Adrenal incidentaloma: the influence of a decision-making algorithm on the short-term outcome of laparoscopy

BACKGROUND: At the present time, the precise indications for laparoscopic surgery of adrenal incidentaloma (AI) have yet to be completely clarified. The most controversial issue is the role of laparoscopy in the treatment of potentially malignant and large adrenal masses. Trying to address these questions, we retrospectively examined a group of patients with AIs. MATERIALS AND METHODS: Forty-two patients with AIs who were laparoscopically treated since 1995 were enrolled in this study. The patients were divided into two groups: the 27 patients of the immediate surgery (IS) group were operated on immediately, whereas the 15 subjects in the delayed surgery (DS) group needed further evaluations and/or a follow-up period before surgery. Surgical timing for both groups was decided according to a widely accepted decision-making algorithm. Many outcome parameters of laparoscopy (operative time, blood loss, conversion rate, time to liquid and solid food nutrition, drainage removal, resumption of normal bowel habits, and average hospital stay) were analyzed in the two groups. The subjects had AIs of various sizes and different histotypes. RESULTS: Patients in the DS group had a higher risk for malignancy. The definitive pathology revealed a malignant biology in 26.6% of DS vs. 0% of IS cases. No difference in the outcome parameters of laparoscopy was observed between the two groups or among pathologically different AIs. A significant correlation was found between the operative time and the size of the AI (r=0.836, P<0.001, linear regression test). CONCLUSION: Our study shows that laparoscopy is feasible and safe for AIs, regardless of the preoperative probability of malignancy. The size of the AI was the only determinant for choosing a laparotomy. Further long-term studies are necessary to confirm the laparoscopic efficacy in terms of oncologic safety.     

Tracheomalacia associated with Mounier-Kuhn syndrome in the Intensive Care Unit: treatment with Freitag stent. A case report

Tracheomalacia is a process characterized by softness of the supporting tracheal cartilages, by the extension of the posterior membranous wall and by reduction of the tracheal antero-posterior diameter. Exceptionally, tracheomalacia can be associated with tracheobronchomegaly or Mounier-Kuhn syndrome. Fibro-bronchoscopy represents the 'gold standard' for diagnosis. The case of a 79-year-old male observed after hospitalization in a medical ward for chronic pulmonary obstructive disease (COPD) decompensation, and with basal left bronchopulmonary focus, is described. During this period, a progressive worsening of clinical conditions occurred, despite cortisone and antibiotic therapy, and the patient was transferred to the ICU for dyspnea, hypoxia, hypocapnia and with a diagnosis of pulmonary fibrosis. Bronchoscopy, performed during spontaneous breathing, revealed tracheomalacia which was responsible for tracheal dynamic complete stenosis during expiration and dynamic subtotal stenosis of the left primary bronchus in the first tract, together with sputum retention. Moreover, this investigation confirmed the diagnosis of tracheobronchomegaly already seen on CT. It was suggested to place a Freitag stent, since the insertion of another model would not have had enough chance of stability, due to the enormous extension of the tracheal lumen and could not have guaranteed good clearance of the secretions. Seven days after this intervention, performed in an outpatients' setting, the patient was dismissed from the ICU, without the help of O2, with good ventilation, saturation in line with his age and good expectoration.     

Hemodynamic results of acute thoracic aortomyoplasty in a canine model: comparison of stimulation regimens

Our previous investigations in a sheep model demonstrated that when electrical stimulation (ES) was applied to a newly mobilized latissimus dorsi muscle (LDM) in a work-rest regimen and at a rate of 15 contractions per minute, it did not damage this muscle. This regimen was used twice during a 60 minute period, once a day for 16 days, with no LDM damage. The goal of our current investigation was to apply this regimen in studies of acute thoracic aortomyoplasty. In two experimental groups, we mobilized the LDM but left it in situ. Two hours later, contractile force (CF) testing (20 g/kg preload, six impulses per burst) was performed until CF dropped to 50% of baseline. Recovery time needed to completely restore CF was calculated. In one group (six sheep), we applied continuous ES; in another (six sheep), we applied ES in a work-rest regimen (1 min work, 1 min rest). In two other groups of six dogs each, aortomyoplasty was performed; the LDM flap was subjected to ES immediately postoperatively (six impulses per burst; ventricular-LDM delay, 290 ms). Again, one group received continuous ES, and the other received work-rest ES. In the mobilized LDM under continuous ES, CF decreased to 50% of baseline values after 52 +/- 8 minutes, and returned to baseline after 84 +/- 16 minutes of rest. Under the work-rest regimen, this decrease took 105 +/- 8 minutes, and the return to baseline took 25 +/- 6 minutes (p < 0.05). In LDM subjected to work-rest ES, light microscopy revealed no additional damage to LDM tissue than was seen immediately after mobilization. However, LDM subjected to continuous ES had evidence of increased basophilic degeneration and wavy fibers. After acute thoracic aortomyoplasty, assisted hemodynamic values under the continuous ES exceeded unassisted values for only 40 minutes, compared with 100 minutes for work-rest ES (p < 0.05). When counterpulsation was completed, for continuous ES, recovery time to baseline was 96 +/- 9 minutes; for work-rest ES, it was only 43 +/- 6 minutes. In conclusion, a work-rest regimen of ES can be started safely immediately postprocedure.     

Magnetic resonance cholangiopancreatography in primary sclerosing cholangitis in children

BACKGROUND: Primary sclerosing cholangitis (PSC) is a chronic cholestatic syndrome of unknown aetiology. Diagnosis is based on clinical and laboratory data in conjunction with imaging of the biliary tree using endoscopic retrograde cholangiopancreatography (ERCP). OBJECTIVE:: To evaluate the clinical usefulness of MR cholangiopancreatography (MRCP) in the diagnosis of PSC in children. MATERIALS AND METHODS: Twenty-one children with clinical and laboratory suspicion of PSC were enrolled. MRCP was performed using a superconductive system with a phased-array coil. Rapid acquisition with relaxation enhancement (RARE) T2-weighted and half-Fourier single-shot turbo-spin-echo (HASTE) sequences were used. The distribution and extent of biliary tree changes were evaluated and classified according to Majoie's classification. A comparison between MRCP and ERCP was performed blind in all cases to evaluate the usefulness of MRI. RESULTS: In 13 cases (62%), MRCP showed abnormalities of the biliary tree which were considered positive for PSC, while in 8 cases there were no signs of PSC. Both MRCP and ERCP correctly identified changes in 13 cases and excluded abnormalities in 5. MRCP had a sensitivity of 81%, specificity of 100%, negative predictive value of 62%, positive predictive value of 100% and an accuracy of 85%. CONCLUSIONS: MRCP can be proposed as the preliminary non-invasive imaging modality for the diagnosis of PSC in children.