Pheochromocytoma associated with neurofibromatosis type 1: concepts and current trends.

BACKGROUND: Neurofibromatosis Type 1(NF-1) has autosomal dominant inheritance with complete penetrance, variable expression and a high rate of new mutation. Pheochromocytoma occurs in 0.1%-5.7% of patients with NF-1. CASE PRESENTATION: We present the case of a 37-year-old patient with laparoscopically resected pheochromocytoma. He was investigated for hypertension, flushing and ectopic heart beat. Abdominal CT and MRI revealed a mass measuring 8 x 4 cm in the right adrenal gland. The diagnosis of pheochromocytoma was confirmed by elevated 24-hour urine levels of VMA, metanephrines and catecholamines as well as positive MIBG scan. The patient presented with classic clinical features of NF-1, which was confirmed by pathologic evaluation of an excised skin nodule. The patient underwent laparoscopic right adrenalectomy through a transabdominal approach and was discharged on the second postoperative day, being normotensive. The patient is normotensive without antihypertensive therapy 11 years after the procedure. CONCLUSION: Nowadays in the era of laparoscopy, patients with pheochromocytoma reach the operating theatre easier than in the past. Despite, the feasibility and oncological efficacy of the laparoscopic approach to the adrenals, continued long term follow-up is needed to establish the minimally invasive technique as the preferred approach. Furthermore, these patients should be further investigated for other neoplasias and stigmata of other neurocutaneous syndromes, taking into account the association of the familial pheochromo-cytoma with other familial basis inherited diseases.

Laparoscopic resection of large adrenal tumors.

BACKGROUND: Laparoscopic adrenalectomy has rapidly replaced open adrenalectomy as the procedure of choice for benign adrenal tumors. It still remains to be clarified whether the laparoscopic resection of large (≥ 8 cm) or potentially malignant tumors is appropriate or not due to technical difficulties and concern about local recurrence. The aim of this study was to evaluate the short- and long-term outcome of 174 consecutive laparoscopic and open adrenalectomies performed in our surgical unit. METHODS: Our data come from a retrospective analysis of 174 consecutive adrenalectomies performed on 166 patients from May 1997 to December 2008. Fifteen patients with tumors ≥ 8 cm underwent laparoscopic adrenalectomy. Sixty-five patients were men and 101 were women, aged 16 years to 80 years. Nine patients underwent either synchronous or metachronous bilateral adrenalectomy. Tumor size ranged from 3.2 cm to 27 cm. The largest laparoscopically excised tumors were a ganglioneuroma with a mean diameter of 13 cm and a myelolipoma of 14 cm. RESULTS: In 135 patients, a laparoscopic procedure was completed successfully, whereas in 14 patients the laparoscopic procedure was converted to open. Seventeen patients were treated with an open approach from the start. There were no conversions in the group of patients with tumors > 8 cm. Operative time for laparoscopic adrenalectomies ranged from 65 minutes to 240 minutes. In the large adrenal tumor group, operative time for laparoscopic resection ranged from 150 minutes to 240 minutes. The postoperative hospital stay for laparoscopic adrenalectomy ranged from 1 day to 2 days (mean, 1.5) and from 5 days to 20 days for patients undergoing the open or converted procedure. The mean postoperative stay was 2 days for the group with large tumors resected by laparoscopy. CONCLUSION: Laparoscopic resection of large (≥ 8 cm) adrenal tumors is feasible and safe. Short- and long-term results did not differ in the 2 groups.

Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: a randomized placebo-controlled study.

BACKGROUND: Recent studies have indicated that unmanaged pain, both acute and chronic, can affect mental status and might precipitate delirium, especially in elderly patients with hip fractures. The aim of this study was to assess the effectiveness of fascia iliaca compartment block (FICB) for prevention of perioperative delirium in hip surgery patients who were at intermediate or high risk for this complication. MATERIALS AND METHODS: On admission, all included patients were divided into three groups according to low, intermediate or high risk for perioperative delirium. Eligible patients (those classified as at intermediate or high risk for developing delirium) were sequentially randomly assigned to study treatment (FICB prophylaxis or placebo) according to a computer-generated randomization code. The primary outcome was perioperative delirium. Diagnosis of the syndrome was defined using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) and Confusion Assessment Method (CAM) criteria. Secondary outcome variables were severity of delirium and delirium duration. RESULTS: Delirium occurred in 33 (15.94%) out of 207 patients randomized to FICB prophylaxis or the placebo group. Incidence of delirium in the FICB prophylaxis group was 10.78% (11/102), significantly different from the incidence (23.8%, 25/105) in the placebo group [relative risk 0.45, 95% confidence interval (CI) 0.23-0.87]. Nine of 17 patients with high risk for delirium and included in the FICB prophylaxis group developed delirium, whereas 10 of 16 high-risk patients included in the placebo group became delirious (relative risk 0.84, CI 0.47-1.52). Two of 85 patients with intermediate risk for delirium and included in the FICB prophylaxis group developed delirium, whereas 15 of 89 intermediate-risk patients included in the placebo group became delirious (relative risk 0.13, CI 0.03-0.53). Severity of delirium according to the highest value of the DRSR-98 during an episode with delirium in patients in the FICB prophylaxis group was on average 14.34, versus 18.61 in the placebo group (mean difference 4.27, 95% CI 1.8-5.64, P < 0.001). Mean duration of delirium in the FICB prophylaxis group was significantly shorter than in the placebo group (FICB 5.22 days versus placebo 10.97 days, 95% CI 3.87-7.62, P < 0.001). CONCLUSION: No significant difference was found among high-risk patients between FICB prophylaxis and placebo groups in terms of delirium incidence. However, FICB prophylaxis significantly prevented delirium occurrence in intermediate-risk patients. Thus FICB prophylaxis could be beneficial, particularly for intermediate-risk patients.

The four-year functional result after a displaced subcapital hip fracture treated with three different surgical options.

According to the literature, hip function after hip fracture is affected by the type of surgery. Our aim was to determine the correlation between surgical treatment of hip fracture and postoperative function in the elderly. Inclusion criteria were displaced hip fracture and age over 70 years. One hundred and twenty-nine participants were randomly divided into three groups according to the type of the surgical operation they underwent (hemi-arthroplasty [Merete, Berlin, Germany], total arthroplasty [Plus; De Puy, Warsaw, IN, USA] and internal fixation [Richards plate screw; Smith & Nephew, Memphis, TN, USA]). The function of the patients was estimated using the following parameters: the Barthel Index and Harris Hip Score, the range of passive hip motion, the gait speed of individuals, after 1 and 4 years of follow-up. The Barthel Index scores after 4 years of follow-up were 85.3, 82.6, 80.1 after total arthroplasty, hemi-arthroplasty and internal fixation respectively. Similarly, the Harris Hip Scores after 4 years of follow-up were 83.7, 79.5 and 73.6. The range of passive hip motion in the three groups of patients did not differ significantly (p>0.05). Also, patients of the total arthroplasty and hemi-arthroplasty groups walked faster than the patients of the internal fixation group 4 years after discharge (p<0.05). In conclusion, we believe that total hip arthroplasty is the treatment of choice for displaced subcapital hip fractures in patients over 70 years old.

Open and laparoscopic approach in incisional hernia repair with ePTFE prosthesis.

BACKGROUND: The aim of this retrospective study was to analyze the results of incisional hernia laparoscopic and open surgery, focusing on the morbidity and postoperative implications. MATERIALS AND METHODS: A group of 106 (42 men, 64 women) patients suffering from incisional hernias were treated with either a laparoscopic (30) or an open (76) placement of a prosthetic mesh between January 1997 and December 2004. The age and gender of the patients, the size and type of the mesh, operation note, the length of postoperative hospital stay, and morbidity were recorded. RESULTS: An expanded polytetrafluoroethylene (ePTFE) mesh was used in 103 patients, whereas a polypropylene mesh was used in 3 patients. In the open technique, 3 patients with the ePTFE prosthetic material developed a mesh infection and required a mesh removal, which was easily performed under local anesthesia. Moreover, 2 patients from the same group developed a hernia recurrence. As for the laparoscopic approach, the only complication observed was one hernia recurrence. Finally, it should be mentioned that 1 patient with a polypropylene mesh developed a colocutaneous fistula. CONCLUSIONS: The benefits of the laparoscopic mesh technique, compared to the open technique, include a shorter hospital stay, less postoperative pain, and possibly, a reduction in wound and mesh complications. Regarding the recurrence rate, the two techniques show similar results.

Ecology of the microbial community removing phosphate from wastewater under continuously aerobic conditions in a sequencing batch reactor.

All activated sludge systems for removing phosphate microbiologically are configured so the biomass is cycled continuously through alternating anaerobic and aerobic zones. This paper describes a novel aerobic process capable of decreasing the amount of phosphate from 10 to 12 mg P liter(-1) to less than 0.1 mg P liter(-1) (when expressed as phosphorus) over an extended period from two wastewaters with low chemical oxygen demand. One wastewater was synthetic, and the other was a clarified effluent from a conventional activated sludge system. Unlike anaerobic/aerobic enhanced biological phosphate removal (EBPR) processes where the organic substrates and the phosphate are supplied simultaneously to the biomass under anaerobic conditions, in this aerobic process, the addition of acetate, which begins the feed stage, is temporally separated from the addition of phosphate, which begins the famine stage. Conditions for establishing this process in a sequencing batch reactor are detailed, together with a description of the changes in poly-beta-hydroxyalkanoate (PHA) and poly(P) levels in the biomass occurring under the feed and famine regimes, which closely resemble those reported in anaerobic/aerobic EBPR processes. Profiles obtained with denaturing gradient gel electrophoresis were very similar for communities fed both wastewaters, and once established, these communities remained stable over prolonged periods of time. 16S rRNA-based clone libraries generated from the two communities were also very similar. Fluorescence in situ hybridization (FISH)/microautoradiography and histochemical staining revealed that "Candidatus Accumulibacter phosphatis" bacteria were the dominant poly(P)-accumulating organisms (PAO) in both communities, with the phenotype expected for PAO. FISH also identified large numbers of betaproteobacterial Dechloromonas and alphaproteobacterial tetrad-forming organisms related to Defluviicoccus in both communities, but while these organisms assimilated acetate and contained intracellular PHA during the feed stages, they never accumulated poly(P) during the cycles, consistent with the phenotype of glycogen-accumulating organisms.

Rupture of adductor longus tendon due to ciprofloxacin.

We present a rare case of spontaneous rupture of the adductor longus tendon induced by ciprofloxacin. A 35-year-old man was diagnosed with pneumonia and was recommended ciprofloxacin 500 mg iv twice a day for 7 days. Three days after receiving the initial dose, he developed discomfort in his left medial thigh, and pain and swelling in the same area followed ten days later. He consulted us when he noted a palpable mass on the medial side of his left thigh, and MRI study revealed adductor longus tendon rupture. There was no obvious underlying disease or other factor causing fragility of his adductor longus tendon. We review the pathophysiological mechanisms leading to fluoroquinolone-related tendon rupture as well as the risk factors and discuss proper management.