Nefrectomia Radical com Trombectomia da Veia Cava Laparoscópica num Caso de Feocromocitoma Maligno

Pheochromocytomas with vena cava thrombus are extremely rare, with only a few cases reported in the literature. Radical nephrectomy with adrenalectomy and inferior vena cava (IVC) thrombectomy is the treatment of choice. However, it is a challenging procedure and its surgical approach is yet to be standardized. We present a case of a 49-year-old male incidentally diagnosed with a pheochromocytoma with aggressive local invasion and a level 1 vena cava thrombus. A laparoscopic right radical nephrectomy with right adrenalectomy, IVC thrombectomy and cavorraphy. A detailed revision of the technique is performed and compared with current strategies for pheochromocytoma optimal treatment. Renal and adrenal masses with vena cava thrombus are associated with high morbidity and mortality, particularly in the case of pheochromocytoma. The management is complex but minimally invasive surgery can be performed safely in the context of an experienced multidisciplinary team.Os feocromocitomas com trombo na veia cava são entidades extremamente raras, estando poucos casos descritos na literatura. Apesar da nefrectomia radical com adrenalectomia/suprarrenalectomia e trombectomia da veia cava inferior (VCI) corresponder ao tratamento de escolha, esta é uma técnica cirúrgica desafiante com uma abordagem ainda não padronizada. Apresenta-se um caso de um homem de 49 anos com diagnóstico incidental de um feocromocitoma localmente invasivo, com trombo na VCI nível 1. Foi proposta uma nefrectomia radical direita laparoscópica com adrenalectomia/suprarrenalectomia, trombectomia da VCI e cavorrafia. Neste artigo faz-se uma descrição detalhada da técnica cirúrgica e uma comparação com as estratégias atualmente utilizadas no tratamento do feocromocitoma. Tumores renais e suprarrenais/adrenais com trombo na veia cava estão associados a maior morbilidade e mortalidade, sobretudo no caso do feocromocitoma. Apesar de complexa, a cirurgia minimamente invasiva é uma opção segura no contexto de uma equipa experiente e multidisciplinar

Management practices for postdural puncture headache in obstetrics: a prospective, international, cohort study

© 2020 British Journal of AnaesthesiaBackground: Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP. Methods: Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months. Results: A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19–1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score≤3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group. Conclusions: Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP

Management practices for postdural puncture headache in obstetrics : a prospective, international, cohort study

Background: Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP. Methods: Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months. Results: A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19-1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score <= 3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group. Conclusions: Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP