To block, or not to block is it still the question? Effectiveness of alpha- and beta-blockade in phaeochromocytoma surgery: an institutional analysis.

INTRODUCTION: Phaeochromocytomas/paraganglioma (PPGL) surgery was historically associated with significant risks of perioperative complications. The decreased mortality (<3.0%) had been attributed in part to optimal preoperative alpha-blockade. The value of alpha-blockade in decreasing morbidity is being challenged. The aim of our study is to present an institutional experience of preoperative alpha-blocking of PPGL and its effect on cardiovascular stability and postoperative morbidity. METHODS: A retrospective study using data from our institutional database was conducted. All patients undergoing adrenalectomy for PPGL from October 2011 to September 2020 were included. All patients were routinely alpha-blocked. Intraoperative cardiovascular instability (ICI) was assessed through number of systolic blood pressure (SBP) episodes >160mmHg, SBP <90mmHg, the need for vasoactive drugs and volume of intraoperative crystalloids administered. Morbidity was also evaluated. RESULTS: A total of 100 consecutive patients undergoing surgery were identified of whom 53 patients had complete anaesthetic records available for analysis. Thirty-two patients (60%) had at least one episode with an SBP >160mmHg. Nine (17%) cases had no intraoperative hypotensive episodes, while 3 (6%) patients had >10 intraoperative episodes of an SBP <90mmHg. Twenty-one (40%) patients received vasoactive drugs during surgery. The median volume of intraoperative crystalloids was 2 litres (1-4). Postoperatively, no patient experienced cardiovascular complications, including arrhythmia or myocardial ischaemia. Only two were admitted to an intensive care unit (ICU) and one 30-day readmission occurred. CONCLUSIONS: Cardiac instability remained significant in PPGL surgery despite optimal alpha- and beta-blockade. While omitting blockade would appear empirically questionable, a randomised controlled trial (RCT) of surgery with and without alpha-blockade will provide an answer.

To block, or not to block is it still the question? Effectiveness of alpha- and beta-blockade in phaeochromocytoma surgery: an institutional analysis.

INTRODUCTION: Phaeochromocytomas/paraganglioma (PPGL) surgery was historically associated with significant risks of perioperative complications. The decreased mortality (<3.0%) had been attributed in part to optimal preoperative alpha-blockade. The value of alpha-blockade in decreasing morbidity is being challenged. The aim of our study is to present an institutional experience of preoperative alpha-blocking of PPGL and its effect on cardiovascular stability and postoperative morbidity. METHODS: A retrospective study using data from our institutional database was conducted. All patients undergoing adrenalectomy for PPGL from October 2011 to September 2020 were included. All patients were routinely alpha-blocked. Intraoperative cardiovascular instability (ICI) was assessed through number of systolic blood pressure (SBP) episodes >160mmHg, SBP <90mmHg, the need for vasoactive drugs and volume of intraoperative crystalloids administered. Morbidity was also evaluated. RESULTS: A total of 100 consecutive patients undergoing surgery were identified of whom 53 patients had complete anaesthetic records available for analysis. Thirty-two patients (60%) had at least one episode with an SBP >160mmHg. Nine (17%) cases had no intraoperative hypotensive episodes, while 3 (6%) patients had >10 intraoperative episodes of an SBP <90mmHg. Twenty-one (40%) patients received vasoactive drugs during surgery. The median volume of intraoperative crystalloids was 2 litres (1-4). Postoperatively, no patient experienced cardiovascular complications, including arrhythmia or myocardial ischaemia. Only two were admitted to an intensive care unit (ICU) and one 30-day readmission occurred. CONCLUSIONS: Cardiac instability remained significant in PPGL surgery despite optimal alpha- and beta-blockade. While omitting blockade would appear empirically questionable, a randomised controlled trial (RCT) of surgery with and without alpha-blockade will provide an answer.

Robotic-assisted parathyroidectomy and short-term outcomes: a systematic review of the literature.

Minimal invasive techniques in endocrine surgery were lately adopted by surgical teams due to significant complications related to inadequate operative space and high risk of injuring crucial surrounding structures, such as vessels and nerves. Over the last years, technological improvements introduced robotic systems and approaches in endocrine surgery. Several case reports and series have described the safety and efficacy of these procedures such as robotic thyroidectomy and robotic parathyroidectomy. In the current review, we included 15 studies which described robotic-assisted parathyroidectomy for cervical parathyroid adenoma, in patients diagnosed with primary hyperparathyroidism or secondary hyperparathyroidism. No significant negative short-term outcomes were observed, in terms of postoperative complications, such as temporary or permanent injury of RLN, postoperative hypoparathyroidism and blood loss. The cosmetic result was, definitely, superior in comparison to conventional open parathyroidectomy. Despite the fact that RAP is an effective and curative method for patients with PHPT or secondary hyperparathyroidism, there are no available randomized clinical trials to establish this modern procedure as a gold-standard treatment strategy for these patients.

Mixed Hepatocellular Cholangiocarcinoma: A Review of Long-Term Outcomes Following Liver Transplantation.

INTRODUCTION: Mixed hepatocellular cholangiocarcinoma (HCC-CC) represents a rare hepatic tumor, which demonstrates histological features of both hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC). HCC-CC can be an unexpected finding in patients undergoing liver transplantation (LT) for HCC. The objective of our review was to review and evaluate long-term outcomes in patients undergoing LT for mixed HCC-CC. METHODS: A meticulous MEDLINE search was performed for articles referring to long-term results in patients who underwent LT and whose final pathology revealed HCC-CC. RESULTS: A total of 7 studies, which comprised 93 patients who underwent LT and whose resected specimen revealed mixed HCC-CC, were included in our review. One-year overall survival (OS) rates ranged from 64% to 93%, 3-year OS ranged from 38% to 78%, and 5-year OS rates range from 14% to 78%. Disease-free-survival (DFS) rates at 1-year from LT ranged from 60-% to 64%, whereas both 3- and 5-year DFS rates ranged from 30% to 53.3%. CONCLUSIONS: Long-term results of LT in the setting of mixed HCC-CC are associated with fairly unfavorable overall outcomes compared to LT for other indications including HCC yet are improved compared to others such as intrahepatic CC. A stricter preoperative evaluation could potentially help identify the patients with mixed HCC-CC who are at high-risk after LT, reduce the risks of recurrence, and improve OS.

Liver Transplantation for Giant Hepatic Hemangioma: A Systematic Review.

INTRODUCTION: Despite their benign nature, liver hemangiomas (LH) are lesions that can cause major complications requiring intervention. Liver transplantation (LT) has been suggested as an effective treatment option in selected patients with giant LHs causing severe symptoms and cannot be treated otherwise. The aim of our study was to investigate the indications, aspects and post-operative outcomes of patients with a LH who underwent LT. MATERIALS AND METHODS: A meticulous search of the literature was performed. Studies presenting cases of LT due to LH were evaluated. Studies presenting patients characteristics and symptoms, aspects of the disease, transplantation indications and details were selected. RESULTS: Fifteen studies were included in the present review that involved 16 patients. Among them, 4 were male while the remaining 12 were female with a mean age of 39.9 ± 8.7 years. The main indications for LT included respiratory distress, massive hemorrhage, Kasabach-Merritt syndrome, and unsuccessful previous treatment strategies. Four patients were transplanted from living donors and the remaining 12 from cadaveric donors. No post-operative deaths were reported and all patients returned to normal activity. No deaths during the long-term follow-up were reported. CONCLUSIONS: LH is an extremely rare indication for LT. Nevertheless, the currently available data suggest that LT is a safe and efficient treatment in the management of symptomatic or complicated LH in selected patients.

Pregnancy Outcomes After Liver Transplantation: A Systematic Review.

PURPOSE: Liver transplantation (LT) constitutes a major therapeutic option for a number of patients suffering from liver pathologies. Pregnancy outcomes in patients who have undergone LT are assessed by a number of studies. The aim of our systematic review was to present the currently available evidence concerning the results of pregnancy in patients with LT. MATERIALS AND METHODS: A meticulous systematic search of the literature published before September 2017 for studies relevant in this field was conducted. All studies, which presented obstetric and maternal outcomes of patients with prior LT, were included. RESULTS: Nineteen studies, which comprised 1290 pregnancies in 885 female LT recipients, were reviewed. A total of 1014 live births were recorded, and the incidence of spontaneous abortions ranged from 0.5% to 33.3%. Concerning live births, a proportion of 32% of pregnancies resulted in preterm births (345 preterm births in 1079 pregnancies, range 0%-39%), and in 16% of pregnancies preeclampsia was reported (188 cases from 1173 pregnancies, range 2%-33.3%). The most commonly administered immunosuppressive drugs were cyclosporine and tacrolimus alone or with steroids. Cesarean section rates ranged from 20% to 67.9% among the included studies, concerning live birth. Moreover, approximately one-third of them resulted in preterm birth. Spontaneous abortions were reported in 176 cases (range: 0.5%-33.3%), and preeclampsia occurred in 188 patients (range: 2%-33.3%). CONCLUSION: Pregnancy outcomes from the included studies are encouraging, nonetheless pregnant patients who have undergone LT are at high risk and therefore require close monitoring by a multidisciplinary team.

Non traumatic liver herniation due to persistent cough mimicking a pulmonary mass.

BACKGROUND: Non traumatic liver herniation through a diaphragmatic defect is rare. CASE REPORT: A 44 year old woman presented with lower lobe opacity at the right lung. Chest Computed tomography (CT) demonstrated a round tumor adjacent to the right diaphragm. Percutaneous needle biopsy revealed liver tissue. A small liver herniation through a diaphragmatic defect was detected in saggital and coronal CT views but no traumatic rupture of the diaphragm or endometriosis were documented. CONCLUSIONS: The patient suffered from gastroesophageal reflux disease and increased transdiaphragmatic pressure from paroxysmal cough due to aspirations may have provoked the diaphragmatic rupture.

Exclusive CNS involvement by lymphomatoid granulomatosis in a 12-year-old boy: a case report.

BACKGROUND: Lymphomatoid granulomatosis [LYG] is an angiocentric, angiodestructive disease at the higher grade end of the spectrum of angiocentric immunoproliferative lesions. It primarily involves the lungs, but it may also involve several extrapulmonary sites including the central nervous system (CNS), skin, and kidneys. CASE DESCRIPTION: Clinical presentation, radiology and treatment of LYG in a 12-year-old male child with multiple intracranial extraaxial lesions is described. A 12-year-old boy presented with sudden onset of left focal motor seizures with associated history of headache and vomiting. Computerized tomographic scan of the brain suggested high-density, bilateral, parietal extraaxial lesions. On magnetic resonance imaging, the lesions were iso- to hyperintense on T1-weighted images and hyperintense on T2-weighted images. The lesions were excised in two stages and histopathological examination confirmed the diagnosis. CONCLUSION: LYG seldom involves the CNS exclusively. The present case demonstrates exclusive CNS involvement by LYG in a young boy.