We aimed to identify presurgical and surgical risk factors for intraoperative complications in patients with pheochromocytomas. A retrospective study of patients with pheochromocytomas who underwent ...surgery in ten Spanish hospitals between 2011 and 2021 was performed. One hundred and sixty-two surgeries performed in 159 patients were included. The mean age was 51.6 ± 16.4 years old and 52.8% were women. Median tumour size was 40 mm (range 10–110). Laparoscopic adrenalectomy was performed in 148 patients and open adrenalectomy in 14 patients. Presurgical alpha- and beta-blockade was performed in 95.1% and 51.9% of the surgeries, respectively. 33.3% of the patients (n = 54) had one or more intraoperative complications. The most common complication was the hypertensive crisis in 21.0%, followed by prolonged hypotension in 20.0%, and hemodynamic instability in 10.5%. Patients pre-treated with doxazosin required intraoperative hypotensive treatment more commonly than patients pre-treated with other antihypertensive drugs (51.1% vs 26.5%, P = 0.002). Intraoperative complications were more common in patients with higher levels of urine metanephrine (OR = 1.01 for each 100 μg/24 h, P = 0.026) and normetanephrine (OR = 1.00 for each 100 μg/24 h, P = 0.025), larger tumours (OR = 1.4 for each 10 mm, P < 0.001), presurgical blood pressure > 130/80 mmHg (OR = 2.25, P = 0.027), pre-treated with doxazosin (OR = 2.20, P = 0.023) and who had not received perioperative hydrocortisone (OR = 3.95, P = 0.008). In conclusion, intraoperative complications in pheochromocytoma surgery are common and can be potentially life-threatening. Higher metanephrine and normetanephrine levels, larger tumour size, insufficient blood pressure control before surgery, pre-treatment with doxazosin, and the lack of treatment with perioperative hydrocortisone are associated with higher risk of intraoperative complications.
Purpose
To identify presurgical and surgical risk factors for postsurgical complications in the pheochromocytoma surgery.
Methods
A retrospective study of pheochromocytomas submitted to surgery in ...ten Spanish hospitals between 2011 and 2021. Postoperative complications were classified according to Clavien-Dindo scale.
Results
One hundred and sixty-two surgeries (159 patients) were included. Preoperative antihypertensive blockade was performed in 95.1% of the patients, being doxazosin in monotherapy (43.8%) the most frequent regimen. Patients pre-treated with doxazosin required intraoperative hypotensive treatment more frequently (49.4% vs 25.0%,
P
= 0.003) than patients treated with phenoxybenzamine, but no differences in the rate of intraoperative and postsurgical complications were observed. However, patients treated with phenoxybenzamine had a longer hospital stay (12.2 ± 11.16 vs 6.2 ± 6.82,
P
< 0.001) than those treated with doxazosin. Hypertension resolution was observed in 78.7% and biochemical cure in 96.6% of the patients. Thirty-one patients (19.1%) had postsurgical complications. Prolonged hypotension was the most common, in 9.9% (
n
= 16), followed by hypoglycaemia in six patients and acute renal failure in four patients. 13.0% of complications had a score ≥3 in the Clavien-Dindo scale. Postsurgical complications were more common in patients with diabetes, cerebrovascular disease, higher plasma glucose levels, higher urinary free metanephrine and norepinephrine, and with pheochromocytomas larger than 5 cm.
Conclusion
Preoperative medical treatment and postsurgical monitoring of pheochromocytoma should be especially careful in patients with diabetes, cerebrovascular disease, higher levels of plasma glucose and urine free metanephrine and norepinephrine, and with pheochromocytomas >5 cm, due to the higher risk of postsurgical complications.
The purpose of our study was to develop a predictive model to rule out pheochromocytoma among adrenal tumours, based on unenhanced computed tomography (CT) and/or magnetic resonance imaging (MRI) ...features. We performed a retrospective multicentre study of 1131 patients presenting with adrenal lesions including 163 subjects with histological confirmation of pheochromocytoma (PHEO), and 968 patients showing no clinical suspicion of pheochromocytoma in whom plasma and/or urinary metanephrines and/or catecholamines were within reference ranges (non-PHEO). We found that tumour size was significantly larger in PHEO than non-PHEO lesions (44.3 ± 33.2 versus 20.6 ± 9.2 mm respectively; P < 0.001). Mean unenhanced CT attenuation was higher in PHEO (52.4 ± 43.1 versus 4.7 ± 17.9HU; P < 0.001). High lipid content in CT was more frequent among non-PHEO (83.6% versus 3.8% respectively; P < 0.001); and this feature alone had 83.6% sensitivity and 96.2% specificity to rule out pheochromocytoma with an area under the receiver operating characteristics curve (AUC-ROC) of 0.899. The combination of high lipid content and tumour size improved the diagnostic accuracy (AUC-ROC 0.961, sensitivity 88.1% and specificity 92.3%). The probability of having a pheochromocytoma was 0.1% for adrenal lesions smaller than 20 mm showing high lipid content in CT. Ninety percent of non-PHEO presented loss of signal in the "out of phase" MRI sequence compared to 39.0% of PHEO (P < 0.001), but the specificity of this feature for the diagnosis of non-PHEO lesions low. In conclusion, our study suggests that sparing biochemical screening for pheochromocytoma might be reasonable in patients with adrenal lesions smaller than 20 mm showing high lipid content in the CT scan, if there are no typical signs and symptoms of pheochromocytoma.
Abstract
Disclosure: M. Araujo-Castro: None. M. Paja Fano: None. M. González Boillos: None. B. Pla Peris: None. E. Pascual-Corrales: None. A. García Cano: None. P. Parra: None. P. Martín ...Rojas-Marcos: None. J. Ruiz-Sanchez: None. A. Vicente Delgado: None. E. Gómez Hoyos: None. R. Ferreira: None. I. García Sanz: None. M. Recasens Sala: None. R. Barahona San Millan: None. M. Picón César: None. P. Díaz Guardiola: None. J. García González: None. C.M. Perdomo: None. L. Manjón Miguélez: None. R. García Centeno: None. Á. Rebollo Román: None. P. Gracia Gimeno: None. C. Robles Lázaro: None. M. Morales-Ruiz: None. M. Calatayud Gutiérrez: None. S. Simone Andree Furio Collao: None. D. Meneses: None. M. Sampedro Nuñez: None. V. Escudero Quesada: None. E. Mena Ribas: None. A. Sanmartin Sánchez: None. C. Gonzalvo Diaz: None. C. Lamas: None. F. Hanzu: None.
Purpose: To evaluate the prevalence of type 2 diabetes mellitus (T2DM) in patients with primary aldosteronism (PA) and the risk factors for its development. Methods: A retrospective multicenter study of PA patients in follow-up in 27 Spanish tertiary hospitals (SPAIN-ALDO Register). Adrenal venous sampling (AVS) was informative of laterality in 128 out of 226 patients and adrenalectomy was performed in 201 patients. Unilateral PA was defined as biochemical cure after adrenalectomy or as a lateralization index in AVS > 2 with ACTH or >3 without ACTH stimulation. Results: Overall, 649 patients with PA were included. Median age was 55.5 (range 27.3-81.6) years, 59.1% were female and 58.5% had hypokalemia at diagnosis. A total of 224 patients were classified as unilateral PA (142 based on biochemical cure after adrenalectomy and 82 based also on AVS results) and 49 as bilateral PA. At diagnosis, 21.2% (n=137) had T2DM and 25 of them had microvascular complications, being diabetic kidney disease the most common (n=19). We identified as risk factors of type 2 diabetes: male sex (OR 2.80 1.81-4.34, P<0.001), older age (OR 1.05 1.03-1.07, P<0.001), familiar history of T2DM (OR 4.64 2.39-8.99), P<0.001), dyslipidemia (OR 4.05 2.67-6.14, P<0.001), cardiovascular (OR 1.30 1.14-1.48, P<0.001) and cerebrovascular disease (OR 1.59 0.92-2.74, P=0.003), sleep apnea syndrome (SAS) (OR 2.21 1.34-3.63, P=0.003), higher BMI (OR 1.06 per unit 1.03-1.10, <0.001), hypertension duration (OR 1.04 per year 1.02-1.06, P<0.001) and the number of antihypertensive drugs (OR 1.50 1.29-1.74, P<0.0001). In the multivariant analysis, all these variables were independent risk factors for T2DM except for SAS, hypertension duration, sex, and BMI. No association was observed with plasma aldosterone concentration, potassium levels, unilaterality of PA or other parameters. No significant differences in the evolution of the glycemic control (fasting plasma glucose and HBA1c) were observed between T2DM who underwent surgery and those medically treated (P>0.05). Conclusion: Type 2 diabetes affects about one quarter of patients with PA and risk factors for its development are common than to the general population. Medical and surgical treatment provide a similar benefit in terms of glucose control in patients with PA and T2DM.
Presentation: Friday, June 16, 2023
Initial evaluation of adrenal incidentalomas (AIs) should be aimed at ruling out malignancy and functionality. For this, a detailed clinical history should be taken, and an adequate radiographic ...assessment and a complete blood chemistry and hormone study should be performed. The most controversial condition, because of the lack of consensus in its definition, is autonomous cortisol secretion (ACS). Our recommendation is that, except when cortisol levels <1.8 µg/dL in the dexamethasone suppression test (DST) rule out diagnosis and levels ≥5 µg/dL establish the presence of ACS, diagnosis should be based on a combined definition of DST ≥ 3 µg/dL and at least one of the following: elevated urinary free cortisol (UFC), ACTH level <10 pg/mL, or elevated nocturnal cortisol (in serum and/or saliva). During follow-up, DST should be repeated, usually every year, on an individual basis depending on the results of prior tests and the presence of comorbidities potentially related to hypercortisolism.
The initial radiographic test of choice for characterization of AIs is a computed tomography (CT) scan without contrast, but there is no unanimous agreement on subsequent monitoring. Our general recommendation is a repeat imaging test 6−12 months after diagnosis (based on the radiographic characteristics of the lesion). If the lesion remains stable and there are no indeterminate characteristics, no additional radiographic studies would be needed.
We think that patients with ACS with comorbidities potentially related to hypercortisolism, particularly if they are young and there is a poor control, may benefit from unilateral adrenalectomy (UA). The indication for UA is clear in patients with overt hormonal syndromes or suspected malignancy.
In conclusion, AIs require a comprehensive evaluation that takes into account the possible clinical signs and comorbidities related to hormonal syndromes or malignancy; a complete hormone profile (taking into account the conditions that may lead to falsely positive and negative results); and an adequate radiographic study. Monitoring and/or treatment will be decided based on the results of the initial evaluation.
La evaluación inicial de los incidentalomas adrenales (IA) se centra en dos objetivos: descartar malignidad y descartar funcionalidad. Para ello se debe realizar una historia clínica detallada, obtener una valoración radiológica adecuada y un estudio bioquímico-hormonal completo. La entidad que más dudas genera, por la falta de consenso en su definición, es la secreción autónoma de cortisol (SAC). Nuestra recomendación es que, salvo para valores de cortisol <1.8 µg/dl en el test de supresión con dexametasona (TSD) que descartan SAC, y ≥5 µg/dl que establecen el diagnóstico; se debe emplear una definición combinada de TSD ≥ 3 µg/dl y al menos uno de los siguientes: cortisol libre urinario (CLU) elevado, ACTH < 10 pg/mL o cortisol nocturno (sérico y/o salival) elevado para establecer el diagnóstico de SAC. En el seguimiento se debe repetir el TSD, generalmente de forma anual, individualizando en función de los resultados de las pruebas previas y de la presencia de comorbilidades potencialmente relacionadas con el hipercortisolismo.
La prueba radiológica inicial de elección para la caracterización de los IA es la tomografía axial computarizada (TAC) sin contraste, pero no existe acuerdo unánime sobre el seguimiento posterior. Nuestra recomendación general es repetir la prueba de imagen a los 6-12 meses del diagnóstico (en función de las características radiológicas de la lesión). Si la lesión se mantiene estable y no existen características indeterminadas, no serían necesarios más estudios radiológicos.
Consideramos que los pacientes con SAC con comorbilidades potencialmente relacionadas con el hipercortisolismo, especialmente si existe un control deficiente y se trata de pacientes jóvenes, se pueden beneficiar de una suprarrenalectomía unilateral (SRU). La indicación de SRU es clara en pacientes con síndromes hormonales manifiestos o sospecha de malignidad.
Como conclusión, los IA deben ser valorados de forma integral, teniendo en cuenta las posibles manifestaciones clínicas y comorbilidades relacionadas con síndromes hormonales o malignidad; un estudio hormonal completo (teniendo en cuenta las situaciones que pueden conllevar resultados falsamente positivos y negativos) y radiológico adecuado. En base a los resultados de la evaluación inicial se planificará el seguimiento y/o tratamiento.
Abstract
Objective
The objective was to assess the effectiveness of neural mobilization (NM) techniques in the management of musculoskeletal neck disorders with nerve-related symptoms (MND-NRS).
...Methods
We conducted a systematic review with meta-analysis, using pain intensity, disability, perceived function, cervical range of motion, and mechanosensitivity as the main outcome measures.
Results
The systematic review included 22 studies (n = 978). More favorable outcomes were observed for NM on pain intensity compared with control interventions (standardized mean differences (SMDs) −0.92; 95% CI −1.66−0.18), but not compared with other treatments (OTs) (SMD 1.06; 95% CI −0.02 to 2.15). Regarding neck pain intensity, no significant differences were found in favor of NM compared with OTs (SMD 0.37; 95% CI −0.35 to 1.1). However, between-treatment differences were found in favor of OT on arm-pain intensity (SMD 0.57; 95% CI 0.08–1.05). In addition, the grouped MA did not show statistically significant differences between NM and OT outcomes on the cervical range of motion (SMD 0.16; 95% CI −0.06 to 0.38). However, compared with no intervention, NM was associated with significantly improved outcomes in cervical rotation (SMD 0.91; 95% CI 0.61–1.22). Similar results were found regarding disability (SMD −0.08; 95% CI −0.36−0.20, and SMD −1.44; 95% CI −2.28−0.6, respectively). Finally, NM was associated with more favorable outcomes on mechanosensitivity compared with OT (SMD 0.79; 95% CI 0.15–1.42) and greater improvements in function compared with no intervention (SMD 0.89; 95% CI 0.16–1.62).
Conclusions
NM appeared to be effective to improve overall pain intensity when embedded in a physiotherapy treatment in the management of MND-NRS. When compared with no intervention, it was effective to improve neck rotation, disability, and function. However, it was not superior to other types of treatments in improving overall pain intensity, neck pain intensity, arm pain intensity, cervical range of motion and disability, except for mechanosensitivity.
Aim: To evaluate the impact of aldosterone excess on renal function in individuals with primary aldosteronism and to compare its evolution after surgery or mineralocorticoid receptor antagonist (MRA) ...treatment. Methods: A multicentre, retrospective cohort study of primary aldosteronism patients in follow-up in 36 Spanish tertiary hospitals, who underwent specific treatment for primary aldosteronism (MRA or adrenalectomy). Results: A total of 789 patients with primary aldosteronism were included, with a median age of 57.5 years and 41.8% being women. At primary aldosteronism diagnosis, the prevalence of chronic kidney disease (CKD) was 10.7% ( n = 84), with 75% of cases classified as state 3a ( n = 63). Primary aldosteronism patients with CKD had a longer duration of hypertension, a higher prevalence of type 2 diabetes, dyslipidaemia, cardiovascular events, hypokalaemia, and albuminuria. Unilateral adrenalectomy was performed in 41.8% of cases ( n = 330), and 459 patients were treated with MRA. After a median follow-up of 30.7 months (range 13.3–68.4), there was a significant decline in the estimated glomerular filtration rate (eGFR) in operated patients and those receiving MRA. During follow-up, 24.4% of patients with CKD at the time of primary aldosteronism diagnosis had normalized renal function, and 39% of those with albuminuria had albuminuria remission. There were no differences in renal function or albuminuria regression between the two therapy groups. However, development of albuminuria was less common in operated than in medically treated patients (0 vs. 6.0%, P = 0.009). Conclusion: CKD affects around 10% of the patients with primary aldosteronism, with a higher risk in individuals with long-term hypertension, type 2 diabetes, dyslipidaemia, cardiovascular events, hypokalaemia, and albuminuria. At short-term, both MRA and surgical treatment lead to a reduction of renal function, but adrenalectomy led to higher renal protection.
(a) to evaluate and compare the psychological treatment needs of patients with cancer and non-cancer, who are going to undergo scheduled thoracic surgery, and (b) evaluate and compare the diagnostic ...accuracy of the screening tests of psychological treatment needs for cancer and non-cancer patients.
The need for psychological treatment was evaluated in a total of 169 patients prior to thoracic surgery, through a clinical interview. The screening tests used were: the physician's judgment (yes/no), the Hospital Anxiety and Depression Scale (HADS) and, the single-item interview to assess depression "Do you feel depressed?" (DEPQ).
The number of patients who needed psychological treatment in the total sample was 47 (27.81%), in non-cancer-patients: 22 (30.99%) and in cancer patients: 25 (25.51%). The participants with treatment needs were more often young women with primary education levels, with more fears and concerns regarding their disease. With respect to the screening tests, the HADS-T (cut-off point ≥13) obtained a sensitivity (SE) of 0.75 and Specificity (SP) of 0.81 in the total sample. In patients with cancer, the HADS total score (cut-off point ≥10) obtained an SE=0.84 and SP=0.80, and, in non-cancer patients, the HADS total score (cut-off point ≥13) showed an SE=0.59 and SP=0.84. The DEPQ and the physician's judgment did not achieve adequate levels of precision.
A high percentage of patients have psychological treatment needs before performing thoracic surgery, which are similar for cancer and non-cancer patients. Preoperative detection of patients who need psychological intervention is feasible with a simple screening test: HADS, which achieves greater precision in cancer patients.
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