[Exclusive use of calcium channel blockers and cardioselective beta-blockers in the pre- and per-operative management of pheochromocytomas. 70 cases]. / Utilisation exclusive des inhibiteurs des canaux calciques et des beta-bloquants cardio-sélectifs dans la prise en charge péri et per-opératoire des phéochromocytomes. A propos de 70 cas.

The pre and intraoperative use of calcium channel blockers (CCB) has been suggested for the management of either eutopic or ectopic pheochromocytomas. We report our experience of 70 pheochromocytomas, operated between 1988 and 1996 and managed with CCB, especially nicardipine. 59 were hypertensive (84.2%). Preparation consisted of nicardipine in 61 patients or another CCB in 9 cases with duration ranging from 24 hours to several weeks depending on plasma volume and blood pressure control. Intraoperatively, nicardipine infusion was started after intubation, adjusted according to systolic blood pressure (SBP) and stopped before ligation of the tumor venous drainage. Increases in SBP greater than 200 mmHg were observed in 10 patients and were effectively controlled by nicardipine in all cases. In 16 patients, the S > BP remained less than 150 mmHg throughout anesthesia. Heart rate greater than 100 b p m occureed in 51 patients and was easily controlled with esmolol whenever used (n = 27). Arythmias were unfrequent (n = 4) and required treatment in only one case. This study confirms the ability to adequately manage pheochromocytomas with the use of nicardipine as sole vasodilating agent.

[Anesthesia-resuscitation in surgery for pheochromocytoma]. / Anesthésie-réanimation pour chirurgie du phéochromocytome.

The perioperative mortality related to cardiovascular complications has been almost completely eliminated in phaeochromocytoma surgery. The anaesthetic management has mainly evolved through refinements in haemodynamic control during the operation. Neither preoperative preparation nor general anaesthesia can totally prevent haemodynamic disturbances during surgical manipulation of the tumour or after removal of the tumour. General anaesthesia, with high doses of opioids, remains the most usual technique. Intraoperative monitoring should include an arterial catheter and a pulmonary arterial catheter. Although a number of antihypertensive drugs have been tested, the preventive use of nicardipine i.v. may provide a simple and effective haemodynamic control. Esmolol, an ultrashort acting agent, ensures a dose-related cardiac beta 1-blockade. It is used for the treatment of arrhythmia and cardiac adrenergic stimulation, which causes tachycardia and increases cardiac output. Volume loading is recognised as the treatment of choice for hypotension following tumour removal. During the postoperative period, the great hazard is hypoglycaemia, and plasma glucose levels should be monitored over the immediate postoperative hours.

[Usefulness and limits of intraoperative hormone determination in the surgery of endocrine duodeno-pancreatic tumors. Experience of 74 cases]. / Utilité et limites des dosages hormonaux per-opératoires dans la chirurgie des tumeurs endocrines duodéno-pancréatiques. Expérience de 74 cas.

74 patients underwent surgery for organic hyperinsulinism (51 cases) or for Zollinger-Ellison syndrome (23 cases). 20 minutes after removal of the specimen, quick intra-operative hormone measurements were done in the systemic and portal blood as well, with intra-operative secretin stimulation test for gastrinoma(s), to assess completeness of surgery. Results accurately predicted cure (all insulinomas) or non-cure (half of gastrinomas) of the disease. Stumbling-blocks of the method are: a) the possibility of normal hormone base line levels at the time of surgery; b) the importance of secretion of proinsulin products by insulinomas. Those products are not taken in account by the modern assay technique with monoclonal antibodies (IRMA). Basal and stimulated portal measurements are more sensitive than measurements in the systematic blood.

Proliferative glomerulonephritis in rats: evidence that mononuclear phagocytes infiltrating the glomeruli stimulate the proliferation of endothelial and mesangial cells.

A proliferative, non-crescentic, glomerulonephritis (GN) was induced in rats preimmunized with rabbit IgG by injecting a sub-nephrotoxic dose of rabbit anti-GMA IgG. Control rats either received anti-GBM IgG only, or were totally irradiated (800 rads, kidneys protected) 2 days before the second injection. All the GN rats developed a severe proteinuria within 2-4 days after the injection of anti-GBM IgG, contrarily to the control rats. At the same time, many mononuclear cells, of predominantly extra-renal origin, infiltrated the glomeruli. Glomeruli were isolated from GN, normal and control rats and were cultivated in RPMI medium. In normal and control rats cultures, epithelial and mesangial cells were observed. In GN rat cultures, not only epithelial and mesangial cells, but also endothelial and macrophagic cells were identified; the outgrowth capacity of the mesangial cells was enhanced. These data were particularly evident in cultures of GN glomeruli isolated within 2-4 days after the induction of the renal disease, exactly when the glomeruli were infiltrated by a large number of mononuclear phagocytes. It is suggested that the mononuclear phagocytes infiltrating the glomeruli of rats with this model of GN stimulate the proliferation of endothelial and mesangial cells in vitro.