Pre- and peri-operative characteristics, complications and outcomes of patients with biochemically silent pheochromocytomas; a case series.

PURPOSE: Pheochromocytomas are rare tumors and biochemically silent ones with normal catecholamine levels are even rarer. Up to date, biochemically inactive pheochromocytomas are poorly investigated. We aimed to systematically assess the pre- and peri-operative characteristics and the outcomes of patients with these tumors who had been treated and followed-up in 2 tertiary centers. METHODS: Clinical, laboratory and imaging data, treatment outcomes and follow-up of biochemically silent pheochromocytoma patients were recorded. RESULTS: Ten patients (5 men) [median age at diagnosis 52.5 years (24-72)] were included. Adrenal masses were incidentally discovered in all patients except from one who presented with pheochromocytoma-related manifestations. Twenty-four-hour urine metanephrine and normetanephrine levels were in the low-normal, normal and high-normal range in 4, 4 and 2 patients and in 1, 6 and 3 patients, respectively. Tumors were unilateral [median size 46 mm (17-125)] and high density on pre-contrast CT imaging or high signal intensity on T2-weighted MRI scans were found in all cases. Pre-operatively, 5 patients were treated with phenoxybenzamine [median total daily dose 70 mg (20-100)]. Intra-operatively, 4 patients developed hypertension requiring vasodilator administration and 8 developed hypotension; vasoconstrictors were required in 5 cases. One patient, not pre-operatively treated with phenoxybenzamine, developed Takotsubo cardiomyopathy. During a median 24-month (12-88) follow-up period, one patient had disease progression. CONCLUSIONS: The majority (90%) of patients with biochemically silent pheochromocytomas developed hemodynamic instability during adrenal surgery. In patients with biochemically silent adrenal lesions and a high suspicion index for pheochromocytoma based on tumor imaging characteristics, pre-operative alpha-blockade treatment may be advisable.

Triple valve endocarditis as an unusual complication of bacterial meningitis.

We report a case of Staphylococcus aureus endocarditis with late onset in a 39-year-old male drug abuser, who presented with bacterial meningitis. Despite resolution of the meningitis as the result of appropriate antimicrobial chemotherapy he developed triple valve endocarditis. Some striking features of this case and a comparison with other reported cases of this uncommon presentation of infective endocarditis are discussed.

Gerstmann's syndrome: can cardiac myxoma be the cause?

Cardiac myxomas are primary cardiac tumours. Clinical presentations vary. Central nervous embolism has been a constant association. We describe a case of a 40-year-old female who presented with neurological signs and symptoms of Gerstmann's syndrome secondary to a left atrial myxoma.

Use of continuous subcutaneous anesthetic infusion in cardiac surgical patients after median sternotomy.

UNLABELLED: The use of opioid analgesics to control pain after median sternotomy in cardiac surgical patients is worldwide accepted and established. However, opioids have a wide range of possible side effects, concerning prolonged extubation time, gastrointestinal tract dyskinesia and urinary tract disorders mostly retention. All these may lead to a prolonged ICU stay or overall hospitalization time increase. OBJECTIVE: To determine whether a continuous subcutaneous regional anesthetic infusion delivered directly to the sternotomy site would result in decreased levels of postoperative pain and opioid requirements in cardiac surgical patients undergoing median sternotomy. METHOD: The continuous subcutaneous infusion (OnQ Painbuster system) was applied in 37 patients. 3 patients were exempted due to prolonged ICU stay. 29 patients underwent CABG, 5 had AVR, 1 MVR and modified Maze, 1 patient had a 3-valve repair due to endocarditis and another one had reconstruction of the left ventricle. Requirements of opioid analgesics were recorded for 96 hours after operation. Pain was assessed using the visual analog scale and the total postoperative hospital length of stay was also measured. RESULTS: The postoperative pain was significantly diminished (0 - 3 at VAS). The mean postoperative length of stay was 5,8 days, rather improved compared to the average stay of 6,7 days. CONCLUSION: Continuous subcutaneous infusion of ropivacaine directly at the median sternotomy significantly diminishes postoperative pain and the need for opioid analgesic use. Moreover, it seems to reduce overall postoperative length of stay for all cardiac surgical patients.

Surgical treatment of coronary subclavian steal syndrome.

The internal mammary artery is the conduit of choice for cardiac revascularization. Atherosclerotic disease of the coronary arteries may simultaneously involve the subclavian artery. Proximal stenosis in the left subclavian artery may result in recurrent myocardial ischemia in patients with a patent left internal mammary artery (LIMA), due to coronary steal syndrome through the LIMA.

Perioperative thyroid hormone kinetics in patients undergoing major oral and maxillofacial operations.

PURPOSE: The aim of this study was to investigate the perioperative response of serum thyroid hormones in patients who underwent extensive maxillofacial operations with desflurane (0.2 to 1.5 MAC) and remifentanil (0.05 to 0.3 microg/kg/min) anesthesia. MATERIALS AND METHODS: Serum thyroxine, total and free triiodothyronine, thyroid-stimulating hormone, interleukin-1beta and 6, TNF-alpha, free fatty acids, S100B protein, CRP, as well as amyloid A protein were measured in 13 patients subjected to extensive oral and maxillofacial operations. Samples were collected before anesthesia induction, at the end, and 6, 12, 24, and 72 hours after the end of surgery. Patients during the study fasted, and at the postoperative period received Ringer's saline or with 5% dextrose alternatively, at the rate of 0.5 to 1.5 mL/kg/hr. RESULTS: Thyroid hormones concentrations showed a significant decrease over time whereas their values recovered to the baseline 72 hours after surgery. Interleukin 1beta, 6, S100B protein, CRP, serum amyloid A protein, and free fatty acids showed a significant increase 6, 12, and 24 hours after the end of the operation as related to the basal value. No significant clinical complications were recorded over the study. CONCLUSION: Patients undergoing extensive oral and maxillofacial surgery exhibit marked decrease in serum thyroid hormones. Stress response, anesthesia, and perioperative fasting may be decisive factors eliciting this response. These metabolic derangements do not deteriorate the clinical outcome and subsequently may be an adaptive response for energy preservation in various organs.