Evaluation of Proton MR Spectroscopy for the Study of the Tongue Tissue in Healthy Subjects and Patients With Tongue Squamous Cell Carcinoma: Preliminary Findings

Purpose

To noninvasively assess spectroscopic and metabolic profiles of healthy tongue tissue and in an exploratory objective in nontreated and treated patients with tongue squamous cell carcinoma (SCC).

Methods

Fourteen healthy subjects (HSs), one patient with nontreated tongue SCC (NT-SCC), and two patients with treated tongue SCC (T-SCC) underwent MRI and single-voxel proton magnetic resonance spectroscopy (1H-MRS) evaluations (3 and 1.5T). Multi-echo-times 1H-MRS was performed at the medial superior part (MSP) and the anterior inferior part (AIP) of the tongue in HS, while 1H-MRS voxel was placed at the most aggressive part of the tumor for patients with tongue SCC. 1H-MRS data analysis yielded spectroscopic metabolite ratios quantified to total creatine.

Results

In HS, compared to MSP and AIP, 1H-MRS spectra revealed higher levels of creatine, a more prominent and well-identified trimethylamine-choline (TMA-Cho) peak. However, larger prominent lipid peaks were better differentiated in the tongue MSP. Compared to HS, patients with NT-SCC exhibited very high levels of lipids and relatively higher values of TMA-Cho peak. Interestingly, patients with T-SCC showed almost nonproliferation activity. However, high lipids levels were measured, although they were relatively lower than lipids levels measured in patients with NT-SCC.

Conclusion

The present study demonstrated the potential use of in-vivo1H-MRS to noninvasively assess spectroscopic and metabolic profiles of the healthy tongue tissue in a spatial location-dependent manner. Preliminary results revealed differences between HS and patients with tongue NT-SCC as well as tongue T-SCC, which should be confirmed with more patients. 1H-MRS could be included, in the future, in the arsenal of tools for treatment response evaluation and noninvasive monitoring of patients with tongue SCC.

[EUROCRINE®: adrenal surgery 2015-2019- surprising initial results]

Hintergrund

Seit 2015 erfolgt in Europa mithilfe des EUROCRINE®-Registers eine systematische Dokumentation endokrin-chirurgischer Operationen. Ziel dieser ersten Auswertung war eine Darstellung der Versorgungsrealität für Nebenniereneingriffe in einem homogenen Versorgungsumfeld, entsprechend des deutschsprachigen Raums – bzw. des Präsenzgebiets der Chirurgischen Arbeitsgemeinschaft Endokrinologie (CAEK) der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) – einschließlich einer Analyse der Adhärenz zu geltenden Therapieempfehlungen.

Methodik

Es erfolgte eine deskriptive Analyse der präoperativen Diagnostik, der angewandten Operationstechniken sowie der zugrunde liegenden histologischen Entitäten der zwischen den Jahren 2015 und 2019 über EUROCRINE® in Deutschland, Österreich und der Schweiz dokumentierten Nebennierenoperationen.

Ergebnisse

In den insgesamt 21 teilnehmenden Kliniken des deutschsprachigen EUROCRINE®-Gebiets wurden 658 Operationen an Nebennieren durchgeführt. In 90 % erfolgten unilaterale, in 3 % bilaterale Adrenalektomien und in 7 % andere Resektionsverfahren. Die in 41 % der Operationen dokumentierte histologische Hauptdiagnose war das adrenokortikale Adenom. In 15 % lagen maligne Befunde zugrunde (einschließlich 6 % Nebennierenrindenkarzinome (ACC) und 8 % Nebennierenmetastasen). 23 % der Operationen erfolgten bei Phäochromozytomen. Diese wurden zu 82 % minimal-invasiv operiert, Nebennierenrindenkarzinome lediglich zu 28 % und Nebennierenmetastasen zu 66 %.

Schlussfolgerung

Überraschenderweise wurden nach Nebennierenadenomen und Phäochromozytomen an dritthäufigster Stelle Nebennierenmetastasen unterschiedlicher Primärtumoren reseziert. 28 % der ACC waren für minimal-invasive Techniken vorgesehen, wobei 20 % dieser Fälle eine Konversion zur offenen Operation erforderten. Die aktuelle Analyse deckte Diskrepanzen zwischen Versorgungsrealität und Leitlinienempfehlungen auf, aus denen sich zahlreiche Fragestellungen ergeben, welche nun in ein überarbeitetes EUROCRINE®-Modul zur Dokumentation von Nebennierenoperationen einfließen werden.

Brain MRI Findings in Severe COVID-19: A Retrospective Observational Study

Background Brain MRI parenchymal signal abnormalities have been associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Purpose To describe the neuroimaging findings (excluding ischemic infarcts) in patients with severe coronavirus disease 2019 (COVID-19) infection. Materials and Methods This was a retrospective study of patients evaluated from March 23, 2020, to April 27, 2020, at 16 hospitals. Inclusion criteria were (a) positive nasopharyngeal or lower respiratory tract reverse transcriptase polymerase chain reaction assays, (b) severe COVID-19 infection defined as a requirement for hospitalization and oxygen therapy, (c) neurologic manifestations, and (d) abnormal brain MRI findings. Exclusion criteria were patients with missing or noncontributory data regarding brain MRI or brain MRI showing ischemic infarcts, cerebral venous thrombosis, or chronic lesions unrelated to the current event. Categorical data were compared using the Fisher exact test. Quantitative data were compared using the Student t test or Wilcoxon test. P < .05 represented a significant difference. Results Thirty men (81%) and seven women (19%) met the inclusion criteria, with a mean age of 61 years ± 12 (standard deviation) (age range, 8-78 years). The most common neurologic manifestations were alteration of consciousness (27 of 37, 73%), abnormal wakefulness when sedation was stopped (15 of 37, 41%), confusion (12 of 37, 32%), and agitation (seven of 37, 19%). The most frequent MRI findings were signal abnormalities located in the medial temporal lobe in 16 of 37 patients (43%; 95% confidence interval [CI]: 27%, 59%), nonconfluent multifocal white matter hyperintense lesions seen with fluid-attenuated inversion recovery and diffusion-weighted sequences with variable enhancement, with associated hemorrhagic lesions in 11 of 37 patients (30%; 95% CI: 15%, 45%), and extensive and isolated white matter microhemorrhages in nine of 37 patients (24%; 95% CI: 10%, 38%). A majority of patients (20 of 37, 54%) had intracerebral hemorrhagic lesions with a more severe clinical presentation and a higher admission rate in intensive care units (20 of 20 patients [100%] vs 12 of 17 patients without hemorrhage [71%], P = .01) and development of the acute respiratory distress syndrome (20 of 20 patients [100%] vs 11 of 17 patients [65%], P = .005). Only one patient had SARS-CoV-2 RNA in the cerebrospinal fluid. Conclusion Patients with severe coronavirus disease 2019 and without ischemic infarcts had a wide range of neurologic manifestations that were associated with abnormal brain MRI scans. Eight distinctive neuroradiologic patterns were described. © RSNA, 2020.

P14.81 Importance of early spectral variations during a longitudinal 60-month follow-up MRI and 1H-MRS in 135 treated glioblastoma patients

BACKGROUND

To better understand glioblastomas tumor metabolism and metabolic responses to chemotherapy, radiotherapy and antiangiogenic treatments during a longitudinal 60-month follow-up MRI and 1H-MRS in 135 treated glioblastoma patients.

MATERIAL AND METHODS

135 patients all biopsied and treated by surgery and STUPP protocol underwent MRI (Sagittal T1, FLAIR, T2*, Diffusion, Perfusion, CoronalT2 and 3DT1 post-Gadolinium) and 1H-MRS (PRESS with multiple TEs: 35ms, 144ms and 288ms on a 6 to 12cm3 volume) exams on 1.5T and 3T GEMS. 92/135 patients underwent resection. MRS data were processed under jMRUI yielding amplitudes, areas under curves and ratios of tCho/tCr, tNAA/tCr, Lip+Lact/tCr, Lact/tCr, Glc/tCr, Glx/tCr and Gln/tCr. Statistical analysis of longitudinal MRI perfusion and spectroscopic data (every 2–3 months above 30 months and 6–9 months over).

RESULTS

Spectroscopic profiles and ratios improve under STUPP protocol and then worsen depending on the percentage of resection. Biopsied patients: a progressive decrease in ratios of tCho/tCr (0–24 months), Lact/tCr (0–18 months) and Glc/tCr (0–18 months) and Glx/tCr (0–12 months) and then increase at respectively 24, 18, 28 and18 months. Resected patients: a progressive decrease in ratios of tCho/tCr (0–9 months), Lact/tCr (0–15 months) and Glc/tCr (0–15 months) and Glx/tCr (0 and 18 months) and then increase at respectively 32, 20, 18 and 24 months. MRI Gadolinium enhancing tumor and necrosis volumes, Diffusion and FLAIR volumes changed less compared to spectroscopic profiles and ratios which do change more.

CONCLUSION

1H-MRS allows non-invasive follow-up of treated glioblastomas tumors. Despite inter-subjects variability, spectroscopic and metabolic changes often come well before clinical deterioration and sometimes before clinical improvement. Therefore, 1H-MRS could be more sensitive and could detect changes earlier than MRI and sometimes is predictive of survival and response to treatment. The analysis of spectral profiles of long survivors is interesting and could help to better understand tumor metabolism and therapeutic responses.

P14.91 Study glycolytic metabolism in 1H-MRS monovoxel in the most aggressive part of 62 glioblastomas before and after 18 months of treatment

BACKGROUND

To study the relationship between glycolytic metabolism, tumor proliferation, survival and treatment response in patients with glioblastoma (GBM).

MATERIAL AND METHODS

Patients: 62 patients with glioblastoma, all having a STUPP Protocol (radiotherapy and concomitant chemotherapy), were selected and separated into 2 groups: Biopsies (30) and resections (32). In total, 269 NMR spectra (PRESS at GE 1.5T and 3T; multi-TEs TE=35ms and TE=144ms) were acquired. Processing: MRS data were processed with jMRUI software and quantitated using HLSVD and QUEST algorithms. Statistical analysis of longitudinal MRS data (every 3 months)

RESULTS

1H-MRS glucose (Glc/tCr) and lactate (Lac/tCr) measurements are highly correlated before the beginning of treatment. This correlation is less obvious after 3, 6, 9 and 12 months of treatment. Proliferation is also strongly correlated with Lactate and Glucose before the beginning of treatment in both groups, whereas these correlations decrease in resected patients.The variability of ratios follow-up is higher in biopsied patients. Tumoral proliferation (tCho/tCr) and Glucose ratio (Glc/tCr) levels decreased along the follow-up. Although, the Lac/tCr ratio progressively decreased, its level remains high until 6 months. After 15 months of treatment, glucose increased although the lactate decreased.

CONCLUSION

The study of glycolytic metabolism in GBM could be used to evaluate the response to treatment. Being able to have a treatment response biomarker at 3 months, especially for patients who could not be resected could help to monitor and adapt treatment. The increase of Glucose at the end of the follow-up shows the interest of spectral and metabolic follow-up of glioblastoma after 18 months of treatment.

P14.100 Measurements of glioblastoma response to recurrence using spectroscopic measurements and MRI volumetry

BACKGROUND

Glioblastoma is the most aggressive and common primary malignant brain tumor in adults. The prognosis of patients with glioblastoma remains poor with a median life expectancy of 15 to 17 months and a survival rate of 5% at five years.Spectroscopy is becoming more and more used and the ratios studied allow in some cases a better prediction, at the recurrence, of the survival between certain ratios such as: Cho / Cr, NAA / Cr, Lac / Cr. Being able to combine all these ratios can allow us to obtain an additional survival index to take into account.This is why our study assesses whether MRS is coupled with volume, it is predictive of survival of the patient at 7 months.

MATERIAL AND METHODS

Population: 30 Patients with glioblastoma treated with the STUPP protocol with and without bevacizumab at recurrence over a period of 36 months. Patients divided into three different groups depending on the type of resection (subtotal (20), partial (13), and biopsy (7)).MRI sequences every 2 months on MRI 3T and 1.5T. Sequences we used: diffusion, T2, T2 *, FLAIR, 3D FLAIR, 3D T1 with gadolinium injection; also monovoxel spectroscopy (TE at 35 and 144 ms, sometimes 288 ms). The volume variations (calculated by Aw.Server and ITK) are evaluated according to the RANO criteria.The MRS ratios (calculated by jMRUI) were clinically used are Cho / Cr (tumor proliferation), NAA / Cr (infiltration) and Lac / Cr (glycolytic metabolism). Longitudinal analyzes of volumes and ratios.

RESULTS

30 patients included in this study. The analysis of the results is that proliferation and / or glycolytic metabolism are more informative and predictive when there is absence of contrast enhancement, hyperperfusion or large volume variation. The global index (choline + lactate / NAA) could be a relevant criterion of judgment to better study the aggressiveness of the tumor and better predict the evolution of tumor volumes and survival. Intra-inter-operator differences on 2 segmentation software.

CONCLUSION

The study shows us and confirms that the widest possible resection is to favor. Spectroscopy ratios vary earlier than the volumetry and give more information on the tumor processes and is sometimes predictive of survival.

P14.92 Study of Glutaminergic and Glutamatergic Metabolism in 1H-MRS Monovoxel in the Most Aggressive Part of 62 Glioblastoma Before and After 18 months Treatment

BACKGROUND

To study the relationships between glutaminergic metabolism (Glx/tCr), tumor proliferation (tCho/tCr) and other metabolic activities in patients with glioblastoma (GBM).

MATERIAL AND METHODS

Patients: 62 patients with glioblastoma, all having a STUPP Protocol (radiotherapy and concomitant chemotherapy), were selected and separated into 2 groups: Biopsies (30) and resections (32). In total, 269 NMR spectra (PRESS at GE 1.5T and 3T; multi-TEs TE=35ms and TE=144ms) were acquired. Processing: MRS data were processed with jMRUI software and quantitated using HLSVD and QUEST algorithms. Statistical analysis of longitudinal MRS data (every 3 months)

RESULTS

Glx/tCr and Lac/tCr ratios are correlated with the tumoral proliferation (tCho/tCr) before the beginning of treatment. This correlations decreases over time in biopsied and resected patients. In biopsied patients, the evolution of lactate (Lac/tCr) and Glx (Glx/tCr) ratios is similar along the follow-up with a progressive decrease in tumor proliferation (tCho/tCr). However, in resected patients, the evolution of lactate (Lac/tCr) and Glx (Glx/tCr) ratios is similar until 6 months and differ above: a progressive decrease of Lac/tCr and Glx/tCr until 18 months with a higher level of Glx/tCr.

CONCLUSION

Despite the difficulties to separate glutamine from glutamate (post-processing improvement is ongoing), spectroscopic measurements of Glx changes before clinical deterioration. The increase of Glx is longer (in time) than the Lactate increase after 6 months of treatment in the resected patients could be predictive of the observed increase of tumor proliferation at 12 months of treatment.The study of glutaminergic metabolism in the GBM could be used to evaluate the response to treatment. Being able to predict the increase of tumor proliferation in resected patients could allow a faster treatment adaptation.

Long-term results of transanal endoscopic microsurgery after endoscopic polypectomy of malignant rectal adenoma

BACKGROUND

There is no consensus on the treatment and prognosis of malignant rectal polyps. The aim of the present study was to determine the role of transanal endoscopic microsurgery (TEM) after endoscopic complete polypectomy of malignant rectal adenomas with long-term follow-up.

METHODS

Of 105 patients with pT1 rectal carcinoma in 32 patients TEM followed complete endoscopic polypectomy while 73 had primary TEM. Local recurrence (LR), distant metastasis, overall and cancer-specific survival were determined by the Kaplan-Meier method.

RESULTS

Median follow-up was 9.1 years. In 32 patients with TEM following complete polypectomy no residual cancer was found. LR occurred in 3/28 (11%) patients with low-risk carcinoma (pT1 G1/2/X, L0/X, R0) and in 1/4 (25%) with high-risk carcinoma (pT1 G3/4 or L1). After primary TEM with complete resection (minimal distance >1 mm) LR occurred in 6/60 (10%) with low-risk carcinoma. After incomplete TEM resection (minimal distance ≤1 mm) LR occurred in 3/8 (38%) patients with low-risk and in 1/5 (20%) patients with high-risk carcinoma. Grading was the only significant risk factor for LR after endoscopic polypectomy followed by TEM (p = 0.002). At all outcomes did not differ between postpolypectomy TEM and primary TEM.

CONCLUSIONS

Patients with malignant rectal polyps removed by endoscopic polypectomy have a substantial risk of LR even if TEM of polyp site is cancer free. Risk of LR depends on tumor characteristics. In low-risk carcinoma long-term follow-up is necessary. The high LR rate in patients with high-risk rectal carcinoma restricts the use of TEM alone.

[Single Centre Study: Results of Transanal Endoscopic Microsurgery of Rectal Tumors since 2003 vs. Results of Endoscopic Submucosal Dissection Reported in the Literature]

BACKGROUND

Due to the variety of methods for local ablation of sessile rectal polyps and low-risk T1 rectal cancer, a retrospective study by transanal local excision, the endoscopic microsurgery (TEM) was performed. The results of the TEM were compared with literature-based results of endoscopic submucosal dissection (ESD).

MATERIALS AND METHODS

174 patients who had received a TEM during the period from March 2003 to October 2011 for a removal of a rectal polyp or low risk cancer were included in the study. The evaluation included the en bloc and R0 resection rate, duration of surgery, the postoperative hospitalisation, postoperative complications and recurrence rate.

RESULTS

The en bloc-resection rate was 87.5 % (152 of 174) and the R0 resection was achieved in 84.5 % (147 of 174) of the cases. The average surgery duration was 33 (5-121) min, with an average specimen size of 4 (1.2-13) cm. The average postoperative length of stay included 5 (1-15) d. The postoperative complication rate was 3 % (4 of 174) and the recurrence rate was 4 % (7 of 174) with an average follow-up of 36 (6-108) months.

CONCLUSION

Compared to the Japanese results of ESD in the rectum based on literature results, we show equal or better results for the TEM. Compared to the European results of the ESD, the results of the TEM show advantages in terms of higher en bloc and R0 resection rates, shorter intervention times also with larger specimen sizes and a lower postoperative complication rate.

Neuroendocrine tumour, mucinous adenocarcinoma and signet-ring cell carcinoma of the appendix: three cases and review of literature

Appendiceal neoplasms are relatively common tumours. Although these tumours are often associated with signs and symptoms of acute appendicitis, most appendiceal neoplasms are clinically silent. Appendiceal neoplasms are found in 0.7 to 1.4 per cent of all appendectomy specimens. The classification of these tumours is still confusing and precise treatment methods for these neoplasms remain unclear. First choice therapy of these neoplasms is still a surgical treatment and the type of operative procedure is determined by histology and metatstatic risk. Here, we report three cases of appendiceal neoplasms and make a short review of literature.

Expression of E-selectin and vascular cell adhesion molecule-1 in so-called 'negative' appendices: first results to support the pathological diagnosis in borderline cases

BACKGROUND

Since the rate of histologically 'negative' appendices still ranges between 15 and 20%, appendicitis in 'borderline' cases remains a challenging disease. As previously described, cell adhesion molecule expression correlates with different stages of appendicitis. Therefore, it was of interest to determine whether the 'negative' appendix correlated with the absence of E-selectin or vascular cell adhesion molecule-1 (VCAM-1).

METHODS

Nineteen grossly normal appendices from a series of 120 appendectomy specimens from patients with suspected appendicitis were analysed in frozen sections for the expression of E-selectin and VCAM-1. As control, 5 normal appendices were stained.

RESULTS

This study showed a coexpression of E-selectin and VCAM-1 in endothelial cells in early and recurrent appendicitis. In patients with symptoms for less than 6 h, only E-selectin was detected. Cases with fibrosis and luminal obliteration were only positive for VCAM-1. In cases of early appendicitis with symptoms of less than 6 h duration, a discordance between histological and immunohistochemical results was found.

CONCLUSIONS

This report indicates that E-selectin and VCAM-1 expression could be useful parameters in the diagnosis of appendicitis in borderline cases.

[Indications for conventional adrenalectomy]

INTRODUCTION

Conventional adrenalectomy still plays an important role, even in the era of minimally invasive endocrine surgery. It was the aim of our study to analyse the indications for conventional adrenalectomy in our own patients since the introduction of the minimally invasive technique in the year 1994 - laparoscopically and retroperitoneoscopically.

PATIENTS AND METHODS

Between January 1994 and September 2006, a total of 412 adrenalectomies were performed in 380 patients. Out of these, 106 operations (25.7 %) were carried out conventionally in 98 patients, and 306 operations (74.3 %) endoscopically in 282 patients.

RESULTS

Indications for conventional adrenalectomy were - as compared with the minimally invasive procedure - significantly more frequent adrenocortical carcinomas (ACC), especially in the context of multivisceral resections, as well as adrenal metastases (synchronous and metachronous). In contrast, adrenal Cushing's disease (including 19 patients with bilateral tumours), pheochromocytoma, incidentaloma and Conn's syndrome constituted a more frequent indication for minimally invasive adrenalectomy. Conventionally operated adrenal pathologies with on average 6.0 (range: 1.2-19.0) cm diameter were significantly larger than the endoscopically removed tumours with on average 3.3 (range: 0.2-9.2) cm diameter (p < 0.0001). The side localisation and the frequency of bilateral adrenal tumours did not differ significantly in the two groups.

CONCLUSION

Since the establishment of the minimally invasive technique in 1994, conventional adrenalectomy has been selected for 26 % of all resected adrenal pathologies at our clinic and, therefore, still plays an important role even in the era of laparoscopic surgery. The benefit of the laparoscopic procedure in the case of malignant pheochromocytoma, adrenocortical carcinoma, and isolated adrenal metastases at a locally confined stage is still unclear and requires prospective, randomised studies.

Pairwise-Substitution Effects and Intramolecular Hydrogen Bonds in Nitrophenols and Methylnitrophenols. Thermochemical Measurements and ab Initio Calculations

The standard molar enthalpies of formation in the gaseous state of a series of nitrophenols, 2-nitrophenol, 3-nitrophenol, 4-nitrophenol, 5-methyl-2-nitrophenol, 2-methyl-5-nitrophenol, and 3-methyl-4-nitrophenol, have been obtained from combustion calorimetry and results from the temperature dependence of the vapor pressure measured by the transpiration method. To verify the experimental data, ab initio calculations of all compounds have been performed using MP, DFT, and G3 methods. Enthalpies of formation derived from the G3 methods are in a good agreement with the experimental results. The quantitative analysis of ortho, meta, and para pairwise-substituent effects in nitrophenols has been performed, and the strength of intramolecular hydrogen bonding in o-nitrophenol has been derived from thermochemical results and compared with those obtained from spectroscopic experiments and ab initio calculations. The new results help to resolve uncertainties in the available thermochemical data on extended series of nitrophenols.

[Nonerosive and erosive gastroesophageal reflux disease. Long-term results of laparoscopic anterior semifundoplication]

BACKGROUND

The aim of this study was to evaluate long-term results of laparoscopic anterior semifundoplication in patients with nonerosive (NERD) and erosive (ERD) gastroesophageal reflux disease.

PATIENTS AND METHODS

The study includes the period from May 1997 to July 2005. Upper gastrointestinal endoscopy was performed in all 190 patients. The severity of reflux esophagitis was classified according to Savary and Miller (grades I-IV). A standardized questionnaire was used for follow-up, and the modified symptomatic DeMeester score was assessed.

RESULTS

58.5 years of age (range 27-80), patients with nonerosive reflux disease (n=83) were significantly older than those with erosive reflux disease (n=107) (48 years range 15-84) (p=0.0001). Patients with NERD had a lower modified symptomatic DeMeester score postoperatively of 0 (range 0-4) than patients with ERD, of 1 (range 0-5), though without statistical significance (p=0.151).

CONCLUSION

Laparoscopic anterior semifundoplication leads to comparable symptomatic long-term results in both NERD and ERD. Anterior semifundoplication is a good therapeutic option for selected patients with persistent reflux-associated symptoms and endoscopically negative esophagitis.

Long-term results of endoscopic adrenalectomy for Conn's syndrome

The long-term effect of adrenalectomy on aldosterone-producing adenomas of the adrenal gland is controversially discussed. The aim of this study was to analyze the long-term course, with special consideration of factors of persisting hypertension after endoscopic adrenalectomy, for Conn's syndrome. Between February 1994 and March 2004, 40 patients with Conn's syndrome underwent endoscopic adrenalectomy. Data were recorded prospectively. Adrenalectomy was carried out unilaterally in all patients. Twenty-three patients (57.5%) were women; the median age was 51.7 (31.2-71.4) years. Preoperatively, all patients presented with arterial hypertension persisting over a median period of 84 (5-240) months; 76.3 per cent of the patients had previously been treated with an aldosterone antagonist, and 85 per cent with specific antihypertensives, whereas 52.6 per cent of all patients were under therapy with potassium compounds at the time of admission. After a median follow-up of 45 (7-114) months, potassium substitution was discontinued in 100 per cent of patients, and the aldosterone antagonist was discontinued in 94.7 per cent of patients. In 60.5 per cent of patients, the specific antihypertensive drugs were reduced. Patients with a reduction in antihypertensive medication had, compared with patients without a reduction, a shorter preoperative duration of arterial hypertension and a lower level of serum aldosterone, and were younger. Endoscopic adrenalectomy for Conn's syndrome leads to an immediate normalization of the electrolyte balance postoperatively, whereas hypertension resolves in 60.5 per cent of patients in the long-term course. Thus, the coexistence of essential hypertension or, respectively, a long duration of preoperative hypertension with associated renovascular alterations are of significance for the long-term result.

Long-Term Results of Endoscopic Adrenalectomy for Conn's Syndrome

The long-term effect of adrenalectomy on aldosterone-producing adenomas of the adrenal gland is controversially discussed. The aim of this study was to analyze the long-term course, with special consideration of factors of persisting hypertension after endoscopic adrenalectomy, for Conn's syndrome. Between February 1994 and March 2004, 40 patients with Conn's syndrome underwent endoscopic adrenalectomy. Data were recorded prospectively. Adrenalectomy was carried out unilaterally in all patients. Twenty-three patients (57.5%) were women; the median age was 51.7 (31.2–71.4) years. Preoperatively, all patients presented with arterial hypertension persisting over a median period of 84 (5–240) months; 76.3 per cent of the patients had previously been treated with an aldosterone antagonist, and 85 per cent with specific antihypertensives, whereas 52.6 per cent of all patients were under therapy with potassium compounds at the time of admission. After a median follow-up of 45 (7–114) months, potassium substitution was discontinued in 100 per cent of patients, and the aldosterone antagonist was discontinued in 94.7 per cent of patients. In 60.5 per cent of patients, the specific antihypertensive drugs were reduced. Patients with a reduction in antihypertensive medication had, compared with patients without a reduction, a shorter preoperative duration of arterial hypertension and a lower level of serum aldosterone, and were younger. Endoscopic adrenalectomy for Conn's syndrome leads to an immediate normalization of the electrolyte balance postoperatively, whereas hypertension resolves in 60.5 per cent of patients in the long-term course. Thus, the coexistence of essential hypertension or, respectively, a long duration of preoperative hypertension with associated renovascular alterations are of significance for the long-term result.

Insulin effects on myocardial function and bioenergetics in L-bupivacaine toxicity in the isolated rat heart

BACKGROUND AND OBJECTIVES

A positive effect of insulin-glucose-potassium infusion in severe bupivacaine-induced cardiovascular collapse has been described in vivo. It has been speculated that an antagonistic influence of insulin on sodium channel inhibition, transient outward potassium current, calcium-dependent adenosine triphosphatase or even improved myocardial energetics may be responsible for this effect. Using an isolated heart model, we therefore sought to further elucidate insulin effects in l-bupivacaine-induced myocardial depression.

METHODS

An isolated rat heart constant-pressure perfused, non-recirculating Langendorff preparation was used. Hearts were exposed to l-bupivacaine 5 microg mL(-1) and insulin 10 mIU mL(-1). Heart rate, systolic pressure, the first derivative of left ventricular pressure (+dP/dt), coronary flow, double product, PR and QRS intervals were recorded. Hearts were freeze-clamped and high-performance liquid chromatography measurement of the total adenine nucleotide pool was performed.

RESULTS

l-Bupivacaine led to a significant decrease in heart rate, +dP/dt, systolic pressure, coronary flow and double product, and to an increase in PR and QRS. Insulin exerted a positive inotropic effect, significantly augmenting +dP/dt and systolic pressure in both l-bupivacaine-treated and control hearts. Heart rate, coronary flow, total adenine nucleotides, PR and QRS were not significantly changed by the insulin intervention.

CONCLUSION

Insulin did not have a significant effect on total adenine nucleotides in controls and in l-bupivacaine-treated hearts. However, it does exert a positive inotropic action in bupivacaine-induced myocardial depression. We conclude that the positive effect of insulin application lies in positive inotropic action and not in changes in total adenine nucleotides.

[Minimally invasive adrenalectomy for pheochromocytoma: routine or risk?]

BACKGROUND

As a result of intraoperative catecholamine secretion with hemodynamic changes, larger tumor size, and marked neovascularization, adrenalectomy is more challenging and prone to complications for pheochromocytoma than for other adrenal diseases. The aim of this study was to examine the relative intraoperative risk of cardiovascular complications with the minimally invasive approach.

PATIENTS AND METHODS

Between February 1992 and May 2005, 82 operations were performed on 71 pheochromocytoma patients at our clinic. Of them, nine adrenalectomies were bilateral, one was trilateral, and two patients had recurrent procedures. Another five patients were included whose first operations took place before 1992. Thirty-six procedures were carried out conventionally (35 transperitoneally, one retroperitoneally) and 46 were endoscopic (28 transperitoneally, 18 retroperitoneally). There was no conversion to open procedure.

RESULTS

The median age at the time of surgery was 45 (24-75) years, and the median history of symptoms was 12 months (0-180). The openly resected pheochromocytomas were significantly larger than those in endoscopic operations: 5.5 cm (1-19 cm) vs 3.5 cm (0.5-8 cm) (P=0.0011). Compared with patients undergoing conventional procedures, those operated on endoscopically showed higher intraoperative systolic and diastolic blood pressures and peaks of more than 200 mmHg, although these differences were statistically insignificant. Multivariate analysis identified gender (P=0.0107), operative approach (P=0.0153), age (P=0.0364), and tumor size (P=0.0484) as factors with a possible influence on intraoperative hemodynamic alterations. Postoperative hospital stay was significantly shorter following endoscopic adrenalectomy (P=0.0001).

CONCLUSION

Endoscopic adrenalectomy for pheochromocytoma is suitable as a routine operation and harbors no increased risk of cardiovascular complications, making it the method of choice. The open procedure should be reserved for extraadrenal tumors or large tumors with the suspicion of malignancy.

Changing pattern of the intraoperative blood pressure during endoscopic adrenalectomy in patients with Conn’s syndrome

BACKGROUND

Primary hyperaldosteronism caused by an aldosterone-producing adenoma of the adrenal gland is regarded as the most common type of endocrine hypertension. The aim of this study was to analyze the changing pattern of the intraoperative blood pressure during endoscopic adrenalectomy recorded in patients with Conn's syndrome compared to patients with hormone-inactive incidentaloma and its possible influence by the surgical approach.

METHODS

From February 1994 to March 2004, 40 patients underwent endoscopic adrenalectomy for Conn's syndrome. All patients had arterial hypertension over a median period of 84 (5-240) months and were pretreated with an aldosterone antagonist in 76.3% and with specific antihypertensive medication in 85%. Over the same period of time, endoscopic adrenalectomy was carried out in 80 patients with incidentaloma. Of these, 41 (53.2%) displayed arterial hypertension requiring drug therapy.

RESULTS

The adrenal gland was resected using the retroperitoneal in 25 and the transperitoneal approach in 15 patients with Conn's syndrome. Conversion to an open procedure was required in two patients. Intraoperative increases in blood pressure necessitating antihypertensive therapy were observed in 17 of 40 patients (44.7%), in 11 of 40 patients (28.9%) blood pressure peaks of >200 mmHg (> 1 min) were noted. Differences between the preoperative and maximum intraoperative blood pressure were significant for the retroperitoneal approach only (systolic: p = 0.0001; diastolic: p = 0.0005), but not for the transperitoneal technique. The increase in intraoperative blood pressure in patients with Conn's syndrome was significantly higher, for both systolic (p < 0.0001) and diastolic (p = 0.0037) readings, compared to that in patients with incidentaloma undergoing endoscopic adrenalectomy during the same period of time.

CONCLUSION

Our results demonstrate that relevant intraoperative increases in blood pressure occur in patients with Conn's syndrome despite prior therapy with an aldosterone antagonist, necessitating specific precautionary measures during anesthesia. Intraoperative blood pressure was significantly higher for the retroperitoneal than for the transperitoneal procedure, which leads us to advocate the latter approach for endoscopic adrenalectomy.

Endoscopic adrenalectomy for pheochromocytoma: difference between the transperitoneal and retroperitoneal approaches in terms of the operative course

BACKGROUND

Due to the intraoperative catecholamine secretion with hemodynamic changes, a larger tumor size and marked neovascularization, as compared with other adrenal pathologies, endoscopic adrenalectomy for pheochromocytoma represents a particular challenge involving a more difficult and morbid procedure. The aim of this study was to identify the optimal surgical approach for endoscopic adrenalectomy in patients with pheochromocytoma.

METHODS

Over a period of 10 years (February 1994 to June 2004), 38 consecutive patients underwent endoscopic adrenalectomy for pheochromocytoma. As three patients underwent a bilateral procedure, a total of 41 adrenalectomies were performed. The transperitoneal approach was carried out in 23 patients, whereas 18 patients underwent a retroperitoneal adrenalectomy by a single operative team. Perioperative parameters were prospectively followed.

RESULTS

There was no conversion to the open procedure. Intraoperative hypertensive episodes occurred in 21 patients (55.3%) and were controlled by antihypertensive agents. In 11 patients (28.9%), blood pressure values rose to above 200 mmHg (> 1 min). A comparison between the retroperitoneal and transperitoneal procedures did not show a significant difference between the maximum intraoperative systolic (p = 0.730) and diastolic (p = 0.663) blood pressure values although intraoperative blood pressure peaks were seen more frequently during retroperitoneal adrenalectomy. The operative time was shorter for the patients who had transperitoneal adrenalectomy than compared to for those who had retroperitoneal adrenalectomy, although the difference was not significant. The intraoperative blood loss, perioperative morbidity, and length of postoperative hospital stay did not differ significantly between the surgical techniques (p > 0.05).

CONCLUSION

After adequate preparation, endoscopic adrenalectomy may be performed in patients with pheochromocytoma via both the retroperitoneal and the transperitoneal approaches. The shorter operating time, less frequent intraoperative blood pressure peaks, and the better overview of the operating field recommend the transperitoneal approach with the patient placed in a lateral position as the preferred operative procedure.

Endoscopic adrenalectomy: an analysis of the transperitoneal and retroperitoneal approaches and results of a prospective follow-up study

BACKGROUND

Endoscopic adrenalectomy is currently performed using either a retroperitoneal or transperitoneal approach. The aim of this study was to determine which of these is the optimal surgical technique in a prospectively designed analysis of a large series of patients operated on by a single team over a 10-year period.

METHODS

From February 1994 to March 2004, 267 endoscopic adrenalectomies (retroperitoneal in 132 patients and transperitoneal in 135 patients) were performed in 245 consecutive patients. There were 102 right lateral and 121 left lateral procedures (22 patients had a bilateral procedure). The most prevalent indication was incidentaloma (35.9%), followed by pheochromocytoma and Conn's adenoma.

RESULTS

The endoscopic procedure was performed in 238 of 245 patients (97.1%). The conversion rate was 1.5% for the transperitoneal approach and 3.8% for the retroperitoneal approach. No statistically significant influence was noted for the parameters of intraoperative blood loss, rate of postoperative complications, and duration of hospital stay with regard to the surgical technique. The operative time and the learning curve proved to be significantly longer for the retroperitoneal adrenalectomy. In addition, a variance analysis identified tumor size (>5 cm) as a significant factor influencing the operative time, whereas body mass index and localization (right/left lateral) did not prove significant.

CONCLUSION

Independent of the underlying pathology, endoscopic adrenalectomy using either the trans- or retroperitoneal approach can be performed in 96-98% of all patients. Differences between the two techniques in operative time and learning curves clearly favor the transperitoneal adrenalectomy.