Laparoscopic adrenalectomy for functioning and non-functioning adrenal tumors: Analysis of surgical aspects based on histological types

BACKGROUND: The aim of this study was to evaluate whether hormonal functions of the tumor influence the operative results of laparoscopic adrenalectomy, and to analyse the clinical outcomes in patients with various hormonally active adrenal tumors. METHODS: Clinical and pathological records of 68 patients were reviewed. The average age of patients was 40 years (range 20-75); 39 were women and 29 men. For the comparison, patients were divided into the non-functioning tumor group (n = 22) and the functioning tumor group (n = 46). RESULTS: All laparoscopic adrenalectomies were finished successfully, and no open surgery was necessary. The median operative time and blood loss in the two groups were similar; however, in subgroup analysis, operative time for pheochromocytoma was significantly longer than that for non-functioning tumor (P = 0.044). No difference was noted in intra- and postoperative data between the groups. Of the 22 patients with aldosteronoma, 18 (81.8%) became normotensive and no longer required postoperative blood pressure medications. Adrenalectomy led to an overall reduction in the median number of antihypertensive medications (P < 0.001). All patients with Cushing adenoma had resolution or improvement of the signs and symptoms during follow-up periods. There was no evidence of biochemical or clinical recurrence in any patient with pheochromocytoma. CONCLUSION: The results of this retrospective review document that laparoscopic adrenalectomy is a safe and effective treatment for functioning as well as non-functioning adrenal tumors, although endocrinologic features may play a significant role.     

Nine‐Month Angiographic and Intravascular Ultrasound Outcomes After Resolute Zotarolimus‐Eluting Stent Implantation for the Treatment of In‐Stent Restenosis

Objectives

We aimed to evaluate the mid‐term outcomes of resolute zotarolimus‐eluting stent (R‐ZES) implantation for in‐stent restenosis (ISR).

Background

There has been a paucity of data regarding the effects of new‐generation drug‐eluting stent to treat ISR.

Methods

From 2009 to 2010, a total of 98 patients with 98 ISR lesions were prospectively enrolled after R‐ZES implantation for the treatment of ISR. Among 98 patients, 73 patients underwent follow‐up angiography at 9 months. Serial intravascular ultrasound (IVUS) at both postprocedure and 9 months was evaluated in 55 patients. The overlapped segment of R‐ZES was defined as the portion of R‐ZES superimposed on previous stent.

Results

Late loss and binary restenosis rate were 0.3 ± 0.5 mm and 5.5% at 9 months. On IVUS, the percentage of neointimal volume and maximum percentage of neointimal area were 3.9 ± 6.3% and 17.3 ± 15.5%, respectively. There was no significant change of vessel volume index between postprocedure and 9 months (16.9 ± 4.7 mm³/mm vs. 17.1 ± 4.6 mm³/mm, P = 0.251). Late‐acquired incomplete stent apposition was observed in 5 (5/55, 9.1%) cases. Compared with nonoverlapped segments of R‐ZES, the overlapped did not show larger neointimal volume index (0.3 ± 0.5 mm³/mm vs. 0.2 ± 0.3 mm³/mm, P = 0.187) on 9‐month IVUS. During follow‐up (median, 353 days), repeat target‐lesion revascularization was performed in four cases, but there were no death or stent thrombosis.

Conclusions

This study suggested that R‐ZES implantation for the treatment of ISR was effective up to 9 months and showed favorable vascular responses on serial IVUS assessment.

     

Effects of Oral Rho Kinase Inhibitor Fasudil on Detrusor Overactivity after Bladder Outlet Obstruction in Rats

Objectives: Bladder outlet obstruction (BOO)‐related detrusor hypertrophy is associated with upregulation of Rho‐kinase (ROCK) activity in an experimental animal model, and has been implicated in BOO‐induced bladder dysfunction. The aim of this study was to test whether chronic oral administration of an oral ROCK inhibitor, fasudil (HA1077, 5‐isoquinolinesulfonyl homopiperazine), could prevent the development of both detrusor hypertrophy and detrusor overactivity in rat model. Methods: Thirty five‐week‐old male Sprague‐Dawley rats were divided into three groups (n = 10 per group): control (sham surgical) with no treatment (group 1); 6‐week obstructed rats (group 2); and 6‐week obstructed rats treated for 6 weeks with fasudil (group 3). Results: The BOO group showed increased detrusor overactivity. Treatment with fasudil partly but significantly ameliorated the development of detrusor overactivity. The expression of RhoA protein in detrusor muscle was significantly greater in the BOO group than in the control group and subsequently decreased with fasudil treatment in the BOO‐induced rat. Conclusion: These findings suggest that fasudil, a specific inhibitor of Rho‐kinase, ameliorates BOO‐induced detrusor overactivity in a rat model. Thus, ROCK inhibitor might be used as a novel agent to treat overactive bladder symptoms.     

Radioisotope synoviorthesis with Holmium‐166‐chitosan complex in haemophilic arthropathy

Summary. Radiosynoviorthesis is a safe and easy method for synovectomy in haemophilic arthropathy. Various agents have been used in radiosynoviorthesis, especially newly developed agent Holmium‐166‐chitosan complex has good clinical outcome. This study analysed clinical results and radiologic evaluation of radioisotope synoviorthesis using Holmium‐166‐chitosan complex in haemophilic arthropathy. From March 2001 to December 2003, 58 radiosynoviorthesis were performed in 53 haemophiliacs. The average age at procedure was 13.8 years. The Arnold and Hilgartner stage of the patients was from I to IV. Holmium‐166‐chitosan complex was injected in 31 ankle joints, 19 elbow joints and 8 knee joints. Average follow‐up was 33 months since primary procedure. The range of motion of each joint, frequency of intra‐articular bleeding and factor dose used were analysed for clinical assessment. There was no significant improvement of range of motion in affected joints. After procedure, the average frequency of bleeding of the elbow joint has decreased from 3.76 to 0.47 times per month, the knee joint from 5.87 to 1.12 times per month, and the ankle joint from 3.62 to 0.73 times per month respectively (P < 0.05). After treatment, the average coagulation factor dose injected was significantly decreased to 779.3 units per month from 2814.8 units per month before treatment (P < 0.001). Radioisotope synoviorthesis with Holmium‐166‐chitosan complex in haemophilic arthropathy is a very safe and simple procedure with the expectation of a satisfactory outcome without serious complication. It has excellent bleeding control effect on target joint and the need for substitution of coagulation factor concentrate can be reduced.     

Septal Dyskinesia and Global Left Ventricular Dysfunction in Pediatric Wolff‐Parkinson‐White Syndrome with Septal Accessory Pathway

LV Dysfunction in WPW Syndrome. Introduction: Echocardiographic studies have shown that some patients with Wolff‐Parkinson‐White (WPW) syndrome have myocardial dyskinesia in the segments precociously activated by an accessory pathway (AP). The aim of the present study was to determine the extent to which the AP contributes to global left ventricular (LV) dysfunction. Methods: Electrophysiological and echocardiographic data from 62 children with WPW (age at diagnosis = 5.9 ± 4.2 years) were retrospectively analyzed. Results: The left ventricular ejection fraction (LVEF) of patients with septal APs (53 ± 11%) was significantly lower than that of patients with right (62 ± 5%) or left (61 ± 4%) APs (P = 0.001). Compared to patients with normal septal motion (n = 56), patients with septal dyskinesia (n = 6) had a reduced LVEF (61 ± 4% and 42 ± 5%, respectively) and an increased LV end diastolic dimension (P < 0.001 for both comparisons). Multivariate analysis identified septal dyskinesia as the only significant risk factor for reduced LVEF. All 6 patients with septal dyskinesia had right septal APs, and a preexcited QRS duration that was longer than that of patients with normal septal motion (140 ± 18 ms and 113 ± 32 ms, respectively; P = 0.045). After RFA there were improvements in both intraventricular dyssynchrony (septal‐to‐posterior wall motion delay, from 154 ± 91 ms to 33 ± 17 ms) and interventricular septal thinning (from 3.0 ± 0.5 mm to 5.3 ± 2.6 mm), and a significant increase in LVEF (from 42 ± 5% to 67 ± 8%; P = 0.001). Conclusion: The dyskinetic segment activated by a right septal AP in WPW syndrome may lead to ventricular dilation and dysfunction. RFA produced mechanical resynchronization, reverse remodeling, and improvements in LV function. (J Cardiovasc Electrophysiol, Vol. 21, pp. 290–295, March 2010)     

Clinical course of guttate psoriasis: Long‐term follow‐up study

Guttate psoriasis, known to have a better prognosis than other types of psoriasis, shows rapid involution and longer remission, but its clinical course has barely been studied. The aim of this study was to determine the clinical course and to compare the clinical and laboratory features of guttate psoriasis. This is a retrospective study of 26 patients with guttate psoriasis. The patients were divided into two groups; the good one with complete remission and long remission for at least 1 year (group A) and the poor one with incomplete remission and progression into chronic plaque psoriasis (group B). Among 36 patients, 22 patients (61.1%) were group A and 14 patients (38.9%) were group B. In group A, most of the skin lesions disappeared within 8 months. In group B, two patients without proper treatment progressed to plaque psoriasis. The onset age was younger and more frequent upper respiratory infection and high anti‐streptolysin O (ASO) titer were found in group A, but family history of psoriasis was more common in group B. Patients had two distingushable clinical courses: rapid involuting course with long‐term remission and chronic course without remission. There was a tendency toward younger age of onset with elevated ASO titer in patients with rapid involuting course.     

URTICARIAL VASCULITIS DEVELOPED ON THE STRIAE DISTENSAE DURING PREGNANCY

A 23-year-old woman (gravida 1, para 0) in her 34th week of pregnancy had urticarial erythema on the legs for a period of 2 weeks. The initial eruptions of erythematous papules, plaques, and urticarial lesions were noted on the calves, at the site of striae distensae. The number of erythematous le-sions had increased during the last 10 days to cover most of the preexisting sites of striae distensae on the lower legs and thighs, with several satellite lesions (Fig. 1). Individual lesions on the legs were pruritic and persisted longer than 1 day. The lesions of striae distensae on the legs (with urticari-al erythema) and on the abdomen (without any overlying urticarial lesions) had occurred during pregnancy over the past 8 months. There was no history of drug use, infection, or any other systemic disorders relevant to the skin dis-ease. Systemic symptoms such as fever, arthralgia, or malaise were not associated with the evolution of the ur-ticarial erythema. Her past medical history and family history were non-contributory. She was healthy and maintained uncomplicat-ed normal pregnancy without any remarkable findings on physical examination except for the skin lesions. A biopsy specimen taken from a satellite lesion showed a moderate degree of perivascular and transmural infiltra-tion of neutrophils, eosinophils, and lymphohistiocytic cells, with some nuclear dust in the upper dermis. Endothe-lial swellings and foci of extravasation of red blood cells were also seen (Fig. 2). The direct immunofluorescence study of the same tissue showed deposits of IgM and C3 in the blood vessel walls of the upper dermis (Fig. 2). The erythrocyte sedimentation rate was elevated to 45 mm/h. Complete blood count with differential, platelet count, urinalysis, and stool test for occult blood were within normal limits or negative. The pattern of serum protein electrophoresis, total serum hemolytic complement, and levels of human chorionic gonadotropin were all normal. The results of the tests for antinuciear antibodies, cryoglob-ulin, hepatitis B surface antigen, and VDRL were negative. The skin lesions of urticarial vasculitis in this patient were treated with oral prednisolone (25 mg/d). The pruritic lesions cleared in a week with no evidence of recurrence until the postpartum period.