Adrenalectomy for Pheochromocytoma: Complications and Predictive Factors of Intraoperative Hemodynamic Instability.

BACKGROUND: Surgery is the treatment of choice for pheochromocytoma. However, this surgery carries a risk of hemodynamic instability (HDI). The aim of this study was to report complications associated with this procedure, to identify risk factors for HDI during surgery, and its impact on postoperative outcomes. METHODS: The charts of all patients who underwent adrenalectomy for pheochromocytoma in two academic centers between 2006 and 2020 were retrospectively reviewed. The primary outcome was HDI defined by a systolic blood pressure >160 mmHg or a mean blood pressure <60 mmHg intraoperatively. The secondary outcomes of interest were the total duration of HDI, the occurrence of intraoperative arrhythmia, perioperative cardiovascular events, and postoperative complications. RESULTS: 205 patients were included. HDI occurred intraoperatively in 155 patients (75.6%) but only 6 (3.2%) experienced arrhythmia. Thirty-eight postoperative complications were reported (18.6%) but only nine were ≥3 according to Clavien-Dindo (4.4%). There were 10 postoperative cardiovascular events (5.7%). Patients with intraoperative HDI had higher rates of postoperative complications (21.3% vs 10%; P = .07), major postoperative complications (5.8% vs 0%; P = .12) and cardiovascular events (6.5% vs 0%; P = .12). Factors associated with intraoperative HDI in univariate analysis were age (OR = 8.14; P = .006), high blood pressure preoperatively (OR = 2.16; P = .04), tumor size (OR = 15.83; P = .0001), and urinary normetanephrine level (OR = 9.33; P = .04). DISCUSSION: In multidisciplinary centers, the overall morbidity of adrenalectomy for pheochromocytoma is low. HDI during adrenalectomy for pheochromocytoma is highly prevalent but rarely associated with major cardiovascular events. There might be a link between HDI and postoperative cardiovascular events.

Relation between hysterectomy, oophorectomy and the risk of incident differentiated thyroid cancer: The E3N cohort.

BACKGROUND: Thyroid cancers are threefold more frequent in women than in men. A role of reproductive or hormonal factors has been suggested but with contradictory results. We investigated potential associations between history of hysterectomy, with or without oophorectomy, and history of benign gynaecological disease (uterine fibroids, endometriosis) and the incidence of differentiated thyroid cancer, in a large French prospective cohort. METHODS: A total of 89 340 women from the E3N cohort were followed up between 1990 and 2012. Gynaecological diseases treated by surgery were self-reported. Thyroid cancers were validated by histological reports. Time-dependent covariates included smoking status, BMI and history of benign thyroid disease. Cox proportional hazard models with age as timescale were used to estimate Hazard Ratios (HR) and 95% confidence intervals (CI). RESULTS: A total of 412 cases of thyroid cancer were diagnosed during follow-up. A history of hysterectomy was associated with an increased risk of differentiated thyroid cancer (adjusted HR=2.05; 95%CI: 1.65-2.55). The association was not altered after further adjustment for reproductive factors. Endometriosis, uterine polyps, ovarian cysts and oophorectomy without hysterectomy were not associated with the risk of thyroid cancer. A history of fibroids was also significantly related to the risk of thyroid cancer over the follow-up period (adjusted HR=1.91; 95%CI: 1.50-2.44) and the increased risk persisted after adjustment for history of hysterectomy. CONCLUSIONS: Women who had either a history of fibroids or hysterectomy had an increased risk of differentiated thyroid cancer. These findings suggest shared biological mechanisms between fibroids and thyroid cancer, which deserve to be further dissected.

Insulin Pump Failures: Has There Been an Improvement? Update of a Prospective Observational Study.

BACKGROUND: Insulin pump failures had been assessed in our center by a prospective observational study from 2001 to 2007. The aim of this study was to update our data since 2008 and to determine whether there exist specific risk factors for insulin pump failures. METHODS: All insulin pump defects were prospectively collected between 2008 and 2013 in a monocentric cohort of 350 new pumps. Clinical consequences were recorded. Brand and model of pumps and type of defects and patients' characteristics (gender, type of diabetes, age at diabetes diagnosis, age at first pump, pump treatment duration, number of previous pumps, and number of previous pump failures) were tested for possible association with insulin pump failure. RESULTS: Malfunctions occurred in 239 (68%) pumps. The incidence rate was 33/100 pump-years. There were 28 (12%) complete failures, 17 (7%) alarms, 83 (35%) mechanical defects, and 105 (44%) minor defects. Survival curves did not differ according to pump brand and model. Hyperglycemia occurred in 2.9% of cases. In multivariate analysis, only patient age less than 40 years at the initiation of pump therapy was associated with higher risk of malfunction (hazard ratio 1.64; 95% confidence interval 1.19-2.24; P = 0.002). CONCLUSIONS: Pump malfunctions remain common with modern pumps. We report less complete failures than in our previous study. This could be because of improvement in quality of pumps or to our strategy of systematic screening and replacement in case of mechanical defects.

A late 17α-hydroxylase deficiency diagnosis that leads to the discovery of a new CYP17 gene mutation.

17α-Hydroxylase deficiency is a rare form of congenital adrenal hyperplasia. It leads to a reduced production of cortisol and sex steroids and thus an increase in adrenocorticotrophic hormone and gonadotrophins levels. High adrenocorticotrophic hormone levels result in an accumulation of 17-deoxysteroids, such as deoxycorticosterone and corticosterone. Deoxycorticosterone and corticosterone have an important mineralocorticoid activity. We report the case of a 66-year-old woman who presented with hypertension and symptomatic hypokalaemia. Primary hyperaldosteronism was suspected and a right adrenal mass was removed. After surgery, the patient was referred to the endocrinology department for persistant hypokalaemia. Actually, she presented some signs of hypogonadism (impuberism, primary amenorrhea, infertility). Cortisol and 17OH-progesterone serum levels were low. Deoxycorticosterone and corticosterone were markedly elevated. The hypothesis of 17α-hydroxylase deficiency was considered and confirmed by genetic exploration. A non-sense mutation c.938G>A (p.Trp313X) in exon 5 of the CYP17 gene was found that had never been reported so far to our knowledge. Moreover, the patient's karyotype found a mosaic Turner syndrome. This case is particularly interesting because of the delay of diagnosis. The 17α-hydroxylase deficiency diagnosis is to be considered when hypertension is associated with hypokalaemia and hypogonadism, even in adult patients.