Comparison of I-gel and LMA Protector in Laparoscopic Cholecystectomy: A Randomized Controlled Trial.

AIMS: Comparison of the use of I-gel and Laringeal Mask Airway (LMA) Protector in laparoscopic cholecystectomy regarding the time and ease of insertion for supraglottic airway devices (SAD) and gastric tube (GT), airway sealing capacity, and postoperative complications. PATIENTS AND METHODS: Sixty-four American Society of Anaesthesiologists (ASA) I-III patients undergoing laparoscopic cholecystectomy were randomly allocated into two groups. After anesthesia induction, LMA Protector was inserted in Group LPRO (LMA Protector) (n = 33) and I-gel was inserted in Group IGEL (I-gel) (n = 31) patients. Time of SAD insertion, number of attempts, time, and ease of GT insertion were recorded. The peak inspiratory pressure (PIP) and oropharyngeal leak pressure (OLP) were measured at the time of SAD insertion, 10 min after insertion, 10 min after pneumoperitoneum, and just before the termination of pneumoperitoneum. The presence of bloodstains on SAD, sore throat, hoarseness, nausea, and pain in swallowing was assessed postoperatively. A P value of < 0.05 was accepted as statistically significant. RESULT: Two patients in Group LPRO needed endotracheal intubation and were excluded from the study. The SAD insertion time was shorter in Group IGEL than in Group LPRO (13 ± 7.4 s vs. 18.8 ± 9.8 s). The number of attempts and success rate on the first attempt were similar in both groups. GT insertion time was shorter in Group IGEL than Group LPRO (11 ± 7.7 s vs. 21 ± 11 s). The insertion of GT was easier in Group IGEL. The OLP levels decreased during the pneumoperitoneum in Group LPRO while they remained constant in Group IGEL. CONCLUSION: We observed that I-gel offers more stable airway sealing and easier GT insertion advantages when compared with LMA Protector in laparoscopic cholecystectomy.

Neutrophil-lymphocyte ratio may predict in-hospital mortality in patients with acute type A aortic dissection.

INTRODUCTION: Inflammation has been reported to be associated with aortic dissection (AD), from the development to the prognosis of AD. In this study we aimed to find the role of the neutrophil-lymphocyte ratio (NLR) in the prediction of clinical events in patients with acute AD type A. PATIENTS AND METHODS: The study comprised 37 patients who were hospitalized at our center between 2009 and 2013 with the diagnosis of acute AD type A. RESULTS: The mean NLR was significantly higher in patients with pericardial effusion than those without effusion (15.6 ± 11.4 vs. 7.5 ± 4.8, p = 0.005). An NLR value > 8.51 yielded an area under the curve (AUC) value of 0.829 [95 % confidence interval (CI) 0.674-0.984, p = 0.004], which demonstrated a sensitivity of 77 % and specificity of 74 % for the prediction of mortality. CONCLUSIONS: The novel inflammatory marker NLR could be used to predict pericardial effusion and in-hospital mortality in patients with acute AD type A.

The effect of nebivolol on internal mammary artery blood flow during coronary artery bypass graft surgery.

BACKGROUND: During coronary artery bypass grafting (CABG), one of the most important complications related to the internal mammary artery (IMA) is perioperative spasm. Nebivolol causes endothelium-dependent vascular relaxation by increasing nitric oxide (NO) release and prevents endothelial dysfunction in long-term use. In our study, we measured the effect of a third generation beta blocker, nebivolol, on the flow dynamics of IMA grafts. METHODS: We recruited 90 hypertensive patients undergoing isolated CABG operation, who were divided into three groups and each group included 30 patients: Group 1 patients were under antihypertensive treatment other than beta-blockers (angiontensin-converting enzyme [ACE] inhibitors, calcium channel blockers or diuretics; monotherapy or combination therapy), Group 2 received metoprolol (50 mg/day) and Group 3 received nebivolol (5 mg/day). These antihypertensive therapies were given for at least one week before the operation and continued thereafter. IMA blood flow volume was measured for one minute just before cardiopulmonary bypass (measurement A) and before left internal mammary artery (LIMA)-left anterior descending (LAD) artery anastomosis (measurement B) in the three groups. Cardiac output measurements were also achieved simultaneously. RESULTS: The measurement A results were 56.3 ± 36.2, 54.6 ± 28.1 and 66.8 ± 34.2 mL/min in Groups 1, 2 and 3, respectively (p<0.05). The measurement B results were 78.3 ± 29.6, 80 ± 28.8 and 91.1 ± 40.8 mL/min in Groups 1, 2 and 3 (p<0.05), respectively. There were no differences in cardiac outputs among the groups; 5.2 ± 1.4, 5.0 ± 1.6 and 5.3 ± 1.1 L/min (p>0.05). While the cardiac outputs were similar within the three groups, the IMA free flow volume was higher in the nebivolol group after local papaverine use. CONCLUSION: Nebivolol might represent a good choice in hypertensive patients undergoing cardiac surgery by preventing perioperative myocardial hypoperfusion which increases early morbidity and mortality.

Evaluation of the minimum effective concentration of foam sclerosant in an ex-vivo study.

BACKGROUND: Foam sclerosants are widely used in sclerotherapy and have been accepted as more effective than the liquid form; however, there is no consensus about the most applicable and effective concentration. OBJECTIVE: The aim of this study was to investigate the histopathological changes caused by various widely used concentrations of foam sclerosant. METHODS: Fifty-six varicose vein segments of 5-10 mm diameter were gently resected and exposed to various concentrations of foam sclerosant (0.5%, 1%, 2%, 3%) for 5 min, and were then prepared for routine histopathological examination. A total damage scoring system, including the presence of endothelial swelling, intimal thickening, cellular vacuolization in the muscle layer, edema in the tunica media and extent of necrosis, was established. RESULTS: The total damage score of the foam sclerosant groups was significantly higher than that of the control group (median 2.75 vs 1, p = 0.007). The highest damage score was achieved by 1% and 2% foam sclerosants (3.5 and 2.5). No significant difference was found among the different concentrations of sclerosant, although the 1% group caused more severe damage at a near significant level (p = 0.074). CONCLUSION: Significant pathological damage can be caused by even the lowest doses of foam sclerosant. The most injurious concentrations were found to be 1% and 2%, morphologically. A working concentration of 1% could thus be preferable to 0.5%, especially in larger veins. Further in-vivo studies are needed in order to validate these findings.

Attenuation of acute lung injury following lower limb ischemia/reperfusion: the pharmacological approach.

AIM: The purpose of this study was to examine the effects of N-acetylcysteine (NAC), calcium dobesilate (DOBE) and aprotinin on the amelioration of lung damage following ischemia/reperfusion injury in a rat hind limb model. A well known antioxidant dimethyl-sulfoxide (DMSO) was also tested for comparison. METHODS: Ischemia was induced in the lower limb for 4 h by vascular clamping and followed by 1 h of reperfusion. Lung injury was evaluated in 5 groups as a saline (control), DMSO, NAC, DOBE and aprotinin group. Plasma creatine kinase, lactate dehydrogenase, thiobarbituric acid reactive substances (TBARS) as well as lung tissue TBARS levels were measured. Lung tissue samples were taken for histological examination. P<0.005 was considered statistically significant. RESULTS: Plasma TBARS values were found to be significantly lower in the DMSO (P<0.005), NAC (P<0.005) and aprotinin (P<0.005) groups compared to the control group. Lung TBARS values were significantly lower in the DMSO, NAC, DOBE and aprotinin groups compared to the control group (P<0.001, P<0.001, P<0.001). Also in the aprotinin group lung TBARS values were found to be significantly lower compared to DMSO (P<0.001), NAC (P<0.001) and DOBE (P<0.001) groups. Histological examination showed less prominent peribronchial leukostasis (P<0.005) and interstitial leukostasis (P<0.005) in all drug groups compared to the control group. CONCLUSION: These observations indicate that DOBE and NAC, which are known to have antioxidant properties and aprotinin, a serine proteinase inhibitor, acted effectively on the prevention of lung injury in a rat hind limb ischemia/reperfusion model. The reason why aprotinin exerts a more protective effect than the other drugs is not clear, however, its clinical use may have the dual advantage of hemostasis and lung protection in surgical practice.

A randomized trial of intravenous iloprost (a stable prostacyclin analogue) versus lumbar sympathectomy in the management of Buerger's disease.

AIM: The aim of this study was to compare the effects of iloprost and lumbar sympathectomy (LS) in the treatment of Buerger's disease. METHODS: Two hundred patients with rest pain and/or ischemic ulcers were randomized to undergo LS or 28-day intravenous treatment of iloprost. The primary endpoint was complete healing without pain or major amputation at 4 and 24 weeks. The secondary endpoints were analgesic requirement, reduction in the ulcer size, 50% reduction of the ulcer, and shift in the modified SVS/ISCVS clinical status grading scale. RESULTS: The comparison was carried out in 162 patients (iloprost: n=84; LS: n=78). Complete healing rate was 61.9% in the iloprost group, but 41% in the LS group at the 4th week (P=0.012); respective values for the 24th week were 85.3%, 52.3%, P<0.001. Analgesic requirement was lower in the iloprost group at the 4th and 24th weeks (P=0.01, and P=0.098, respectively). The size of the ulcers decreased more in the iloprost group than the LS group (P=0.044 and P=0.035 at 4th and 24th weeks); 50% reduction in the ulcer size in the iloprost group was greater than in the LS group (P=0.001 and P=0.009 at 4th and 24th weeks). SVS/ISCVS grading scale demonstrated a better clinical benefit in patients treated with iloprost (P<0.001 at 4th week, and P<0.001 and at 24th week). CONCLUSIONS: The results of this independent study indicate that using iloprost relieves ischemic symptoms better than LS. In the era of stable prostacyclin analogues, there is no reliable evidence to support the use of LS in Buerger's disease.

The effects of clopidogrel and calcium dobesilate on intimal hyperplasia following vascular injury.

BACKGROUND: Neo-intimal hyperplasia is one of the most common causes of failure of arterial patency following cardiovascular interventions. It has been proposed that clopidogrel and calcium dobesilate may play an important role in the amelioration of intimal hyperplasia. The aim of this study is to examine the effect of these agents on intimal hyperplasia occurring after experimental balloon catheter injury. MATERIAL AND METHODS: Twenty-four male New Zealand rabbits were divided into three groups. Endothelial injury was caused by introducing a 2.5 x 20 mm balloon angioplasty-catheter into the left iliac artery. After the procedure, clopidogrel (25 mg/kg/day/orally) or calcium dobesilate (100 mg/kg/day/orally) were given for 2 weeks. Eight rabbits were given a placebo and served as controls. The contralateral non-injured iliac arteries of the control group were considered as normal iliac artery samples. Iliac artery specimens were examined planimetrically and the intima/media ratio was obtained for each vessel. RESULTS: In the control group, the intima/media ratio was still significantly higher (p < 0.05) than the contralateral normal artery 14 days after the balloon catheter injury. In the clopidogrel and calcium dobesilate groups, this ratio had significantly decreased when compared with the control group (p < 0.05). No significant difference was found when the clopidogrel and calcium dobesilate groups were compared. CONCLUSION: The anti-agregant agent clopidogrel, and the venous endothelial regulator calcium dobesilate, ameliorate intimal hyperplasia after experimentally induced vascular injury in rabbit iliac arteries.

The effects of tranexamic acid and 6% hydroxyethyl starch (HES) solution (130/0.4) on postoperative bleeding in coronary artery bypass graft (CABG) surgery.

BACKGROUND: The addition of 6% hydroxyethyl starch (HES) into Ringer lactate priming solution may have adverse effects on hemostasis in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) with or without the use of tranexamic acid. METHODS: In a prospective, randomized clinical trial, 132 patients were assigned to receive 20 ml/kg of Ringer priming solution with or without tranexamic acid (TA) (Group RS-TA, n=34 and Group RS-noTA, n=32) or 10 ml/kg of 6% HES plus 10 ml/kg of RS priming solution with or without intravenous tranexamic acid (Group HES-TA, n=35 and Group HES-noTA, n=31). Estimated blood loss, chest tube drainage, amount of blood products, hemoglobin, hematocrit, platelet and coagulation parameters were examined before and 24 hour after surgery. RESULTS: For Group HES with tranexamic acid, when compared to other groups, estimated blood loss, postoperative 24 hour drainage loss and blood product transfusions were less (P=0.023; P=0.003; P=0.001; respectively) and hemoglobin, hematocrit values at 12 and 24 hours after surgery increased in comparison to other groups (P=0.041, P=0.034, P=0.004, P=0.001; respectively). Platelet concentrations were similar between groups (P>0.05). CONCLUSIONS: In CABG, the administration of tranexamic acid in HES 130/0.4 prime solution study group decreased estimated blood loss and chest tube drainage in comparison to patients receving Ringer prime solution with or without tranexamic acid postoperatively however, no effects on renal functions or postoperative complications were shown.

Histopathological and immunohistochemical detection of protective effects of University of Wisconsin solution supplemented with iloprost on donor lung damage.

OBJECTIVE: Histopathological evaluation and immunohistochemical markers of surfactant B and CD34 were used to detect alveolar type II cell and pulmonary endothelial cell damage in order to assess the efficacy on donor lung protection of University of Wisconsin (UW) solution supplementation with iloprost. METHODS: Twelve rats were divided into two groups: UW solution was used alone in group I, and UW iloprost solution in group II. Lung samples were taken at regular intervals for pathological examination to evaluate alveolar cell integrity with hematoxylin and eosin staining. Preservation, of alveolar type II cell and pulmonary endothelial cells was assessed using surfactant B and CD34 immunomarkers, respectively. RESULTS: In both groups, alveolar integrity, surfactant, and CD34 revealed time-dependent, progressive damage, although this deterioration was less apparent among the iloprost-supplemented group. Alveolar integrity was better preserved at 4, 6, 8, 12, and 48 hours among group II rate. Surfactant staining showed significantly more deterioration at 12 and 24 hours in group I. Similarly, CD34 demonstrated significantly more injury at 6, 12, 24, and 48 hours in group I. CONCLUSION: Although progressive lung tissue damage assessed by histopathological and immunohistochemical methods was observed in both groups, our findings suggest less deterioration in the iloprost-supplemented group.

The role of antioxidant supplementation in cardiac transplantation: an experimental study in rats.

BACKGROUND: We investigated three antioxidants, inositol hexaphosphate (IP6), superoxide dismutase (SOD), and catalase (CAT), using a Langendorf model of heart transplantation. METHODS: Rat hearts were mounted on a Langendorf perfusion apparatus with addition of IP6, SOD+CAT, IP6+SOD+CAT to St. Thomas Hospital solution (n=6 for each) versus a control group (n=6), not containing supplementation. Global ischemia was achieved for 6 hours. RESULTS: The worst peak-to-peak (PP) and +dp/dt maximum values were observed in the IP6+SOD+CAT group, the values being significantly lower than those in the SOD+CAT group. The lowest plasma creatine kinase (CK), CK-muscle-band (CK-MB), and lactate dehydrogenase levels were measured from the SOD+CAT group. The highest values for CK were in the control group, and those for CK-MB were in the IP6 group. The lowest myocardial malondialdehyde and adenosine triphosphate values were observed in the SOD+CAT group. CONCLUSIONS: Supplementing St. Thomas Hospital solution with IP6 did not ameliorate myocardial damage following global ischemia. The contractility deteriorated further when IP6+SOD+CAT were used together; however, SOD+CAT improved cardiac mechanical functions, and significantly reduced myocardial damage.

Cardiac echinococcosis in a 3-year-old child.

A 3-year-old girl was admitted with the diagnosis of left ventricular hydatid cyst. She also had pulmonary, hepatic and splenic cysts. The diagnosis of the left ventricular cyst was made by means of computerized tomography and confirmed using cardiac magnetic resonance imaging and transthoracic echocardiography. The patient was submitted to cystectomy on beating heart with a straightforward postoperative period.

A brachial aneurysm in childhood caused by Ehlers-Danlos syndrome.

A case of an 11-year-old boy with Ehlers-Danlos syndrome (EDS) type IV is presented. He was referred with a pulsatile mass above the right antecubital fossa and Doppler revealed a saccular aneurysm. Excision and ligation of the brachial artery aneurysm was performed. The diagnosis was confirmed by skin fibroblast cultures and histopathologic evaluation. We conclude that arteriography should be avoided in EDS and color-Doppler should be the sole means of diagnosis. Ligation rather than arterial reconstruction should be preferred.

Hemorrheological variables in critical limb ischemia.

BACKGROUND: Impaired hemorrheological properties may worsen the tissue hypoxia distal to an arterial narrowing in patients with peripheral arterial occlusive disease (PAOD). The objective of this study was to investigate the changes in red blood cell rigidity, blood viscosity and plasma viscosity as contributing factors in the development of hypoxia in patients with critical limb ischemia (CLI). METHODS: Forty patients with critical limb ischemia and 40 healthy subjects were included in the study. The subjects included in the study were non-diabetic with blood pressure measurements within the normal range. Compound known to interfere with hemorrheological parameters were not taken by the patients for at least 7 days prior to investigation. Routine blood counts (WBC, RBC, Hb, Hct), plasma fibrinogen levels, plasma total cholesterol levels, red blood cell rigidity, blood and plasma viscosity were determined in both groups. Statistical evaluation of the results of both groups was compared by student's "t"-test. The level of significance was set at p<0.05. RESULTS: Blood viscosity at a shear rate of 6.00 sec(-1) was found to be significantly lower in the CLI group (p<0.001), whereas no significant difference was encountered when blood viscosity was measured at a shear rate of 225 sec(-1). Plasma viscosity and plasma fibrinogen levels were comparable. Plasma total cholesterol levels were found to be significantly higher in the CLI group (p<0.05) and red blood cell rigidity significantly lower (p<0.001). CONCLUSIONS: These findings may provide new insights into the role of blood viscosity in patients with CLI contrary to the previous reports in the literature. Therapies that address red blood cell rigidity more directly may decrease tissue hypoxia distal to arterial narrowing by preventing hemolysis, improving microcirculation, and increasing oxygen carrying capacity and may be more beneficial for these patients.

Impaired plasma viscosity via increased cholesterol levels in peripheral occlusive arterial disease [correction of disase].

The aim of this study was to investigate the relationship between plasma viscosity and lipoprotein and apolipoprotein pattern in normo- and hypercholesterolemic patients with peripheral occlusive arterial disease (POAD). 40 patients with POAD have been selected (8 females and 32 males, mean age: 54+/-3.2 years) with clinically evident superficial femoral occlusive artery disease. They were separated into two groups as normocholesterolemic (plasma total cholesterol <200 mg/dl) and hypercholesterolemic (plasma total cholesterol >200 mg/dl). Plasma total cholesterol, high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), triglycerides, total protein, and albumin levels were determined by enzymatic methods using commercial kits. Levels of apolipoprotein AI (apo AI), and apolipoprotein B (apo B) were measured using a immunoturbidometric method. Plasma viscosity (PV) was measured by capillary viscometer. Classifying the patients with PAOD according to the cholesterol levels; hypercholesterolemic (mean total-cholesterol: 227.90+/-26.97 mg/dl) patients had significantly higher LDL-C, PV and triglyceride levels compared with nornocholesterolemic patients (p<0.001, p<0.001, p<0.001, respectively). HDL-C and apo B were significantly lower in hypercholesterolemic patients than in normocholesterolemic patients (p<0.001, p<0.001, respectively). PV was positively correlated with total cholesterol (r=0.485, p<0.05), atherogenic index (r=0.624, p<0.01), total-C/HDL-C ratio (r=0.624, p<0.05), and LDL-C/HDL-C ratio (r=0.707, p<0.001) in hypercholesterolemic patients with POAD. PV was higher in hypercholesterolemic patients with POAD than in normocholesterolemic patients with POAD. We suggest that POAD patients should be regarded as a heterogenous group with lipid and lipoprotein parameters in order to assess the microcirculation in the affected limb. In case of dyslipidemia in POAD patients an elevated plasma viscosity should be considered as coexisting risk factor.

Patency of the saphenous vein conduit anastomosed to the aortic dacron graft.

AIM: The medium term patency rate of proximal saphenous vein conduit anastomosed onto the aortic dacron graft in patients was investigated. METHODS: Forty-eight patients who underwent aortic graft replacement and coronary artery bypass grafting (CABG) in our clinic between February 2004 and December 2011 were included in the study. The study was designed as two phases. In the first phase, records of the patients who have undergone ascending aorta replacement with concomitant CABG were scanned retrospectively. In the second phase, saphenous vein graft patency was assessed in living patients with multislice computerized tomography (CT) by cross-sectional prospective study. RESULTS: A total of 61 saphenous vein grafts (SVG) were used in patients who have undergone concomitant CABG. A total of 39.6% of the patients had single vessel disease, 45.8% of the patients had two-vessel disease and 14.6% three-vessel or more disease. The mean follow-up duration was 3.7±1.9 years. SVG cumulative patency rate was 45.9%. Although the coronary artery position in which the saphenous graft was least occluded was the left anterior descending artery (9.1%) and the position in which it was most occluded was right coronary artery (51.5%), there was no statistically significant difference among the coronary positions in which the SVG was used (p>0.05). CONCLUSION: The saphenous vein conduit anastomosed to the aortic dacron graft may have negative effects on graft patency. The placement of saphenous vein on a native tissue like the innominate artery may have beneficial effects of graft patency by slowing down neointimal hyperplasia.

Serine protease inhibitor aprotinin ameliorates renal injury in a rat model of ischemia-perfusion injury.

BACKGROUND: Renal ischemia-reperfusion (I/R) injury may occur after renal transplantation, thoracoabdominal aortic surgery, and renal artery interventions. OBJECTIVE: To investigate the therapeutic effects of aprotinin on tissue protection against I/R injury in a rat model. N-acetylcysteine (NAC), a potent antioxidant, was also tested to assess the experimental model. MATERIALS AND METHODS: Twenty-four rats were categorized into 3 groups of 8 rats each: those receiving isotonic sodium chloride solution (control group); NAC, 150 mg/kg; and aprotinin, 40,000 KIU/kg. The animals underwent unilateral nephrectomy after 60 minutes of warm ischemia and 60 minutes of reperfusion of the kidney. Malondialdehyde, a lipid peroxidation marker, and antioxidant glutathione levels were measured in the kidney parenchyma. Tissue samples were obtained for histologic analysis. RESULTS: Compared with the control group, the NAC group demonstrated significantly low levels of malondialdehyde (P = .04) and high levels of glutathione (P = .01). At histopathologic analysis, less acute tubular necrosis (ATN) and cellular swelling was noted in the NAC group (P = .002 and P = .005, respectively). In the aprotinin group, histopathologic analysis revealed less tissue damage in terms of ATN (P < .001, cellular swelling (P < .001), and vacuolysis (P = .002). Compared with the NAC group, ATN (P = .01), vacuolysis (P = .04), and congestion (P = .05) were significantly less in the aprotinin group. CONCLUSIONS: Our results suggest that administration of aprotinin attenuates renal I/R injury. This observation has potential application for kidney preservation for transplantation, for aortic surgery, and for renal artery interventions by protecting cells from free radical damage.

The Role of Polytetrafluoroethylene Graft Material in Buerger's Disease

The early and long-term results of polytetrafluoroethylene (PTFE) grafts in different anatomical locations were evaluated in 14 patients with Buerger's disease (thromboangiitis obliterans). During a 10-year period, 2160 patients with peripheral vascular disease were treated and, in 258, the diagnosis of Buerger's disease was made. Fourteen of these 258 patients underwent revascularization with PTFE grafts. In a follow-up period, up to 8 years patency rates were as follows: aorto/ilofemoral bypass 80%, femoropopliteal bypass 40%, femorocrural bypass 50% with a cumulative patency rate of 57.1%, and limb salvage rate of 88.9%. Because of the diverse nature and small number of the operations, the numerical results are not amenable to statistical analysis, but 88.9% limb salvage rate is satisfying in Buerger's disease. To the best of our knowledge, this is the first report on the use of PTFE grafts in Buerger's disease and it validates limb salvage even below the inguinal ligament.