Laparoscopic adrenalectomy for primary aldosteronism: clinical experience in 12 patients.

Laparoscopic adrenalectomy has become a viable option for removal of small adrenal neoplasms. We present our initial experience of this operation for primary aldosteronism. In this prospective study, 12 consecutive patients with primary aldosteronism were operated on laparoscopically by one surgeon. Operative time, blood loss, postoperative pain, complications, hospital stay, convalescence time, and outcome were analyzed. Five right-sided and seven left-sided adrenalectomies were performed in six female and six male patients with a mean age of 51 years. The mean operative time was 126 minutes. All procedures were successfully carried out laparoscopically. No major complications occurred. All patients turned normokalemic and the medication for hypertension could be stopped or diminished in all cases. The mean hospital stay was 3.4 days, and the mean sick leave was 13 days. Laparoscopic adrenalectomy seems to be a safe and effective treatment for primary aldosteronism and should be considered the operation of choice.

Adrenalectomy for primary aldosteronism: long-term follow-up study in 29 patients.

Primary aldosteronism consists of a mixture of subgroups. The operative treatment is successful only in cases of aldosterone-producing neoplasia (and in rare cases of primary unilateral hyperplasia); all other cases should be treated medically. The aim of this study was to determine if aldosterone-producing neoplasia had been successfully differentiated from the other subgroups and the outcome of operative treatment. Altogether 29 patients with primary aldosteronism were operated on between January 1, 1979 and December 31, 1993. Patient charts were reviewed retrospectively. The follow-up data were collected from the patients' charts, and all patients were contacted to obtain recent blood pressure and serum potassium values. The patients were asked about symptoms related to hyperaldosteronism. If any suspicion of recidive aldosteronism was present, patients were carefully reexamined by hormonal tests and computed tomography (CT). A total of 27 patients had unilateral adenoma, 1 patient had hyperplasia, and 1 patient had an aldosterone-producing cortical carcinoma. There was no operative mortality or morbidity. The serum potassium level had normalized in all patients. Mean follow-up time was 76 months. One patient died during the follow-up from cholangiocarcinoma; 11 patients (41%) were cured by the operation, 10 patients (37%) have a mild but medicated hypertension, and in the remaining 22% the hypertension persisted but was well controlled by the medication. Of the 29 patients, 28 were correctly diagnosed as having an aldosterone-producing neoplasm. Basic hormonal studies and CT can be used effectively to differentiate aldosterone-producing neoplasia from hyperplasia in most cases.

Long-term Results of Gastroplasty for Morbid Obesity: Binge-Eating as a Predictor of Poor Outcome.

We investigated the long-term results after vertical banded gastroplasty (VBG) for morbid obesity and evaluated some predictors of poor outcome. Twenty-seven morbidly obese patients (mean BMI 50 kg/m(2)) who underwent VBG a mean of 5.4 years earlier were studied. The mean weight loss was 31 kg or 40.5% of excess weight. Ten patients (37%) were within 50% of their ideal weight. The patients were classified as bingers (n = 10) and non-bingers (n = 17) according to the modified Binge Eating Scale. One-year postoperative weight losses were 55% and 57% respectively of excess weight, but at the time of the study weight losses were 24% and 50% of excess weight (p = 0.04) in the bingers and non-bingers, respectively. The mean weight regain was 23 kg in the bingers vs 8 kg in the non-bingers, p = 0.01. Two bingers had excellent weight loss results, but otherwise an unsuccessful outcome. Weight reduction did not correlate with age, sex or age of onset of obesity. These results show that binge-eating strongly predicts poor weight loss maintenance after gastroplasty in the long-term, though initial weight reduction is good. We suggest that binge-eating should be evaluated before gastroplasty and taken into consideration in the design of treatment.

Incidentalomas of the adrenal gland: 36 operated patients and review of literature.

Incidental discovery of an adrenal mass during radiologic examinations is common. Several recommendations have been made for the management of so-called incidentalomas. It has become clear that not all incidentalomas should be operated, but the criteria for nonoperative treatment have been under continuous debate. In this study 36 operated incidentalomas are presented, and the indications for operative treatment are discussed with a review of the recent literature on the subject. Four pheochromocytomas and three hormonally active cortical adenomas, two producing cortisol and one androgens, were found. In this series there were no malignancies. The operation could have been avoided in most cases, and patients could have been followed up with repeated radiologic examinations. It is suggested that masses smaller than 6 cm in diameter be followed radiologically after 3, 9, and 18 months. Masses between 3 and 6 cm could be further examined using magnetic resonance imaging and fine needle aspiration and then operated if features suggestive of malignancy are found. Masses larger than 6 cm in diameter should be treated operatively.

Obstructive sleep apnoea syndrome in morbidly obese patients.

Twenty-seven morbidly obese patients (13 men and 14 women) with body mass index greater than or equal to 40 kg m-2 were examined. The mean age of the subjects was 36.9 +/- 8.2 years (range 23-51 years), and the mean BMI was 50.2 +/- 6.2 kg m-2 (range 40.0-62.9 kg m-2). A whole-night sleep recording was made for all patients with signs or symptoms indicative of possible obstructive sleep apnoea syndrome (OSAS). If the first nocturnal sleep recording was abnormal, it was controlled after 1 year. Eleven (10 men and one woman) of the 27 patients had an oxygen desaturation index (ODI) of 10 h-1. They were symptomatic with excessive daytime sleepiness or other daytime symptoms of OSAS. The occurrence of OSAS in men and women was 76.9 and 7.1%, respectively. Arterial hypertension was associated with OSAS, but not with smoking or the degree of obesity. Antihypertensive treatment was received by nine of the 27 patients; six of them had OSAS. Thus six of the 11 (54.5%) patients with OSAS and three of the 16 (18.8%) nonapnoeic patients were treated for arterial hypertension (Fisher exact test, P = 0.042). The odds ratio of OSAS for arterial hypertension is 5.2 (95% CI, 0.71-43.6). Vertical-banded gastroplasty was performed in 14 patients, three of whom had OSAS. The selection of patients for gastroplasty was made without taking into account the results of sleep recordings. In the three OSAS patients, a 30-38% reduction in BMI was achieved by surgery. Eight patients with OSAS were treated with an intensified dietary regimen, and the reduction in BMI ranged from -2.6 to 33%. OSAS was either cured or significantly improved in six (55%) patients, with a mean reduction in BMI of 27%, while in patients with persistent OSAS the mean reduction in BMI was only 7%.

Adult Hirschsprung's disease. Clinical features and functional outcome after surgery.

To assess the clinical features and long-term functional outcome after surgery, eight patients operated on for adult Hirschsprung's disease during the 20-year period, 1968-1988, were re-examined. There were six men and two women with a mean age of 40 +/- 3 years at the time of survey. The mean age of the patients at the time of diagnosis was 23.8 years (range, 16 to 41 years). Results were compared with eight consecutive patients operated on for Hirschsprung's disease during the neonatal period. The Duhamel operation was performed initially on seven patients in the adult group and on all patients in the neonatal group. Anterior resection was performed on one adult patient initially but this was converted subsequently to Soave's pull-through operation. None of the patients had constipation after definitive surgery. The mean defecation frequency was two in both groups. Three patients in the adult group and two patients in the neonatal group were completely continent, others had occasional soiling. The mean anal sphincter pressures were lower in the neonatal group than in the adult group and in each group lower than in normal controls. Adult Hirschsprung's disease must always be suspected in the context of chronic constipation. Functional results after surgery in adult patients are similar to those achieved in children.

Endocrine abnormalities in patients with adrenal tumours incidentally discovered on computed tomography.

To determine endocrine activity of adrenal tumours incidentally discovered on C.T., we examined 20 consecutive patients. They underwent thorough hormonal assessment and scintigraphic scanning with radioactive cholesterol under dexamethasone suppression (19 patients). Biochemical findings compatible with cortisol hypersecretion were detected in 5 patients. One patient had reduced reserves of cortisol secretion and one had hyporeninemic hypoaldosteronism. The scintigraphy showed no uptake in 10, unilateral uptake in 4, and bilateral uptake in 5 patients. In 3 patients the finding was unilateral on CT. but bilateral on scintigraphy. Signs of autonomous cortisol production were more common among patients who had uptake on scintigraphy. At the operation of 8 patients only benign lesions were found. During the follow-up (9 to 49 months) of the 12 unoperated patients, the tumour disappeared in one and remained unchanged in the others. No changes occurred in the biochemical findings except in one patient whose cortisol response to 1 mg of dexamethasone became abnormal. Since slight hypercortisolism or a bilateral disease often exists behind an incidentally discovered adrenal tumour, we emphasize the importance of careful assessment of cortisol metabolism and a scintigraphic scanning under dexamethasone suppression in the examination of these patients.

Haematological changes during parenteral nutrition of malnourished patients with an enteral disease.

The present study assesses the blood haemoglobin concentration, the mean corpuscular haemoglobin concentration and the mean corpuscular volumes, as well as the serum iron levels and the total iron binding capacities in 28 malnourished patients with an enteral disease before and after 10-12 days of pre-operative parenteral nutrition of three different kinds: one with glucose, a second with glucose and fat as energy source, and a third rich in amino acids. About half of the patients in each group also received intramuscular iron supplementation of 1.79 mmol every 2 days. Before the nutritional therapy, 54% of the patients had a subnormal serum iron level; on average, serum iron was 10.5 (SD 7.4) mumol/l. In spite of this, 50% of the patients had a TIBC level less than normal and 43% of the patients within the normal range. Ninety-three percent of the patients had an anaemia which, in most cases, was normochromic and normocytic. On average, blood haemoglobin was 110 (SD 12) g/l. After 10-12 days of parenteral nutrition, the blood haemoglobin concentration decreased independently of the quality of the intravenous alimentation, the serum iron level and the intramuscular iron supplementation. The fall in the blood haemoglobin level was on average 11.2%.(ABSTRACT TRUNCATED AT 250 WORDS)

Results of 32 major hepatic resections for primary and secondary malignancies of the liver.

Thirty-two consecutive liver resections performed during the years 1972-1984 for liver malignancies have been analysed. Among indications for resection were primary liver malignancy and liver secondaries equally often in 16 patients, mostly originating from colorectal cancer (12 patients). Ultrasound (US) was the most reliable diagnostic method being fully confident in 11 patients studied. Computed tomography (CT) missed one lesion out of 13 (confidence rate 92%), whereas angiography and liver scintiscan missed two and three lesions respectively with a confidence rate of 84 and 79. Most of the patients (94%) experienced an anatomical liver resection including 12 extended right lobectomies (ERL), eight right lobectomies (RL), five left lobectomies (LL), and five left lateral segmentectomies (LLS). The hospital mortality (16%) was almost exclusively connected to the ERL procedure with a 33% mortality rate. The crude 3-year survival rate of the series was 28%. Among the patients undergoing liver resection for colorectal cancer secondaries the corresponding figure was 41%. More than half of the patients surviving surgery have died of the same malignancy mostly developing in the remaining liver.

Long-term outcome after jejunoileal bypass for morbid obesity.

Long-term results after jejunoileal bypass operation for morbid obesity in 47 patients are presented. Two patients died postoperatively and a reanastomosis was made in three. Forty-one patients were re-examined on average 4.7 years after operation. Mean weight loss was 43 kg or 31 per cent of original weight. Increased stool frequency and abdominal discomfort were common postoperative symptoms. Abnormalities in serum electrolytes, serum vitamin levels and in liver function were relatively uncommon and in none serious. The net effect of the operation on joint and back symptoms was positive. In most patients the quality of life was clearly improved and all except two were satisfied with the results. Our experience suggests that jejunoileal bypass is still an alternative in the treatment of morbid obesity.

Morphological fatty changes and function of the liver, serum free fatty acids, and triglycerides during parenteral nutrition.

Morphological fatty changes and function of the liver and serum free fatty acids and triglycerides were investigated in 37 catabolic patients (22 men, 15 women) given different parenteral nutrition regimens. In the glucose group energy was supplied as carbohydrate alone, in the lipid group as carbohydrates and fats, and in addition both groups received amino acids. In the amino acid group amino acids were given in excess and less energy was supplied as carbohydrates. Each patient served as his own control. During parenteral nutrition liver steatosis rose from 5% to 35% (p less than 0.001) in the glucose group and from 7% to 23% (p less than 0.01) in the amino acid group, but no increase occurred in the lipid group. Liver fat accumulation was associated with the rises in serum aminotransferase activities and with the lack of or a poor rise in serum prothrombin and proconvertin. The conjugation function of the liver was not disturbed. No cholestatis was found. During lipid infusion serum free fatty acids increased to 4.41 mmol/l (p less than 0.01) and serum triglycerides to 3.06 mmol/l (p less than 0.01), but they decreased to normal range 12 h after lipid infusion was stopped. In the glucose and amino acid groups serum free fatty acid levels fell, as expected, below the normal range. Serum triglycerides rose 1.4-fold (p less than 0.05) in the amino acid group. On the basis of liver tests and histological examination steatosis in the liver caused only a minor disturbance in hepatocellular integrity. The very high levels of serum free fatty acids and triglycerides during lipid infusion may be harmful in certain pathological states.

Changes in nitrogen metabolism in catabolic patients given three different parenteral nutrition regimens.

Nitrogen metabolism was investigated in 24 catabolic patients (15 men and 9 women) given three different parenteral nutrition regimens for 10-12 days. Energy was supplied as either carbohydrates alone (glucose group) or as carbohydrates and fats (lipid group) and nitrogen as amino acids. In the third group (amino acid group) amino acids were given in excess and less energy was supplied as carbohydrate. Each patient served as his own control. On the basis of daily urinary urea excretion all infused amino acid was retained in the body in the glucose and lipid groups during parenteral nutrition, but in the amino acid group 54% of infused amino acids were metabolized in gluconeogenesis apparently for energy production. In the glucose and lipid groups nitrogen balance rose to a "plateau" within 2-4 days but in the amino acid group within 5-7 days. The increment of nitrogen balance, 0.169 +/- 0.030 g N/kg/day, in the glucose group was greater than that, 0.140 +/- 0.037 g N/kg/day, in the lipid group (p less than 0.05) and that, 0.122 +/- 0.044 g N/kg/day, in the amino acid group (p less than 0.01). The initially low values of serum and liver protein did not change in the glucose and lipid groups, but in the amino acid group serum protein rose from 53.7 +/- 6.5 g/l to 61.1 +/- 5.9 g/l (less than 0.01) and liver protein from 47.4 +/- 7.2 mg/mgDNA to 65.0 +/- 22.6 mg/mgDNA (p less than 0.05). It seems tht a parenteral nutrition program rich in amino acids stimulates the vital protein synthesis of the liver more than regimens with abundance of non-nitrogen energy sources and poorer in amino acids. Nitrogen balance does not reveal information about the important protein metabolism of the liver. The results of this study support the opinion that during parenteral nutrition carbohydrates improve nitrogen balance more than isocaloric amount of fat.

Innervation of the rat Harderian gland by adrenergic and cholinergic nerve fibres.

The innervation of the rat Harderian gland was studied using histochemical methods for catecholamines and acetylcholinesterase (AChE). Selective denervations were performed to investigate the neural connections of this gland with various ganglia. Light microscopically the AChE-positive nerves seemed to run as thick bundles in the intertubular connective tissue. These bundles sent finer branches around the acini. The blood vessels, localized in the connective tissue septa, were surrounded by a dense plexus of AChE-containing fibres. By electron microscopy, the AChE-positive fibres were seen to terminate near the myoepithelial cells surrounding secretory cells. These fibres were also observed in contact with the blood vessels and occasionally close to the secretory cells. Fluorescent adrenergic nerves surrounded the blood vessels. Some fibres were also observed in the interlobular tissue. All the AChE-containing nerves degenerated after cutting the zygomatic nerve. On the other hand, removal of the ciliary ganglion or the superior cervical ganglion, or stereotactic coagulation of the ophthalmic nerve did not affect these nerves. The fluorescent adrenergic fibres disappeared following both removal of the superior cervical ganglion and coagulation of the ophthalmic nerve. These fibres were intact after removal of the ciliary ganglion.

Effects of denervations on the acetylcholinesterase-containing and fluorescent nerves of the rat iris.

The thiocholine method for the demonstration of AChE-containing fibres and the formaldehyde-induced fluorescence technique for the visualization of adrenergic fibres were employed to study the innervation of the albino rat iris. The following denervations were performed in order to verify the origins of different nerve types: (1) extirpation of the ciliary ganglion, (2) extirpation of the superior cervical ganglion, (3) stereotactic coagulation of the ophthalmic division of the trigeminal nerve, and (4) all possible combinations of the above-mentioned procedures. The denervations disclosed three main types of AChE-containing nerves in the iris: (1) nerve fibres degenerating after ciliary ganglionectomy, (2) thick nerve bundles in the dilator region disappearing after trigeminal neurotomy, and (3) fibres remaining intact after any type of denervation. Cervical sympathectomy had no effect on AChE-positive fibres. Under electron microscope AChE activity could be seen in the axolemma both in unmyelinated and in myelinated fibres. All fluorescent fibres vanished after ipsilateral cervical sympathectomy. Most of these fibres also disappeared after trigeminal neurotomy and the remaining fibres degenerated after subsequent ciliary ganglionectomy. On the basis of the present findings, the following conclusions can be drawn: (1) Most AChE-containing fibres of the rat iris originate in the ciliary ganglion. (2) The majority of the myelinated sensory fibres of the rat iris also contain AChE. (3) There is no AChE in the adrenergic fibres of the rat iris. (4) All adrenergic fibres of the rat iris originate in the ipsilateral superior cervical ganglion, and (5) these fibres enter the iris along with both the long and short ciliary nerves.