Laparoscopic Single-Incision Triangulated Umbilical Surgery Adrenalectomy for Large (>5 cm) Tumors of the Adrenal Gland: Initial Experience with 16 Cases.

Background and ObjectivesLaparoscopic single-incision triangulated umbilical surgery (SITUS), which enables the extraction of intraabdominal specimens through a single umbilical incision, has yet to be used to perform adrenalectomy. We have modified SITUS to enable extraction of large (>5 cm) adrenal masses with optimal cosmetic outcomes and investigated efficacy and safety. Methods. In this retrospective study, we analyzed data of 16 patients with adrenal tumors >5 cm who had undergone adrenalectomy by SITUS between October 2015 and April 2018. Two C-shaped incisions were made around the umbilicus and sutured centripetally. After extracting the specimen, we evaluated these patients' operative/postoperative data. Results. SITUS was performed in all 16 patients without conversion to laparoscopic or open surgery. The mean operation time was 75.31 ± 21.54 min (intraperitoneal time 41.94 ± 17.57 min; incision suturing time 33.38 ± 6.34 min). The estimated median blood loss was 57.5 mL (range 30-610 mL). Drainage time and duration of hospital stay were 55.69 ± 12.92 h and 3.94 ± 0.90 d, respectively. After surgery, all incisions were hidden under the umbilicus. Three patients developed keloid diathesis, resulting in enlargement of their scars. Conclusions. SITUS is a safe and feasible procedure for removing large adrenal tumors. In addition to its cosmetic advantages, SITUS facilitates functional recovery, particularly in patients with large adrenal tumors.

Kounis syndrome leads to cardiogenic shock.

Kounis syndrome has been defined as an acute coronary syndrome that manifests as unstable vasospastic or nonvasospastic angina, and even as acute myocardial infarction. It is triggered by the release of inflammatory mediators following an allergic insult or patient ill health, drug intake or environmental exposure. We report on a patient who was admitted to our hospital and diagnosed with unstable angina or acute myocardial infarction - according to analytical parameters, electrocardiographic abnormalities, and/or coronary angiography - in the context of progesterone as inducing factor. The results of a laboratory study revealed electrocardiogram changes, and increased myocardial enzymes, IgE antibodies and eosinophils. The patient experienced recurring chest pain, acute myocardial infarction, and cardiogenic shock after taking progesterone capsules; her medication history of progesterone clearly correlated with the onset of chest pain, which suggested that the cause of the vasospasm may have been related to progesterone use. We did not include patients with a history of bronchial asthma or allergic constitution. Nevertheless, the case suggests there is a correlation between Kounis syndrome and progesterone as inducing factor.

Synaptic connections between endomorphin 2-immunoreactive terminals and µ-opioid receptor-expressing neurons in the sacral parasympathetic nucleus of the rat.

The urinary bladder is innervated by parasympathetic preganglionic neurons (PPNs) that express µ-opioid receptors (MOR) in the sacral parasympathetic nucleus (SPN) at lumbosacral segments L6-S1. The SPN also contains endomorphin 2 (EM2)-immunoreactive (IR) fibers and terminals. EM2 is the endogenous ligand of MOR. In the present study, retrograde tract-tracing with cholera toxin subunit b (CTb) or wheat germ agglutinin-conjugated horseradish peroxidase (WGA-HRP) via the pelvic nerve combined with immunohistochemical staining for EM2 and MOR to identify PPNs within the SPN as well as synaptic connections between the EM2-IR terminals and MOR-expressing PPNs in the SPN of the rat. After CTb was injected into the pelvic nerve, CTb retrogradely labeled neurons were almost exclusively located in the lateral part of the intermediolateral gray matter at L6-S1 of the lumbosacral spinal cord. All of the them also expressed MOR. EM2-IR terminals formed symmetric synapses with MOR-IR, WGA-HRP-labeled and WGA-HRP/MOR double-labeled neuronal cell bodies and dendrites within the SPN. These results provided morphological evidence that EM2-containing axon terminals formed symmetric synapses with MOR-expressing PPNs in the SPN. The present results also show that EM2 and MOR might be involved in both the homeostatic control and information transmission of micturition.