Intraoperative angioedema induced by angiotensin II receptor blocker: a case report

Background

Angiotensin II receptor blockers are a class of antihypertensive agent that is developed to exclude the adverse effects of angiotensin converting enzyme inhibitors. However, as angiotensin II receptor blockers have begun to be more widely prescribed, cases of angiotensin II receptor blocker-induced angioedema have been reported. Rare cases of angioedema following surgery in patients using angiotensin converting enzyme inhibitors have been published.

Case presentation

A 38-year-old man with past history of hypertension was admitted for an elective lumbosacral spine surgery. He had been taking Valsartan 160 mg a day for the past 4 years.At the end of the surgical procedure and turning the patient into supine position, we noticed severe swelling in the neck and the face with.an edematous tongue, floor of the mouth, glottis, and supraglottic areas. A diagnosis of drug induced angioedema was made and intravenous dexamethasone, diphenhydramine and ranitidine were given. The patient remained intubated and was transferred to the intensive care unit. The valsartan was suspected to be the precipitating factor for the angioedema and was therefore discontinued.The swelling started to regress after 2 h, and resolved completely by the third day.

Conclusion

The precise mechanism of angiotensin II receptor blocker-induced angioedema is still unknown and should be thoroughly investigated. This report demonstrates a unique case of intraoperative angiotensin II receptor blocker-induced angioedema. Potential differential diagnoses of postoperative facial edema are discussed in detail, including the prolonged prone positioning for posterior spine surgery. Anesthesiologists should be aware of such rare, but potentially dangerous, perioperative adverse reaction that can occur with angiotensin II receptor blockers use.

     

Outcomes of Sleeve Gastrectomy in Septuagenarians

Background

Few previous studies have assessed the safety of bariatric surgery in septuagenarians.

Methods

A retrospective analysis of all patients 70 years or older who underwent laparoscopic sleeve gastrectomy at our institution between 2012 and 2017 was performed. This group was compared to a matched cohort of younger LSG patients (18–50 years) who were operated during the same time period.

Results

Thirty septuagenarian LSG patients were compared to 60 younger patients. Gender distribution, preoperative weight, and preoperative body mass index (BMI) were comparable, although patients in the older age group suffered from more preoperative comorbidities (100 vs. 51.7%, p?<?0.001). Operative time was longer (77.2 vs. 57.3 min, p?=?0.005) and more hiatal hernias were repaired (46.7 vs. 8.3%, p?<?0.001) in the older age group. Intraoperative complications occurred more in the older age group (6.7 vs. 0%, p?=?0.04) but the overall complication rate (13.3 vs. 5.0%, p?=?0.17) and the postoperative complication rate (10.0 vs. 5.0%, p?=?0.38) were comparable. After a mean follow-up period of 31.3 and 33.5 months, the percentage of total body weight loss was 24.6 and 28.3% for the older and younger patients, respectively (p?=?0.11). Rates of improvement/remission of comorbidities were comparable between the groups.

Conclusions

In a carefully selected group of severely obese patients ≥?70 years old, LSG may be safe, with acceptable postoperative complication rates, weight loss results, and improvement in comorbidities.

     

PTOV1 is overexpressed in human high-grade malignant tumors

The prostate tumor overexpressed-1 (PTOV1) protein was first described overexpressed in prostate cancer but not detected in normal prostate. PTOV1 expression is associated to increased cancer proliferation in vivo and in vitro. In prostate biopsy, PTOV1 detection is helpful in the early diagnosis of cancer. The purpose of this study was to analyze the relevance of PTOV1 expression to identify aggressive tumors derived from 12 different histological tissues. Tissue microarrays (TMAs) containing 182 biopsy samples, including 168 human tumors, were analyzed for PTOV1 and Ki67 expression by immunohistochemistry. Tumors of low and high histological grade were selected from lung, breast, endometrium, pancreas liver, skin, ovary, colon, stomach, kidney, bladder, and cerebral gliomas. One TMA with representative tissues without cancer (14 samples) was used as control. PTOV1 expression was analyzed semiquantitatively for the intensity and percentage of positive cells. Ki67 was evaluated for tumors proliferative index. Results show that PTOV1 was expressed in over 95% of tumors examined. Its expression was significantly associated to high-grade tumors (p = 0.014). This association was most significant in urothelial bladder carcinomas (p = 0.026). Overall, the expression of Ki67 was associated to high-grade tumors, and it was significant in several tumor types. PTOV1 and Ki67 were significantly co-overexpressed in all tumors (p = 0.001), and this association was significant in clear cell renal carcinoma (p = 0.005). In conclusion, PTOV1 expression is associated to more aggressive human carcinomas and more significantly to bladder carcinomas suggesting that this protein is a potential new marker of aggressive disease in the latter tumors.     

Severe hepatotoxicity associated with bromfenac sodium

Subacute hepatitis and liver failure occurred in a 40-yr-old woman following a 1-month course of treatment with the nonsteroidal anti-inflammatory drug bromfenac. Serologies for hepatitis A, B, and C were negative, as were antinuclear antibodies and ceruloplasmin. A transjugular liver biopsy demonstrated submassive hepatic necrosis. The clinical course was complicated by encephalopathy, fluid retention, and spontaneous bacterial peritonitis, prompting consideration for liver transplantation. With supportive measures, jaundice and fluid retention resolved over a 3-month period. We conclude that prolonged use of bromfenac was the etiological agent in this case, and that this drug can cause severe hepatotoxicity resulting in liver failure.     

Wilson's disease

Progressive hepatolenticular degeneration, or Wilson's disease, is a genetic disorder of copper metabolism. Knowledge of the clinical presentations and treatment of the disease are important both to the generalist and to specialists in gastroenterology and hepatology, neurology, psychiatry, and paediatrics. Wilson's disease invariably results in severe disability and death if untreated. The diagnosis is easily overlooked but if discovered early, effective treatments are available that will prevent or reverse many manifestations of this disorder. Studies have identified the role of copper in disease pathogenesis and clinical, biochemical, and genetic markers that can be useful in diagnosis. There are several chelating agents and zinc salts for medical therapy. Liver transplantation corrects the underlying pathophysiology and can be lifesaving. The discovery of the Wilson's disease gene has opened up a new molecular diagnostic approach, and could form the basis of future gene therapy.