostic factor to predict survival and recurrence. Distant recurrence is related to poor outcome.

[Necrotizing descendent mediastinitis of oropharyngeal origin]. / Mediastinitis descendente necrosante de origen orofaríngeo.

The spread of oropharyngeal infections to the mediastinum can give rise to descending necrotizing mediastinitis (DNM), which causes a high rate of mortality (around 40%), particularly when diagnosis is late and drainage inadequate. In the first case we report, successful drainage of the mediastinum was achieved at the cervical and sub-xiphisternum levels and by thoracotomy. Given the condition of the second patient, transcervical drainage alone was considered the best option, but this treatment was inadequate. Rapid start of appropriate drainage of the mediastinum is of great importance. Cervical drains, which may be adequate when there is perforation of the cervical esophagus, is insufficient in DNM, which calls for more aggressive, early drainage, such as can be achieved by thoracotomy. Computerized axial tomography of the chest is essential for rapid diagnosis, to plan the most appropriate surgical approach and for follow-up and evaluation of drainage.

[Short and long term follow-up of spontaneous pneumothorax treated using video-thoracoscopy]. / Seguimiento a corto y largo plazo del neumotórax espontáneo tratado por videotoracoscopia.

The outcome of video-assisted thoracoscopic treatment of spontaneous pneumothorax was analyzed. Eighty-three procedures were performed in 79 patients (58 men, 21 women: mean age 28.3 years, range 16 to 76 years). The reasons for intervention were recurring pneumothorax in 53 patients, contralateral pneumothorax in 10 (one of whom was treated on both sides), bilateral involvement in 3, and persistent air leakage in 13. Seven patients (8.4%) also required open thoracotomy. In 72 (88%) of the remaining 76 procedures, only video thoracoscopy was used. Three patients (3.6%) underwent video-assisted thoracotomy. Mean postoperative hospital stay was 5.1 days (2 to 24 days). No related deaths occurred but surgical complications were reported for 3 (3.9%). Significant postoperative complications developed in 9 cases (11.8%). One patient with prolonged air leakage underwent a second procedure, video-assisted thoracotomy, 12 days after the first intervention. Seventy-one of the 72 patients received follow-up examinations, with a mean follow-up period of 28.1 months (range 54 days to 54 months). Three recurrences (3.9%) were recorded but there were no cases of chronic pain requiring analgesia. We conclude that video thoracoscopy is an effective approach, with the advantage of being minimally invasive. We therefore believe it should be the procedure of choice, once improved morbidity and recurrence rates are observed, as these factors are influenced by the learning curve.

[Granular cell myoblastoma localized in the thoracic wall]. / Mioblastoma de células granulosas localizado en la pared torácica.

We report the case or a 40-year-old man with a large right parasternal tumor. Computerized tomography (CT) and magnetic resonance (MR) imaging showed a soft tissue mass infiltrating contiguous structures with no sign of adenopathy and with disease limited the chest wall. The histological type was granular cell tumor (GCT) with discrete cell pleomorphism and nuclei that varied in form and size, with prominent nucleoli. Eighteen months after surgery, the patient was asymptomatic and disease free. GCT is a rare entity that is uncommonly found on the chest wall. A diagnosis of malignancy is established when metastasis is found to be of the same histological type as that of the primitive tumor. Neither cell pleomorphism or nuclei with nucleoli allows for a diagnosis of malignancy; only a size greater than 5 cm and locally invasive behavior should lead to an assumption that these tumors are of unspecified malignancy. We believe the treatment of choice for these lesions is radical removal

[Thymectomy in myasthenia gravis]. / Timectomía en la miastenia gravis.

OBJECTIVE: To analyze outcome after thymectomy in patients with myasthenia gravis (MG). MATERIAL AND METHODS: Thirty-five patients with MG underwent surgery in our service between June 1987 and June 1998. Ten had associated thymomas. Preoperative Osserman classification showed 2 at level I, 20 at level IIA, 11 at level IIB and 2 at level III. Extended thymectomy through a medial sternotomy was performed in all. RESULTS: Postoperative complications developed in three patients (1 medullary aplasia, 1 postoperative reintubation, 1 myasthenic crisis). Mean follow-up was 89 months, with 22.8% achieving complete remission and 97.1% reporting improvements. The results were similar in the 10 patients with thymomas (20% full remission and 90% showing improvement). By DeFilippi classification, 22.8% were in class 1, 22.8% in class 2, 51.4% in class 3 and 2.8% in class 4. By Osserman classification, 9 were in the same category before and after surgery, 12 had improved one level, 10 had improved 2 levels, 3 had improved 3 levels and 1 patient had improved 4 levels. CONCLUSION: Thymectomy is an appropriate therapeutic procedure in the multidisciplinary treatment of patients with MG and it is the approach of choice for patients with associated thymomas. The intra- and post-operative complication rate is low and the rate of clinical improvement is high.

[Severe hypoglycemia secondary to a fibrous pleural tumor]. / Hipoglucemias severas secundarias a tumor fibroso pleural.

A case with recurrent hypoglycemias following a thoracic tumor is presented. Neurologic symptoms due to hypoglycemia were dominant. Subcutaneous somatostatin was administrated preoperatively and hypoglycemia was controlled following tumor resection. Histology analysis shows a localized fibrous pleural tumor. Origin has been widely questioned but now it is accepted to be mesenchymal and not mesothelial. Lung disease owing to chronic compression of the tumor made necessary a lobectomy. Postoperative atelectasis required reoperation and a pneumonectomy was performed. To date insulin-like factors secreted by the tumor are supposed to be responsible for hypoglycemics discharges.