Selected publications from PubMed
Clinical Case An adrenal incidentaloma is a lesion larger than 1 cm in diameter, serendipitously discovered by radiologic examination. Its prevalence is increasing, from 0.4% to 4% in the last reports, reaching 10% in te elderly patients. The etiology of adrenal incidentalomas varies and includes benign and malignant lesions derived from the adrenal cortex, the medulla or of extra-adrenal origin. Some authors conclude that the prevalence of malignant and functional lesions is likely to be overestimated, mainly because of the higher prevalence of malignancy in surgical literature. Up to 80% of adrenal tumors are benign, with malignant lesions amounting to about 5%. Two questions must follow the discovery of an adrenal mass: is it malignant? And: is it functioning? Even though malignancy is an uncommon cause of adrenal incidentaloma a CT-scan or MRI may allow for a prediction of the histologic type of tumour. The use of a PET-scan may provide information on its function. Adrenal biopsy is generally discouraged unless there is a history of extra-adrenal malignancy and additional criteria are fulfiled: The lesion is hormonally inactive. The lesion has not been conclusively characterized as benign by imaging. The therapeutic approach would be altered by knowledge of the histology. While most adrenal incidentalomas are nonfunctional (89.7%) 10% to 15% secrete excess hormone amounts: Primary adrenal carcinoma 1.9% Metastases: 0.7% Subclinical Cushing’s syndrome: 6.4% Pheochromocytoma: 3.1% Primary aldosteronism: 0.6% The functional presentation of the tumors helps to categorize them into three entities: Subclinical Cushing's syndrome is the glucocorticoid secretory autonomy without clinical manifestations of Cushing's syndrome. It is the most frequent hormonal abnormality detected in patients with adrenalomas. Pheochromocytoma: catecholamines-secreting tumors that arise from chromaffin cells of the adrenal medulla and the sympathetic ganglia are referred to as "pheochromocytomas". The presence of a pheochromocytoma should be suspected in patients with severe hypertension, tachycardia, palpitations, cardiac arrhythmias, anxiety attacks, weight loss, or sweating. Aldosteronomas are rare (less than 1 percent) causes of adrenal incidentaloma. However, because the majority of patients with primary aldosteronism are not hypokalemic, all patients with hypertension and an adrenal incidentaloma should be evaluated by measurements of plasma aldosterone concentration and plasma renin activity. Treatment of this tumor depends on the histology and should change if there is a unilateral tumour or if both adrenal glands are affected. Unilateral adrenal masses: All patients with documented pheochromocytoma and adrenocortical cancer should undergo prompt surgical intervention because untreated pheochromocytoma may result in significant cardiovascular complications. Alpha blockade should be prescribed before adrenalectomy. Patients with aldosterone-producing adenomas should be offered surgery to cure the aldosterone excess. Adrenal masses with either suspicious imaging phenotype or size larger than 4 cm should be considered for resection because a substantial fraction will be adrenocortical carcinomas. Bilateral adrenal masses: management of bilateral adrenal masses is different from that for unilateral masses. As an example, in cases of subclinical bilateral macronodular adrenal hyperplasia (BMAH), size is not an indication for surgery, as some can be as large as 5 to 10 cm, with insufficient hormone production to require surgery. Patients with bilateral adrenal masses should be investigated for congenital adrenal hyperplasia Laparoscopic adrenalectomy has been associated with less pain, shorter hospitalization time, less blood loss, and faster recovery than open adrenalectomy. The latter is recommended for large (> 10 cm) adrenal masses including those benign imaging features, as the adrenal mass may be diagnosed as malignant on a definitive histologic review. Incidentalomas with a benign appearance may be followed up through another CT or MRI in 6 to 12 months’ time. Most experts would consider resecting any tumor that enlarges by more than 1 cm in diameter during the follow-up period. However, most adrenal masses that grow are not malignant.
Published
Nov 2017
Clinical Case We present the case of a 54-year-old male patient, with a history of gastric ulcer due to H. Pylori more than 10 years ago and no other past medical history. The patient presented with hematochezia and significant fatigue in the last 24 hours in the emergency room with a hypovolemic shock. An emergency endoscopy showed a 2-cm lesion on the greater curvature, with a macroscopically normal mucosa and no ulceration, but a pounding blood vessel. Hemostasis was achieved with clips. The CT scan revealed a 25 mm solid tumor in the greater curvature, suggesting GIST. The patient stabilized in the ICU although he had a new bleeding episode, which was treated again endoscopically with sclerotherapy, but definitive surgical intervention was then proposed. Procedure: The patient was placed in the supine position with open legs. A total of four trocars were used. Adhesions were freed between the stomach, omentum and abdominal wall. Dissection had to be careful to avoid opening the tumor. Ligasure was used to complete the dissection and good hemostasis. Subsequently, it was necessary to delimit the size of the tumor, controlling it both proximally and distally by means of sutures. The surgeon corroborates that the proximal stomach is completely free from adhesions, which allows proper manipulation during the section of the gastric wall. An orogastric tube - such as a Foucher tube - must be introduced to calibrate the wedge resection, preserve a sufficient gastric lumen, and ensure neoplasia-free margins. After delimiting the limits of the tumor, the Endo GIA stapler is introduced for wedge resection, starting distally and continuing proximally in order to complete the tumor resection. It is important to check anteriorly and posteriorly before firing the mechanical suture as well as check the staple line and confirm hemostasis. Operative time was 95 minutes. The patient started oral intake the next day after the surgery and left hospital on the 3rd postoperative day with no complications. The final pathology was described as a 3 cm tumor located in the submucosa, with free margins and Ki67 proliferative activity in less than 2% of the cells, compatible with GIST.
Published
Oct 2017
Clinical Case Sutures hold apposing tissues together to facilitate the healing process. Knowledge of the fundamental concepts regarding sutures, such as external configuration, strength, memory and types of materials is crucial to select the most suitable suture for each stage during a surgical procedure. 1. Physical Configuration >Multifilament sutures can be braided or twisted. They provide greater knot security than monofilament sutures, which have more "memory". Monofilament sutures are more resistant to serious infection than multifilament sutures and natural fibers. 2. Tensile strength Tensile strength is defined as the weight required to break a suture divided by its cross sectional area. The designation is the number of zeros (1-0 to 10-0): the smaller the size, the lower the strength. 3.Knot strength Knot strength is the force required to cause a knot to slip and is directly proportional to the friction coefficient for a given material. 4. Elasticity and memory Elasticity is a material’s intrinsic ability to hold its original shape and length after being stretched. Memory refers to the inherent ability of a material to return to its former shape after being manipulated, and is often a reflection of its stiffness. 5.Synthetic versus Natural Materials Synthetic sutures provide greater uniformity, tensile strength and wound security, longer duration of support during wound healing and cause less inflammatory response than natural fibers. 6.Absorbable and non-absorbable Sutures Non-absorbable sutures typically maintain tensile strength for more than two months, and many synthetic sutures remain in the incision permanently. Synthetic sutures provide longer wound security (300 days or more). Knowledge of the characteristics of the sutures is crucial for the surgeon as each type of suture has specific characteristics which may make it appropriate for a specific circumstance.
Published
Oct 2017
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