Does the Treatment of Pelvic Venous Insufficiency Really Not Influence Lower Limb Venous Disease?

Pelvic venous insufficiency is a common problem in multiparous women. Besides burdensome symptoms, it correlates with the development of venous disease in the lower limbs. Therefore, the sequential treatment of abdominal/pelvic before leg veins could improve treatment effectiveness. The medical records of 243 patients with venous disease who were subjected to sequential treatment were analyzed retrospectively. The symptoms and patient satisfaction were assessed using dedicated questionnaires, both before and after treatment. Clinical effectiveness was verified using a Doppler scan, both before and after treatment. Among 243 analyzed cases, 195 underwent whole treatment; however, 48 women after embolization did not require further intervention. The total-symptom-score change (11.6 vs. 13.0, respectively) and the satisfaction score (1.6 vs. 1.5, respectively) did not differ between groups. After embolization, some patients, besides symptoms improvement, experienced reflux reduction and, hence, might avoid further intervention. A better explanation for this beneficial effect of the sequential/descending approach requires further studies.

May the Number of Pregnancies Predict the Progression and the Outcome of Venous Disease Treatment?

Pregnancy is a well-known risk factor for venous insufficiency. However, even nulliparous women experience venous problems. Therefore, we aimed to assess the possible associations between the number of pregnancies, veins condition and treatment outcome in women with venous disease. The retrospective assessment concerned data of 297 women with diagnosed venous insufficiency. Based on their pregnancy history, the patients' records were divided into: nulliparous women (15.5%), those after 1-2 term pregnancies (57.9%) and those after ≥3 pregnancies (26.6%). The analysis concerned data from the diagnostics of the abdominal/pelvic and leg veins and the treatment results expressed as a symptoms/satisfaction score. Most of the nulliparous women developed venous disease due to mild anatomic abnormalities of the abdominal/pelvic veins. They responded to treatment (mostly unilateral embolization) very well. In the second group, the majority of the combined venous abnormalities responded to treatment with significant improvement, even after embolization alone, although nearly two-thirds still required further leg treatment. The third group was comprised of more advanced cases; nearly 40% of them with recurrence. In order to improve their condition, three-fourths of the cases required sequential treatment in both the pelvic and leg veins compartments. In conclusion, the number of pregnancies is a potent modifying factor in the pathogenesis of venous disease, especially in multiparous women. Together with abnormal venous anatomy, it may determine the treatment outcome.

Huge Hematoma as First Manifestation of Adrenocortical Carcinoma: A Case Report.

BACKGROUND Adrenocortical carcinoma (ACC) is a rare malignancy associated with unfavorable prognosis. It is mainly diagnosed in the fifth or sixth decade of life. Symptoms of ACC are associated with hormonal activity, presence of metastases, and size of the tumor. The treatment and prognosis depend on the stage of the disease assessed with the ENSAT staging system. CASE REPORT A 38-year-old White man was admitted to our department from the city hospital due to a huge hematoma of the right adrenal gland (130×100 mm). On admission, the patient's condition was stable, and no active bleeding or other complications were present. Therefore, initially, conservative treatment was performed. The control CT scan showed reduction of the hematoma (90×80 mm). Due to the unknown character of the tumor and the sudden onset of bleeding, the patient was prepared for elective surgery according to the phaeochromocytoma surgery protocol. Following preparation, the patient underwent right-sided adrenalectomy. In the postoperative histopathological examination, adrenocortical carcinoma was diagnosed, which allowed the patient to receive appropriate oncological treatment. CONCLUSIONS There is currently no clear algorithm for the management of adrenal hemorrhage. A hemodynamically unstable patient requires urgent surgical treatment. Patients in good general condition should be prepared for early elective surgery.

Adrenal-sparing surgery for a hormonally active tumour - a single-centre experience.

INTRODUCTION: Surgeries that spare the adrenal cortex during adrenalectomy have profound justification. Indications for this type of surgery are fairly strict, and more than 30 years of observations continuously verify the results of the procedure. MATERIAL AND METHODS: Of a total of 650 adrenalectomies, 22 (3.4%) were adrenal cortex-sparing surgeries. There were 16 women and six men in this group. In 10 cases, surgery was performed for pheochromocytoma, eight cases involved Conn's syndrome, and in four cases - paragangliomas located in the para-adrenal region. Secretory activity was identified in all cases. RESULTS: Laparoscopic partial adrenalectomy was performed in 20 patients. Conversion to open laparotomy was necessary in two cases. In patients after bilateral resection of pheochromocytoma surgery, glucocorticoids were supplemented for six weeks. No significant surgical complications were observed in this group. CONCLUSIONS: Partial adrenalectomy for minor lesions should be a much more commonly utilised treatment method (of choice). Where bilateral adrenalectomy is necessary, a sparing procedure on one side protects patients from the need for hormonal substitution. The remaining part of the adrenal gland undertakes satisfactory secretory function after six weeks at the latest.

Undiagnosed Pheochromocytoma Presenting as a Pancreatic Tumor: A Case Report.

Pheochromocytoma is a rare catecholamine-producing tumor of the adrenal gland. Patients with known pheochromocytoma undergoing surgery require preoperative treatment with alpha-blockers to reduce the risk of intraoperative complications related to catecholamine release. If undiagnosed, pheochromocytoma can lead to life-threatening surgical complications. We report the case of a patient with a suspected solid pseudopapillary neoplasm in the pancreatic tail, for whom pancreatoduodenectomy was scheduled. However, shortly after abdominal incision, hypertensive crisis developed and was followed by severe hypotension requiring intravenous vasopressors, which prompted discontinuation of the operation. Further diagnostic evaluation revealed marked elevations in urinary excretion of methylated catecholamines and suggested that the tumor was in fact a pheochromocytoma extending from the left adrenal gland. After preoperative treatment with doxazosin, the patient underwent lateral transperitoneal laparoscopic adrenalectomy, with no major complications and an uneventful postoperative course. The pathological report confirmed a diagnosis of pheochromocytoma. Due to the potential for life-threatening surgical complications in patients with pheochromocytoma not treated preoperatively with alpha-blockers, this tumor type should be included in the differential diagnosis of abdominal tumors of unknown origin.

Prevalence of obstructive sleep apnea in patients with peripheral arterial diseases.

BACKGROUND: The presence of obstructive sleep apnea (OSA), a novel cardiovascular risk factor, contributes to the development of peripheral arterial diseases (PAD). There is a lack of data showing how often these diseases coexist. AIMS: The aim of the study was to determine the prevalence of OSA in the population of patients with PAD. METHODS: Patients previously qualified for the first revascularization due to PAD were included in the study. All patients underwent an overnight sleep study to detect OSA. Diagnosis of OSA was made when the apnea-hypopnea index (AHI) was ≥5 per hour. RESULTS: From 141 patients (60% men, age 69.6 ± 9.5 years), OSA was diagnosed in 68 patients (48%). OSA occurred in mild form (5 ≤ AHI < 15/h) in 39 cases (28%), in moderate form (15 ≤ AHI < 30/h) in 21 cases (15%), and in severe form (AHI ≥ 30/h) in 8 cases (6%). Patients without OSA had significantly lower body mass index (BMI; 26.9 ± 5.5 vs. 27.7 ± 5.3 kg/m2, p = 0.01) and lower hip circumference (97.4 ± 11.7 vs. 98.7 ± 7.4, p = 0.04). There were no differences in the distribution of other investigated cardiovascular risk factors and diseases between these groups. There were no significant differences in OSA distribution or its severity between patients with lower extremity artery disease and carotid artery disease. CONCLUSIONS: The prevalence of OSA in patients with PAD is very high, affecting nearly half of the studied population.

Surgical treatment of abdominal paragangliomas.

INTRODUCTION: Extraperitoneal, abdominal paragangliomas most commonly originate from the sympathetic nervous system. Typical features include catecholamine overproduction and the potential for malignancy. Lesions are usually located paravertebrally, but when growing in a more expansive manner they may also appear between the inferior vena cava and aorta. In the authors' opinion this site excludes laparoscopic tumourectomy. MATERIAL AND METHODS: Twenty-eight patients were selected for surgical management of abdominal paragangliomas in the past eight years at our endocrine surgical centre. This group consisted of 21 (75%) women and seven (25%) men, aged 14 to 84 years (mean 47.9). In 13 (46.4%) cases paroxysmal hypertension was observed. Type 2 diabetes was noted in another 10 (35.7%) patients, and Takotsubo acute coronary syndrome in two (7.1%). Patients were preoperatively qualified for either open surgery or laparoscopic tumourectomy based on visualisation and location of the tumours in imaging studies. RESULTS: All patients were successfully operated. Eleven (39.3%) patients qualified for laparoscopy, while the remaining 17 (60.7%) were treated with an open surgical approach due to difficult access to the lesion. The mean operative time was 130 minutes for laparoscopy and 120 minutes for laparotomy (p = 0.2). There were no local or general complications after either type of procedure. CONCLUSIONS: The use of laparoscopic access is practically excluded in the treatment of paragangliomas located between the inferior vena cava and aorta, especially at the level of the renal vessels and extending superiorly to the diaphragm.

Lateral laparoscopic adrenalectomy in patients with previous abdominal surgery - single-center experience.

INTRODUCTION: Lateral transabdominal adrenalectomy (LTA) is the most common minimally invasive technique used to treat patients with adrenal tumors. AIM: To analyze intra-operative and post-operative complications and reasons for conversion to open surgery in patients who underwent LTA and had previous abdominal surgery. MATERIAL AND METHODS: Five hundred and nineteen patients underwent LTA in our center between 2005 and 2016. We identified a study group of 150 patients, with previous abdominal surgery. We analyzed the frequency of intra-operative and post-operative complications and the reasons for conversion from laparoscopic to open adrenalectomy. RESULTS: The patients' mean age was 58; they underwent LTA due to hormonally active tumors (n = 79, 53%) and non-functioning adrenal tumors (n = 71, 47%). The size of adrenal lesions ranged from 20 mm to 90 mm. Seventy-eight (52%) adrenal lesions were found in the right adrenal gland, and 72 (48%) lesions in the left adrenal gland. The mean operating time was 130 min. The mean stay in hospital was five days. The intra-operative complications included blood pressure fluctuations (n = 32), abnormal vascular supply of the adrenal glands causing difficulties with dissections (n = 3), and respiratory problems (n = 1). Two (1.3%) patients had post-operative bleeding at the site of removed adrenal glands; 1 patient had an exacerbation of asthma postoperatively. Of the 150 patients analyzed, 3 (2%) required conversion to open adrenalectomy. The conversions were not caused by abdominal adhesions. CONCLUSIONS: Lateral transabdominal adrenalectomy is feasible and safe in patients with previous abdominal surgery. In our study, conversion from laparoscopic to open adrenalectomy was not caused by abdominal adhesions.

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.

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 Cushing's syndrome. For our study, we compared patients with ACTH-independent hypercortisolaemia (n = 25) with those with Cushing's 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.

Peripheral ARtery Atherosclerotic DIsease and SlEep disordered breathing (PARADISE) trial - protocol for an observational cohort study.

BACKGROUND: Peripheral arterial disease (PAD) is in fact a group of disease entities with different symptoms and course but a common underlying cause, i.e. atherosclerosis. Atherosclerosis is known to be aggravated by several cardiovascular risk factors, including obstructive sleep apnoea (OSA). AIM: Following paper is a protocol for the Peripheral ARtery Atherosclerotic DIsease and SlEep disordered breathing (PARADISE) trial, which aims to describe the prevalence of OSA in PAD patients scheduled for revascularisation, and to determine the effect of OSA on the procedure outcomes. METHODS: The PARADISE study is an observational cohort trial. It plans to include 200 consecutive patients hospitalised for revascularisation due to PAD. In every patient an overnight sleep study will be performed to diagnose sleep disorders. Accord¬ing to the results of the test, patients will be divided into two groups: group A - patients with OSA, and group B - patients without OSA (control group). All patients will also be screened for classical and non-classical cardiovascular risk factors. In some of the patients, during surgery, a fragment of atherosclerotic plaque will be collected for further testing. Patients will be followed for one year for adverse events and end-points. Primary end-point of the study will be the failure of revascularisa¬tion defined as recurrence or new onset of the symptoms of ischaemia from the treated region, a need for re-operation or procedure revision, or recurrence of ischaemia signs on the imaging tests. DISCUSSION: The data obtained will help determine the incidence of OSA in the population of patients with PAD. The au¬thors expect to show that, as with other cardiovascular diseases associated with atherosclerosis, also in patients with PAD the incidence of undiagnosed OSA is high and its presence is associated with elevated cholesterol, inflammatory markers, and higher prevalence of arterial hypertension and poor control of other cardiovascular risk factors. In addition, due to increased oxidative stress and vascular endothelial injury associated with OSA, patients afflicted with this condition will not only have more advanced atherosclerotic lesions, but also in their histopathological examination their atherosclerotic plaque will exhibit evidence of greater instability and adverse morphology. We also expect to show that in patients with OSA, achieving cor¬rect control of cardiovascular risk factors will be more difficult. The study may improve PAD control through assuring better multispecialty care in PAD patients.

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.

Intravascular Treatment of Left Subclavian Artery Aneurysm Coexisting with Aortic Coarctation in an Adult Patient.

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.