Case of functional paraganglioma with intraoperative hypertensive crisis during robot-assisted thoracoscopic resection.

BACKGROUND: Mediastinal paragangliomas are rare. Their dangerousness may unfold during surgery, especially if hormonal activity was previously unknown. We report our experience with this case in context to the incidence and localization of atypically located mediastinal paragangliomas in the literature. CASE PRESENTATION: A 69-year-old female patient who was scheduled for thoracoscopic resection due to a posterior mediastinal tumor that had been progressing in size for several years and increasing symptoms. The induction of anesthesia, the ventilation of the lungs and the gas exchange after lung separation was uneventful. After initially stable circulatory conditions, there was a sudden increase in blood pressure up to 300/130 mmHg and tachycardia up to 130/min. This hypertensive phase was difficult to influence and required a rapid and consistent use of antihypertensive medication to bring down the blood pressure to reasonable values. The patient stabilized after tumor resection. The postoperative course was unremarkable. During the intraoperative blood pressure crisis, blood was drawn for analysis. These samples showed elevated concentrations of normetanephrine and metanephrine. The tumor subsequently presented as a catecholamine-secreting paraganglioma. CONCLUSION: In order to avoid life-threatening blood pressure crises, hormone activity should be ruled out preoperatively in the case of mediastinal tumor, in which a paraganglioma could be considered in the differential diagnosis, especially if there are indications of hypertension in the medical history. Robotic-assisted thoracoscopic resection of the posterior mediastinal tumor was a feasible surgical method, even in the case of unexpected functional paraganglioma.

Hemodynamics and cutaneous microcirculation during induction of general anesthesia with and without esketamine.

OBJECTIVE: Currently, there are limited data on the effect of macrocirculatory hemodynamic changes on human microcirculation, especially during the induction of general anesthesia (GA). METHODS: We performed a non-randomized observational trial on patients receiving GA for elective surgery. In the control group (CG), for GA induction sufentanil, propofol, and rocuronium was administered. Patients assigned to the esketamine group (EG) received additional esketamine for GA induction. Invasive blood pressure (IBP) and pulse contour cardiac output (CO) measurement were performed continuously. Microcirculation was assessed using cutaneous Laser Doppler Flowmetry (forehead and sternum LDF), peripheral and central Capillary Refill Time (pCRT, cCRT), as well as brachial temperature gradient (Tskin-diff) at baseline, 5, 10 and 15 minutes after induction of GA. RESULTS: 42 patients were included in the analysis (CG n = 22, EG n = 20). pCRT, cCRT, Tskin-diff, forehead and sternum LDF decreased following GA induction in both groups. IBP and CO were significantly more stable in esketamine group. However, the changes in the microcirculatory parameters were not significantly different between the groups. CONCLUSIONS: The addition of esketamine for GA induction warranted better hemodynamic stability for the first five minutes, but had no significant effect on any of the cutaneous microcirculatory parameters measured.

First application of intraoperative MRI of the liver during ALPPS procedure for colorectal liver metastases.

PURPOSE: Intraoperative detection of intrahepatic lesions can be demanding. The use of preoperative contrast-enhanced magnetic resonance imaging (MRI) or computer tomography (CT) combined with intraoperative ultrasound of the liver is state of the art. Near totally regressed colorectal liver metastases (CRLM) after neoadjuvant chemotherapy or nodules in severely altered liver tissue as steatosis or cirrhosis are often hard to detect during the operative procedure. Especially differentiation between benign atypical nodules and malignant tumors can be very difficult. The intraoperative use of contrast-enhanced ultrasound or intraoperative navigation are helpful tools. However, both methods show relevant limitations. The use of intraoperative MRI (ioMRI) can overcome this problem. Relevant structures can be marked within the operative site or immediate control of complete tumor resection can be achieved. This might allow immediate surgical optimization in case of failure. METHODS: We report the intraoperative application of ioMRI in a case of a 61-year-old male patient suffering from rectal cancer with 10 synchronous bilobar CRLM who was treated stepwise by multimodal treatment and staged hepatectomy. Intraoperative contrast-enhanced MRI of the liver was used during completion procedure of an extended right hemihepatectomy performed as "Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS)". RESULTS: ioMRI provided excellent images and showed absence of liver metastases in the liver remnant. Procedure of ioMRI was safe, fast and feasible. CONCLUSION: To the best of our knowledge, we describe the first case of intraoperative application of a contrast-enhanced MRI during open liver surgery at the University Hospital of Dresden.