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The determination of real fluid requirements in laparoscopic resection of pheochromocytoma using minimally invasive hemodynamic monitoring: a prospectively designed trial. Surg Endosc 2019; 34:368-376. [PMID: 30976898 PMCID: PMC6946750 DOI: 10.1007/s00464-019-06777-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 04/02/2019] [Indexed: 02/07/2023]
Abstract
Background Hemodynamic instability is frequently observed during adrenalectomy for pheochromocytoma (PCC). Guidelines recommend liberal preoperative volume administration. However, it is unclear whether fluid deficiency or vasoplegia causes shifting hemodynamics and whether minimally invasive hemodynamic monitoring with esophageal Doppler (EDM) can help visualize intraoperative changes avoiding volume overload and complications. Methods Ten patients with biochemically verified PCC and five patients with hormonally inactive adrenal tumors (HIAT; control group) were treated following a strict protocol. During laparoscopic adrenalectomy, goal-directed fluid therapy was performed using EDM. Hemodynamic and biochemical data were documented. The primary outcome variables were fluid requirement and hemodynamic parameters. Results Applying EDM, total intraoperative fluid administration was slightly higher in PCC patients than in patients with HIAT (2100 ± 516 vs. 1550 ± 622 ml, p = 0.097; 12.9 ± 4.8 vs. 8.3 ± 0.7 ml kg−1 h−1, p = 0.014). Hemodynamics varied considerably within the PCC group and was associated with type and level of secreted catecholamines. Arterial blood pressure and systemic vascular resistance index reached their minimum in the 10-min period after resection of PCC. Without liberal fluid administration, an increase in cardiac index was observed in both groups comparing baseline measurements to end of surgery. This increase was statistically significant only in PCC patients (PCC: 2.31 vs. 3.15 l min−1 m−2, p = 0.005; HIAT: 2.08 vs. 2.56 l min−1 m−2, p = 0.225). Conclusions As vasoplegia, but not hypovolemia, was documented after tumor resection, there is no evidence that PCC patients profit from liberal fluid administration during laparoscopic adrenalectomy. To avoid volume overload, noninvasive techniques such as EDM should be routinely used to visualize the variable intraoperative course. Trial registration: ClinicalTrials.gov, Identifier: NCT01425710.
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Aronoff L, Malkin D, van Engelen K, Gallinger B, Wasserman J, Kim RH, Villani A, Meyn MS, Druker H. Evidence for genetic anticipation in vonHippel-Lindau syndrome. J Med Genet 2018; 55:395-402. [PMID: 29437867 DOI: 10.1136/jmedgenet-2017-104882] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 01/16/2018] [Accepted: 01/23/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND von Hippel-Lindau (vHL) syndrome is a rare autosomal-dominant disorder that confers a lifelong risk for developing both benign and malignant tumours in multiple organs. Recent evidence suggests that vHL may exhibit genetic anticipation (GA). The aim of this study was to determine if GA occurs in vHL, and if telomere shortening may be a factor in GA. METHODS A retrospective chart review of vHL families seen at The Hospital for Sick Children between 1984 and 2016 was performed. Age of onset (AOO, defined as the age of first physician-diagnosed vHL-related manifestation) was confirmed for 96 patients from 20 unrelated families (80 clinically affected and 16 unaffected carriers). Flow-FISH(flow cytometry sorting of cells whose telomeres are labeled by Fluorescence In Situ Hybridization) was used to measure mean telomere length of six white blood cell subtypes from 14 known VHL pathogenic variant carriers. RESULTS The median AOO for generations I, II and III were 32.5, 22.5 and 12.0 years, respectively. The differences in the AOO between generations were highly significant using a Cox proportional hazards model (P=6.00×10-12). Telomere lengths were significantly different for granulocytes and natural killer lymphocytes of patients with vHL compared with age-matched controls. For six vHL parent-child pairs, median white blood cell telomere lengths between parent and child were not significantly different. CONCLUSIONS Our results suggest that vHL telomere abnormalities may be primarily somatic in origin rather than a cause of GA. As tumour development exhibits GA in our cohort, vHL surveillance guidelines may need to account for a patient's generational position within a vHL pedigree.
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Affiliation(s)
- Laura Aronoff
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - David Malkin
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Genetics and Genome Biology Program, The Hospital for Sick Children Research Institute, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Kalene van Engelen
- Genetics and Genome Biology Program, The Hospital for Sick Children Research Institute, Toronto, Canada
| | - Bailey Gallinger
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Genetics and Genome Biology Program, The Hospital for Sick Children Research Institute, Toronto, Canada.,Department of Molecular Genetics, University of Toronto, Toronto, Canada.,Department of Genetic Counselling, The Hospital for Sick Children, Toronto, Canada
| | - Jonathan Wasserman
- Genetics and Genome Biology Program, The Hospital for Sick Children Research Institute, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,Division of Endocrinology, The Hospital for Sick Children, Toronto, Canada
| | - Raymond H Kim
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Canada.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Anita Villani
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - M Stephen Meyn
- Genetics and Genome Biology Program, The Hospital for Sick Children Research Institute, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,Department of Molecular Genetics, University of Toronto, Toronto, Canada.,Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Canada
| | - Harriet Druker
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Department of Molecular Genetics, University of Toronto, Toronto, Canada.,Department of Genetic Counselling, The Hospital for Sick Children, Toronto, Canada
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