Indications for laparoscopic adrenalectomy for non-functional adrenal tumor with hypertension: Usefulness of adrenocortical scintigraphy

AIM: Laparoscopic adrenalectomy is currently indicated for biochemically and clinically functional adrenal tumors and potentially malignant tumors of the adrenal glands. Non-functional adenomas greater than 5 cm in diameter of the adrenal gland are generally considered to represent potentially malignant tumors. The present study shows indications of laparoscopic adrenalectomy for non-functional adrenal tumors with hypertension in a retrospective fashion. METHODS: Between 1994 and 2004, 110 laparoscopic adrenalectomies were performed at Tokushima University Hospital. All 110 patients underwent detailed endocrinological examination before surgery. Medical and operative records of these 110 patients (57 men, 53 women), including operative parameters, histopathological findings and pre- and postoperative hypertension, were reviewed. Forty-five patients underwent laparoscopic adrenalectomy for non-functional adrenal tumors, and [(131)I]6beta-iodomethyl-19-norcholest-5(10)-en-3beta-ol (NP-59) scintigraphy was performed for patients with preoperative hypertension. RESULTS: Mean patient age was 55.0 years (range, 22-77 years). Mean maximum tumor diameter was 42 mm (range, 20-105 mm). All adrenal tumors were removed successfully by laparoscopic surgery. Hypertension was postoperatively improved in seven of the 11 patients with preoperative hypertension, without subclinical Cushing syndrome. Importantly, all patients who improved hypertension after adrenalectomy displayed strong accumulation in adrenal tumors with visualization of the contralateral gland on NP-59 scintigraphy. Conversely, blood pressure did not improve in four patients for whom scintigraphy yielded negative results. CONCLUSIONS: The indication of laparoscopic adrenalectomy for non-functional adrenal tumors is generally considered for lesions more than 5 cm diameter. However, the present study suggests that laparoscopic surgery should be considered even in patients with tumors less than 5 cm in diameter, if both hypertension and accumulation in tumors on NP-59 scintigraphy are present.     

Bilateral adrenal myelolipoma associated with adrenogenital syndrome

Adrenal myelolipoma is a rare benign tumor, occasionally reported in association with endocrine disorders. We report herein a case of bilateral adrenal myelolipoma associated with adrenogenital syndrome caused by 21-hydroxylase deficiency. A diagnosis of 21-hydroxylase deficiency was confirmed by mutation analysis of the CYP21 gene. Our case represents only the second case of bilateral adrenal myelolipoma associated with adrenogenital syndrome caused by 21-hydroxylase deficiency.     

Allogeneic Bone Marrow Transplantation for the Treatment of Acute Leukemia: The Kanazawa Experience

Twelve patients with acute leukemia (7 with nonlymphoblasticleukemia and 5 with lymphoblastic leukemia) were treated withhigh-dose cyclophosphamide and 1,000 rad total body irradiationfollowed by allogeneic bone marrow transplantation from theirHLA-identical sibling donors. Of eight patients given transplantsat relapse, only one patient has become a long-term survivor;he is alive in disease-free complete remission (CR) 4 yr afterthe transplantation. A cure is probable in this patient. Offour patients given transplants during remission, two have survivedin unmaintained CR for almost 1 yr or more. Recurrent leukemiawas observed in two patients whose disease was resistant toconventional therapy at the time of transplantation. Major causesof treatment failure were interstitial pneumonia, hepatic failuredue to veno-occlusive disease, severe infection and relapse.Transplantation-related complications were more frequent andserious in patients who received transplants at relapse thanin those receiving them during remission. The incidence of graft-versus-hostdisease was relatively high but the disease was neither primarynor leading cause of death. These preliminary but relativelyencouraging data suggest that transplantation during remissionmay reduce posttransplant morbidity and mortality. This approachwill contribute to producing long-term survival or cure in patientswith adult acute leukemia if a suitable donor is available.     

A study of cognitive development and behavior problems in mentally retarded children

Abstract Cognitive development in seventy-one mentally retarded children (19 autistic, 52 non-autistic; aged 7–19 years) from a school for handicapped children was studied, using Ohta's scale for evaluating cognitive development level based on language comprehension (Ohta's stage), and other developmental scales. Behavior problems were also examined. The present study reports on the utility of Ohta's stage in non-autistic children, and the relationship between cognitive development level and behavior problems in mentally retarded children. In non-autistic children, there were temporal correlations between Ohta's stage and other development scales (a standard developmental test, speech development, symbolic play development, imitation development), suggesting that in non-autistic children as well, Ohta's stage may serve well as a scale for cognitive development, and reflect symbolic representational functioning. In non-autistic children, most behavior problems in feeding, elimination and sleeping, hyperkinesis, hypokinesis, stereotyped behaviors, self-injurious behavior and licking were closely associated with cognitive development level, and were more often noted in children of lower cognitive development level rather than only in the severely mentally retarded children. Some behavior problems may often occur in the sensorimotor period and hardly occur in the symbolic representational period.     

LAPAROSCOPIC NEPHRECTOMY FOR INFLAMMATORY RENAL CONDITIONS

PURPOSE: Inflammatory and infectious renal conditions may result in severe perirenal fibrosis, making the laparoscopic approach challenging. The theoretical advantages of laparoscopy for managing inflammatory and infectious renal conditions have been questioned. We identified whether laparoscopy for inflammatory renal conditions is associated with higher morbidity than for other benign renal conditions. Furthermore, several technical modifications are discussed that may help to improve the outcome. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients who underwent laparoscopic nephrectomy for inflammatory and infectious renal conditions between 1998 and 2000. The transperitoneal approach was used and specimens were removed after morcellation. Operative data were compared with those from a similar group of patients who underwent laparoscopic nephrectomy for other benign conditions. RESULTS: Laparoscopic nephrectomy done for inflammatory or infectious conditions in 12 cases and for other benign conditions in 9 matched cases was completed successfully in 10 (83%) and 9 (100%), respectively. In the inflammatory and benign groups mean blood loss plus or minus standard deviation was 155 +/- 163 and 59 +/- 23 ml. (p = 0.099), mean operative time was 284 +/- 126 and 226 +/- 62 minutes (p = 0.225), and mean postoperative hospital stay was 4.1 +/- 2 and 3 +/- 1 days (p = 0.157), respectively. CONCLUSIONS: Laparoscopic nephrectomy can be performed safely in most cases of inflammatory renal conditions. Although they were not statistically significant, a higher conversion rate and longer operative time should be expected. Early conversion may be required due to failure to progress. Similar advantages were observed in patients with inflammatory and other benign renal conditions via the laparoscopic approach.     

Reduction in blood glucose values following indomethacin therapy for patent ductus arteriosus

PURPOSE: To evaluate the effects of indomethacin on blood glucose values in premature infants with patent ductus arteriosus (PDA). METHODS: Twenty-five very low birthweight infants with PDA were given 0.2 mg/kg, i.v., indomethacin for up to three doses. We examined the relationship between blood glucose values and glucose infusion rate before and after indomethacin therapy. RESULTS: There was a significant reduction in blood glucose values between 12 and 96 h following i.v. indomethacin therapy. Eleven of 25 infants (44%) had blood glucose values below 40 mg/dL between 12 and 60 h (mean 32.7 h) after the initial dose. Although the glucose infusion rate during the first 12 h was constant (3.56 +/- 0.98 mg/kg per min), the blood glucose values decreased from 96 +/- 32 mg/dL at the starting point to 75 +/- 29 mg/dL at 12 h (P < 0.05). The maximum blood glucose reduction was 51.6 +/- 34.7 mg/dL and the maximum blood glucose reduction rate was 50.4 +/- 20.2%. CONCLUSIONS: The results suggest that blood glucose values should be measured at least every 6 h for 72 h until they stabilize in order to prevent unexpected hypoglycemia.