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Emmanuel L Bravo

Publications and source records attributed to Emmanuel L Bravo.

9 recordsLinked to original sources
PubMed2005

Pheochromocytoma: current perspectives in the pathogenesis, diagnosis, and management.

Pheochromocytomas (pheo) cause the most dramatic, life-threatening crises in all of endocrinology. A proper screening for pheo must be performed in any patient who has: 1) episodic headaches, tachycardia, and diaphoresis; 2) family history of pheo or multiple endocrine neoplasia; 3) incidental suprarenal mass; 4) paroxysms of tachyarrhythmias or hypertension; 5) adverse cardiovascular responses to anesthetic agents, histamine, phenothiazine, tricyclic antidepressants, etc); and 6) spells occurring during exercise, straining, etc. The key to diagnosing pheo is to suspect it, then to confirm it. Early recognition of its presence is critical to avoiding significant morbidity and mortality. Once suspected, the diagnosis can be confirmed with biochemical testing in virtually all patients. The combination of resting plasma catecholamines > or =2000 pg/mL and urinary metanephrines > or =1.8 mg/24 h has a diagnostic accuracy of 98% in both sporadic and hereditary pheos. When available, measurement of plasma free metanephrines should be performed especially in hereditary pheos. Provocative (glucagon) and suppression tests (clonidine) may be necessary when baseline measurements are inconclusive. CT and MRI are equally sensitive for localization (98% and 100%, respectively), but have lower specificities (70% and 67%). MIBG is 100% specific, but less sensitive (78%). The availability of various medical (selective alpha-1- and beta-adrenergic receptor antagonists, calcium channel blockers) and surgical modalities have made successful management more promising than ever before.

Adrenal Gland Neoplasms↗
PubMed2004

Clinical utility of noncontrast computed tomography attenuation value (hounsfield units) to differentiate adrenal adenomas/hyperplasias from nonadenomas: Cleveland Clinic experience.

Radiological characterization of an adrenal tumor as adenoma may decrease the need for follow-up imaging studies, biopsies, and unnecessary adrenalectomies. We retrospectively reviewed 299 adrenalectomies in 290 patients at Cleveland Clinic Foundation over a recent 5-yr period to assess the value of noncontrast Hounsfield units (HU) in characterizing whether an adrenal mass is adenoma or nonadenoma. The mean (+/- SD) HU value for the adrenocortical adenoma/hyperplasia group was 16.2 +/- 13.6 and significantly lower (P < 0.0001) than primary adrenocortical cancers (36.9 +/- 4.1), metastases (39.2 +/- 15.2), and pheochromocytomas (38.6 +/- 8.2). The sensitivity and specificity for 10- and 20-HU cutoff values to differentiate adenomas/hyperplasias from nonadenomas were 40.5 and 100% and 58.2 and 96.9%, respectively. The size of the adrenal tumor had less value with only 40.7 and 81.3% sensitivity and 94.7 and 61.4% specificity for 2- and 4-cm cutoff values. A combination of less than or equal to 4-cm adrenal mass size and noncontrast computed tomography HU less than or equal to 20 had 42.1% sensitivity and 100% specificity. Our study, the largest with surgical histopathology as the gold standard for diagnosis, supports a noncontrast computed tomography attenuation value of 10 HU as a safe cutoff value to differentiate adrenal adenomas/hyperplasias from nonadenomas.

Adenoma↗
PubMed2003

Aldosterone and specific aldosterone receptor antagonists in hypertension and cardiovascular disease.

Recent preclinical and clinical studies indicate that aldosterone, independent of angiotensin II and elevated blood pressure, may play a role in health and disease. In addition to its role in fluid and electrolyte balance and circulatory homeostasis, more recent studies have identified aldosterone as a critical mediator of vascular damage. In animal studies, aldosterone is implicated in cardiac and vascular fibrosis, renal disease, and cerebrovascular damage. These lesions are prevented by specific aldosterone receptor blockade. In clinical studies, aldosterone receptor antagonism is associated with decreased hospitalization, symptomatology, and mortality, and improvement of endothelial dysfunction in patients with chronic heart failure. A better understanding of aldosterone's actions in nonepithelial tissues should pave the way to better protection of organs at risk such as the kidneys, heart, and brain.

Aldosterone↗
PubMed2003

Pheochromocytoma: state-of-the-art and future prospects.

This review provides current understanding of the pathophysiology of pheochromocytoma and the wide range of associated clinical manifestations that have led to earlier recognition of the disease. In addition, it reviews optimal screening methods and localization techniques that have enhanced the clinician's ability to make the diagnosis with greater certainty. This article will also discuss alternative antihypertensive regimens and innovative anesthetic and surgical procedures that have made successful management more promising than ever before. Areas requiring further development include additional clinical experience with the measurement of plasma metanephrines that have been shown to have high sensitivity and specificity in the diagnosis of sporadic and familial pheochromocytoma, optimizing cost effectiveness of diagnostic imaging, improving the ability to predict and treat malignant pheochromocytoma, and elucidating not only the surgical approach but, perhaps with rapid advances in molecular genetics, ways of preventing familial pheochromocytoma.

Adrenal Gland Neoplasms↗
PubMed2002

Robotic-assisted laparoscopic adrenalectomy.

INTRODUCTION: Remote robotic telemanipulators have been recently used in performing laparoscopic urologic procedures, both in the laboratory and in clinical practice. We present, to our knowledge, the initial 2 cases of robotic-assisted laparoscopic adrenalectomy in humans. TECHNICAL CONSIDERATIONS: Robotic-assisted laparoscopic adrenalectomy (one right, one left) was performed in 2 patients with an adrenal tumor (one nonfunctional, one pheochromocytoma). Patient age was 81 and 47 years, and tumor size was 4.5 and 3 cm, respectively. Both cases were performed transperitoneally using the da Vinci Robotic Surgical System. Robotic-assisted laparoscopic adrenalectomy was successful in both cases without conversion to conventional laparoscopy or open surgery. The operative time was 110 and 165 minutes, the blood loss was 50 and 100 mL, and the hospital stay was 2 and 3 days. No intraoperative or postoperative complications occurred. CONCLUSIONS: Robotic-assisted laparoscopic adrenalectomy is technically feasible. With increasing experience and refinement in the technology, the role of robotics in urologic laparoscopy is likely to expand.

Adrenal Gland Neoplasms↗
PubMed2002

Laparoscopic bilateral partial adrenalectomy for pheochromocytoma.

INTRODUCTION: To describe the technique of transperitoneal laparoscopic bilateral synchronous partial adrenalectomy in a patient with bilateral adrenal pheochromocytoma. TECHNICAL CONSIDERATIONS: An 81-year-old woman with bilateral adrenal pheochromocytoma underwent bilateral laparoscopic partial adrenalectomy. A three-port transperitoneal approach was used for each side, with an additional port for liver retraction during right partial adrenalectomy. Laparoscopic flexible ultrasonography was invaluable for localizing the adrenal tumor and for precise planning of the line of excision. The right main adrenal vein was preserved. Dissection and enucleation of the adrenal tumor and parenchymal hemostasis was achieved effectively using a harmonic scalpel. The total operative time was 2 and 2.5 hours for the left and right adrenal gland, respectively. No major intraoperative hemodynamic instability was noted. The total blood loss was 150 mL, and the hospital stay was 4 days. Pathologic examination confirmed bilateral adrenal pheochromocytoma. CONCLUSIONS: Laparoscopic partial adrenalectomy for pheochromocytoma is safe and technically feasible. Intraoperative ultrasonography is helpful to accurately plan resection of the tumor. If tumor location permits, the main adrenal vein should be preserved to ensure adequate vascularity for the adrenal remnant.

Adrenal Gland Neoplasms↗
PubMed2002

Pheochromocytoma: an approach to antihypertensive management.

Pheochromocytoma and paragangliomas are rare tumors of chromaffin tissue that secrete catecholamines either intermittently or continuously, producing hypertension with a constellation of symptoms and signs that can be frightening to the patient and that continue to provide perplexing problems for clinicians. With surgical treatment, symptoms will be relieved and hypertension normalized or ameliorated for patients who do not have malignant tumors. Appropriate antihypertensive drugs are used to manage hypertension, to control associated cardiovascular symptoms, and to prepare patients for operation. The question debated most often regarding medical therapy of pheochromocytoma is whether antihypertensive treatment regimens other than nonspecific alpha-blockade are just as effective and safe. Understanding the pathophysiologic mechanisms that sustain the hypertension and the pharmacology of antihypertensive agents allows better selection of antihypertensive therapy.

Adrenal Gland Neoplasms↗
PubMedDate not supplied

Pheochromocytoma.

Pheochromocytomas cause the most dramatic, life-threatening crises in all of endocrinology. Pheochromocytoma is an explosive clinical syndrome characterized by severe hypertension associated with cardiac complications, hypotension, or even shock and sudden death. The key to diagnosing pheochromocytoma is to suspect it, then confirm it. The cases reported in this review illustrate how the diagnosis can be easily missed and definitive treatment delayed. An appreciation of the wide range of clinical manifestations, based on clear understanding of the mechanisms of catecholamine action and the pathophysiology of pheochromocytoma, and the availability of simple and accurate diagnostic tests should lead to earlier detection of these tumors. Advances in localization techniques and availability of various treatment modalities have made successful management more promising than ever before.

Adrenal Gland Neoplasms↗