Preoperative treatment and survival of patients with pheochromocytomas.

BACKGROUND: Operative treatment is the method of choice for pheochromocytomas. The best success of the operation requires both good operative technique and effective preoperative medication. Phenoxybenzamine hydrochloride, an alpha-receptor blocker, has been our traditional premedication. Since 1988 we have used it in a combination with alpha-methylthyrosine, a catecholamine-synthesis blocker. AIM: To evaluate different preoperative medications. MATERIAL AND METHODS: Between 1984 and 1994 22 patients were operated on for pheochromocytomas in Tampere University Hospital. Five patients received alpha-receptor blocker, three patients received catecholamine-synthesis blocker, and 14 patients received their combination for a median of 33 days prior to the operation. RESULTS: Three of the five patients receiving alpha-receptor blocker, two of the three patients receiving catecholamine-synthesis blocker, and four of the 14 patients receiving combination therapy demonstrated high systolic blood pressure during the operation. Three patients, one in the alpha-receptor blocker group and two in the combination therapy group, demonstrated a short hypotensive period during the operation. None of the patients experienced severe perioperative cardiac arrhythmias. Mild sedation occurred similarly in either premedications, but the treatment did not need to be discontinued due to adverse reactions. There was no hospital mortality. Two patients had postoperative complications. CONCLUSION: Our initial experience with the combination therapy with alpha-receptor blocker and catecholamine-synthesis blocker is encouraging.

Posterior approach for adrenal surgery: experiences with 59 patients.

BACKGROUND: The laparoscopic approach has become popular for adrenal surgery. AIM: When starting with laparoscopic adrenalectomies we studied our experiences of posterior open approach for different adrenal disorders to obtain reference data. MATERIAL AND METHODS: Between 1983 and 1993 95 adrenalectomies were performed, of which 59 were via the posterior route. There were 51 unilateral (7 phaeochromocytomas, 6 Cushing's syndromes, 33 Conn's syndromes, 1 sex steroid secreting tumour and 4 incidentalomas) and 8 (Cushing's disease) bilateral adrenalectomies. RESULTS: Of the 4 incidentalomas one was a benign adenoma, one was cyst, one was cortical carcinoma, and one was a metastasis from breast cancer. Operative blood loss was median 300 ml, being higher in the bilateral than in the unilateral adrenalectomies (median 500 (range 300-1,250) ml vs. 300 (30-4,500 ml) (P = 0.01). Complications occurred in overall 11 patients (19%) (8 wound infections, 3 postoperative bleeding, 2 pneumonias, 1 urinary infection). Complications were more frequent in Cushing's patients than in the others (6/14 (43%) vs. 5/45 (11%); P = 0.015). Postoperative hospital stay was median 8 (range 5-21) days. The patients started liquids orally and were mobilised on the first post operative day, except for the 3 re-operated patients. Thromboembolic complications did not occur. Narcotics were used postoperatively for median 2 (range 0-7) days. CONCLUSIONS: With the posterior approach mortality and complications related to the pancreas, spleen, colon and duodenum were avoided. Other complications were rare except for the patients with Cushing's disease or syndrome.

Primary hyperparathyroidism: surgical results of 147 consecutive patients.

Surgery has been used to treat primary hyperparathyroidism since 1925. The indications for surgery in mild hypercalcaemia and in asymptomatic patients are not clearly established, but the attitude to surgery is liberal if the surgical results are good. The value of preoperative localisation studies prior to the initial neck exploration is also questionable. We evaluated the results of 147 consecutive patients, who had been operated on for hyperparathyroidism. We analysed also the results of preoperative localisation studies. Most of the patients had symptoms which could be related to primary hyperparathyroidism. Hypercalcaemia was cured by surgery in 96% of the patients, but six patients needed more than one procedure. Permanent hypocalcaemia ensued in 3% of the patients. Complications were rare, but occurred more often in patients with previous thyroid or parathyroid operations, and in patients who needed a simultaneous thyroid operation. Preoperative ultrasonography, which was made in 135 patients, revealed an abnormal parathyroid gland correctly in 47% of the patients. The result was incorrect in 26%, and there was no finding in 27% of the patients. Thallium-technetium subtraction scintigraphy, which was made in 96 patients, was correct in 29%, incorrect 41%, and uninformative in 30% of the patients. Angiography was performed in eight patients with a correct finding in six patients. We conclude that operative treatment for primary hyperparathyroidism is successful and safe in experienced hands. The reliability of noninvasive localisation studies is poor, and they are not necessary before the initial neck explorations.

Serum vitamin D metabolite concentrations in primary hyperparathyroidism.

Forty-nine patients with primary hyperparathyroidism were examined preoperatively and three months after parathyroid operation for their serum vitamin D metabolites and routine laboratory samples related to calcium metabolism. The preoperative serum 24,25-dihydroxyvitamin D level, mean (SE) was 1.86 (0.22) nmol/l and the postoperative level 5.35 (0.63) nmol/l, the difference being highly significant (P less than 0.001). Serum 1,25-dihydroxyvitamin D levels fell significantly (P less than 0.001) from a preoperative level of 175.5 (17.9) pmol/l to 102.8 (10.1) pmol/l postoperatively. The preoperative 25-hydroxyvitamin D level did not change significantly after surgery. The preoperative serum 24,25-dihydroxyvitamin D level was very low, especially in patients with bone disease while serum parathormone was significantly higher than in patients without bone disease.

Clinical and biochemical features in primary hyperparathyroidism.

Sixty-one consecutive patients were examined to determine the current mode of presentation of primary hyperparathyroidism (pHPT). Of these patients, 37.7% were asymptomatic, and the initial indication of pHPT was hypercalcemia, which was found unexpectedly on biochemical screening of the serum in elderly patients. Hypertension was twice as common among patients with pHPT as in the general population (36.1%). The next most common presentations were urinary calculi (18%) and mental depression (18%). The most useful discriminant laboratory tests were serum calcium, phosphorus, chloride, and parathormone (PTH). The calculated coefficient of correlation of PTH to land weight was high (r = 0.571, p less than 0.001). There was very significant correlation between PTH and seriousness of bone disease (r = 0.620, p less than 0.001). After parathyroidectomy, 3.3% of patients remained hypercalcemic, 93% were normocalcemic, and 1.6% were hypocalcemic.

Adrenal pheochromocytoma-ganglioneuroma producing catecholamines and various neuropeptides.

A 65-year-old woman presenting with back pain, difficulties in walking and watery diarrhea. A right adrenal tumor and high excretion of catecholamines were found. Laboratory examinations showed raised levels of vasoactive intestinal polypeptide, pancreatic polypeptide, gastrin and calcitonin. Histology showed a combined pheochromocytoma-ganglioneuroma. The neoplastic cell population was immunohistochemically shown to contain tyrosine hydroxylase, neuropeptide Y, met-enkephalin, substance P, vasoactive intestinal polypeptide, calcitonin and calcitonin gene-related peptide. Postoperatively, the patient recovered fully and the hormone levels returned to normal.

Antifibrinolytic therapy for prevention of hemorrhage during surgery of the thyroid gland.

The amount of fibrinolytic activity in the thyroid gland equals that of the prostate. In order to examine the effect of the antifibrinolytic drug tranexemic acid on perioperative bleeding saline or tranexemic acid were given randomized double blind to 76 consecutive patients who came for scheduled thyroid surgery. No significant differences were found in perioperative bleeding between patients in the treatment group (n = 39) and control group (n = 37).