Predictive Factors of Operative Hemodynamic Instability for Pheochromocytoma.

Pheochromocytoma is an uncommon catecholamine-secreting tumor in which resection is often associated with hemodynamic instability (HI). In this study, we aim to clarify the factors affecting surgical HI in patients who underwent surgery with the diagnosis of pheochromocytoma. All patients who underwent surgery with the diagnosis of pheochromocytoma between 2008 and 2015 were analyzed retrospectively. Patients with inconsistent diagnosis or missing outcomes and follow-up data were excluded. A total of 37 patients were included in this study. Patient demographics, operative time, tumor size, period of medical treatment until surgery, catecholamine levels in urine, and HI patterns were analyzed. There were 23 (62%) male and 14 (38%) female patients. Hemodynamic instability occurred in 13 (35%) patients. Overall, HI was higher in patients with tumor size <6 cm (P < 0.02); moreover, urine catecholamine levels were detected significantly higher than a cutoff value of 2000 µg/24 hours in hemodynamically instable group. In this study, tumor diameter of <6 cm and urine catecholamine levels >2000 µg/24 hours were associated with HI. Preoperative management is essential for preventing hypertensive crisis and HI before or during surgery.

Somatostatin and propranolol to treat small-for-size syndrome that occurred despite splenic artery ligation.

We report our success with somatostatin and propranolol to treat small-for-size syndrome that occurred despite splenic artery ligation. A 48-year-old woman with cirrhosis due to autoimmune hepatitis underwent living-donor liver transplant; her graft-to-body weight ratio of the right lobe was 0.91%. After arterial reperfusion, portal pressure and flow were 24 cm H20 and 2.22 L/min (ie, 360 mL/100g graft/min), respectively. Following splenic artery ligation, the portal pressure decreased to 16 cm H20 and portal flow to 1.74 L/min (ie, 282 mL/100g graft/min). On the second postoperative day, small-for-size syndrome was diagnosed based on the marked prolongation of prothrombin time (international normalized ratio, 4.4), hyperbilirubinemia (359.1 micromol/L), rapid escalation of transaminases (alanine aminotransferase 2488 U/L, aspartate aminotransferase 1075 U/L) and very high portal flow rate (> 90 cm/sec). Oral propranolol (40 mg/day b.i.d.) and somatostatin infusion (250-microgram bolus followed by perfusion at a rate of 250 microgram/h for 5 days) were started. Prothrombin time and transaminase levels began to decrease the following day, although the bilirubin level increased to 495.9 micromol/L before returning to normal. The patient was discharged in excellent health 5 weeks after surgery. Despite reduction of portal pressure by splenic artery ligation, small-for-size syndrome may develop in patients with persistent high portal flow. To the best of our knowledge, this is the first report of the successful treatment of small-for-size syndrome by somatostatin and propranolol in the clinical setting.

Transplantation for Large Liver Tumors in the Setting of Abernethy Malformation.

In this study, we report our experiences on the role of transplantation in 2 patients with large liver tumors in the setting of Abernethy malformation. Patient 1 was a 17-year-old boy who was referred for hepatic masses and recurrent hepatic encephalopathy episodes. Computed tomography and magnetic resonance imaging showed 2 large tumors (4 and 8 cm) in the liver. The portal vein drained directly into the vena cava. Core biopsy of the larger mass revealed fibrosis and regenerative hyperplasia. There were hyperintense signals in the T1-weighted images in the globus pallidus. The Stanford-Binet intelligence scale showed moderate mental retardation (IQ 39); however, the patient showed good ability for caring for himself. His cognitive defect was ascribed partially to chronic encephalopathy. The patient received a right hepatic lobe from his older brother. The congenital portacaval shunt was disconnected to provide inflow to the graft. Pathologic examination of the explanted liver revealed no evidence of malignancy. His IQ improved to 75 at 29 months posttransplant. The hyperintensity of the globus pallidus on magnetic resonance imaging disappeared. The patient has maintained a normal life during 9 years of follow-up. Patient 2 was a 17-year-old girl who was referred for multiple hepatic masses; she had no symptoms at admission. Magnetic resonance imaging showed type 1 Abernethy malformation and multiple hepatic masses (largest was 10 cm), which appeared to be hyperplastic lesions. Because malignancy could not be definitely excluded, she received a right lobe without the middle hepatic vein from her uncle. Pathologic examination of the explanted liver showed localized nodular hyperplasia; there was no evidence of malignancy. She has maintained normal life activities during 3 years of follow-up. Liver transplant is a curative treatment option for patients with large liver tumors, replacing the hepatic parenchyma in the setting of Abernethy malformation.

Successful living-donor liver transplantation and retransplantation with cavoportal hemitransposition: a case report.

An 11-month-old female infant underwent living-donor liver transplantation for secondary biliary cirrhosis 8 months after Kasai operation. The portal vein was hypoplastic, and its diameter was only 4 mm at the level of the splenomesenteric confluence. End-to-end anastomosis of the recipient suprarenal vena cava to the graft portal vein (a left lateral section from the patient's mother) was performed. An end-to-side portocaval shunt with the recipient portal vein was constructed to mitigate portal hypertension. The early postoperative course was relatively uneventful. However, persistent hepatitis caused by infection with Cytomegalovirus and chronic rejection resulted in progressive hepatic dysfunction. Nine months after the initial operation, a living-donor retransplantation (a left lateral section from the patient's grandmother) was performed. One month after retransplantation, severe acute rejection that eventually required OKT3 treatment developed. The patient was in excellent health until 4 months after retransplantation, when another acute rejection episode (for which she was successfully treated) developed. Cavoportal hemitransposition should be included in the armamentarium of the transplant surgeon for the management of extensive portal system thrombosis and portal vein hypoplasia. An additional shunt may be useful in mitigating portal hypertension.

[Spinal anesthesia in cesarean section with different combinations of bupivacaine and fentanyl]. / Sezaryen operasyonlarinda farkli fentanil ve bupivakain kombinasyonlari ile spinal anestezi.

The use of opioids for spinal anesthesia increases the anesthetic quality, reduces side effects and also has advantages for the postoperative analgesia. The aim of this study was to evaluate the effects of subarachnoid %0.5 hyperbaric bupivacaine (B) alone or combined with 10 or 20 mg fentanyl (F) on the anesthetic properties for cesarean section and newborn. 45 patients were randomized to three groups to receive 1.8 ml anesthetic drug for spinal anesthesia. GI (n=15) received B, GII (n=15) 10 mg F+B, GIII (n=15) 20 mg F+B. The onset of sensory blok at T4 level, maximum anesthetic level and the onset time, the level of the motor block, duration of effective analgesia, use of total i.v. fluids and ephedrine, relaxation at the operative area, side effects, umblical cord blood gases, Apgar and neurological and adaptive capacity scores of the newborn were compared among the groups. We conclude that compared to control group, the addition of fentanyl to hyperbaric bupivacaine leads to a decrease in local anesthetic doses and so to a decrease in the incidence of side effects and postoperative analgesic consumption. 7 mg B+20 mg F seems to be the preferable combination for that reasons.

Effects of Head Position on Cerebral Oxygenation and Blood Flow Velocity During Thyroidectomy.

OBJECTIVE: Determining the blood flow through intra and extra-cranial arteries during neck extension may be helpful but is a controversial issue. We aimed to elucidate the changes in cerebral blood flow related to head positioning during thyroid surgery by carotid Doppler examination and regional oxygen saturation variations. METHODS: Thirty patients were recruited to the study. Patients were positioned with a final position of thyroidectomy consisting a 30° semi Fowler with the extension of neck and head. Values of peak systolic velocity, average velocity, arterial diameter and blood flow volume of the common carotid artery were calculated. Bilateral regional cerebral oxygen saturation were monitored continuously. RESULTS: At the end of the operation, peak systolic velocity, average velocity and blood flowvolume of the common carotid artery decreased significantly compared to the baseline measurement (p<0.001). Both left and right cerebral oximetry measurements showed a significant increase after induction and the increased oxymetric values persisted at the end of the operation (p<0.001). Age, body mass index, surgical duration and anaesthesia duration were found not to be correlated with the changes occurred in the values of peak systolic velocity, average velocity, arterial diameter, blood flow volume of the common carotid artery, left and right regional cerebral oxygen saturation after induction and at the end of surgery. CONCLUSION: The head and neck extension given for thyroidectomy negatively affect carotid blood flow and cerebral oxygenation gradually and become pronounced especially at the end of surgery. In conclusion, it is important to maintain the cerebral perfusion pressure and cerebral blood flow.

[Iatrogenic hypernatremia during hydatid cyst operation]. / Karaciger Kist Hidatik Operasyonunda Iyatrojenik Hipernatremi.

Hypernatremia due to salt gain is generally iatrogenic. This case report presents a 55 year-old woman who was operated because of hepatic hydatid cyst. At the end of the operation, following extubation the patient was unconscious and serum sodium concentration was found to be 185 mEq/ L. The patient was entubated again and transferred to the intensive care unit. When the patient awaked and became conscious at 36th hour in intensive care unit, she was extubated and transferred to ward with serum sodium concentration of 142 mEq/L. The serum sodium concentration should be monitored carefully in hydatid cyst operation, during which hypertonic saline is used for scelosidal effects as general anesthesia can mask neurologic signs due to hypernatremia.

Predictive Factors Involved in Development of Postoperative Pulmonary Complications.

OBJECTIVE: In the present study, we applied the method of the multi-center Prospective Evaluation of a Risk Score for postoperative pulmonary Complications in Europe (PERISCOPE) study, which was designed to predict postoperative complications and funded by the European Society of Anaesthesiology, to patients in our institution with the aim of prospectively analyzing the postoperative risk factors of pulmonary complications. METHODS: One hundred patients over 18 years of age who had emergency or elective non-thoracic or non-obstetric surgery under general anaesthesia or neuraxial blocks were included in the study. Collected data regarding the preoperative and postoperative period were filled in separate forms for all patients. RESULTS: A total of 11 patients developed pulmonary complications. We observed respiratory failure in 8 patients, pleural effusion in 3 patients, atelectasis in 5 patients, bronchospasm in 3 patients, and pneumothorax in 1 patient. In the univariate logistic regression model, patient age, gender, weight, rate of preoperative respiratory symptoms, cough test results, American Society of Anesthesiology (ASA) score, and the duration of surgery did not significantly increase the complication risk (p>0.05). However, in the univariate logistic regression model, the presence of respiratory symptoms increased the risk for complications approximately 5.34-fold (p=0.014). There was an increase in the possibility of complications in parallel with the increase in the duration of postoperative hospital stay (p=0.012). More respiratory symptoms (p=0.019) and longer hospital stay (6.5 vs. 3.5 days respectively, p=0.029) were recorded in patients with postoperative pulmonary complications. CONCLUSION: Considering patients undergoing non-thoracic or non-obstetric surgery, the prevalence of postoperative pulmonary complications is higher in patients diagnosed with respiratory symptoms in the preoperative period. These complications significantly extend the length of hospital stay.

Implantable cardioverter-defibrillator placement in patients with mild-to- moderate left ventricular dysfunction: hemodynamics and recovery profile with two different anesthetics used during deep sedation.

OBJECTIVE: To compare the effects of thiopental and propofol during defibrillation threshold testing (DFT) on hemodynamics and recovery profile in patients requiring automatic internal cardioverter-defibrilator placement. DESIGN: Prospective clinical investigation. SETTING: University hospital. PARTICIPANTS: Thirty-four adult patients. INTERVENTIONS: After administration of midazolam, 0.025 mg/kg, and fentanyl, 0.5 to 1 mug/kg, surgery was performed under topical infiltration with 1% lidocaine. In group I (GI) (n = 17), patients received thiopental by slow injection and patients in group II (GII) (n = 17) received propofol before induction of ventricular fibrillation (VF). MEASUREMENTS AND MAIN RESULTS: Patients received 4.1 +/- 1.4 mg of midazolam, 114 +/- 34 mug of fentanyl, and 280 +/- 78 mg of thiopental in GI; and 4.6 +/- 1.7 mg of midazolam, 119 +/- 62 mug of fentanyl, and 147 +/- 40 mg of propofol in GII (p > 0.05). Hemodynamics did not show significant differences between the groups at any recording time. Average time needed to regain the pretest sedation level was 16.4 +/- 8.8 minutes in GI and 10.9 +/- 5.5 minutes in GII (p = 0.03). Time required to achieve a score of 10 using a modified Aldrete score was 26.4 +/- 9.3 minutes in GI and 17.4 +/- 4.9 in GII (p = 0.001). Seven patients in GII (41%) and 1 patient in GI (6%) became hypotensive after DFT (p = 0.04). CONCLUSIONS: Deepening the sedation level by slow injection of thiopental or propofol before DFT provided satisfactory conditions during brief episodes of VF. Delay in recovery of arterial pressure after DFT with propofol and delay in arousal and discharge of patients with thiopental are major disadvantages of the regimens.