Differential modulatory effects of Propofol and Sevoflurane anesthesia on blood monocyte HLA-DR and CD163 expression during and after cardiac surgery with cardiopulmonary bypass: a preliminary randomized flow cytometry study.

INTRODUCTION: The increase of the anti-inflammatory CD163highHLA-DRlow blood monocyte subset is one of the mechanisms dampening inflammation during cardiac surgery with cardiopulmonary bypass. We evaluated the effect of two different anesthetic protocols, intravenous Propofol infusion or Sevoflurane-gas administration, on the perioperative frequency of this subset. METHODS: Blood from patients (Propofol = 11, Sevoflurane = 13) undergoing minimally invasive mitral valve surgery was drawn preoperatively (T1), before declamping (T2), at 6 (T3), 24 (T4), 48 (T5), and 72 hours (T6) after declamping. C-reactive protein, haptoglobin, and lactate dehydrogenase were measured. A hemolytic index, as C-reactive protein/haptoglobin ratio, was introduced. Monocyte expression of HLA-DR, CD163, and the CD163highHLA-DRlow subset fraction was quantified by flow cytometry. Baseline-referred variations of plasmatic and cellular data at T2 were normalized for clamping times. Subsequent time-point variations were normalized for the final cardiopulmonary bypass times. RESULTS: Variations of hemolytic index and lactate dehydrogenase were higher with Propofol at T3 (p = 0.004 and p = 0.02, respectively) when compared with Sevoflurane. At T2, the down-modulation of CD163 was higher with Propofol (p = 0.005). Starting from T3, the up-regulatory trend of CD163 was basically higher with Propofol, although not significantly. Propofol induced higher increments of HLA-DR low fractions, at T2 (p = 0.04) and, to a lesser extent, at T4 (p = 0.06). Starting from T3, the CD163highHLA-DRlow subset variations were higher with Propofol, especially at T4 and T6. CONCLUSION: Propofol seems to induce a higher postoperative fraction of the CD163highHLA-DRlow monocyte subset. This could represent either a compensatory mechanism dampening the higher inflammatory condition observed with Propofol at T2 or a consequence of a higher postoperative Propofol-induced hemolysis.

A Trial of Two Anesthetic Regimes for Minimally Invasive Mitral Valve Repair.

OBJECTIVE: Minimally invasive mitral valve repair may be associated with prolonged cardioplegic arrest times and ischemic reperfusion injury. Intravenous (propofol) and volatile (sevoflurane) anesthesia are used routinely during cardiac surgery and are thought to provide cardioprotection; however, the individual contribution of each regimen to cardioprotection is unknown. Therefore, the authors sought to compare the cardioprotective effects of propofol and sevoflurane anesthesia in patients undergoing minimally invasive mitral valve repair. DESIGN: A single-center single-blind randomized controlled trial. SETTING: A specialized regional cardiac surgery center in Italy. PARTICIPANTS: The study enrolled 62 adults undergoing elective isolated minimally invasive mitral valve repair for degenerative disease. Exclusion criteria included secondary mitral regurgitation, previously treated coronary artery disease, diabetes mellitus, chronic renal failure requiring dialysis, atrial fibrillation, and documented allergy to either propofol or sevoflurane. INTERVENTIONS: All patients received video-assisted minimally invasive right minithoracotomy. Patients were randomized to receive propofol or sevoflurane anesthesia in a 1:1 ratio. MEASUREMENTS AND MAIN RESULTS: Cardiac troponin I release was measured over the first 72 hours postoperatively. Operative, cross-clamp, and total bypass times were similar between groups. Cardiac troponin I release was reduced nonsignificantly in the propofol group (p = 0.62), and peak troponin I release was correlated with cross-clamp time in both groups. There were no differences in terms of intraoperative lactate release and blood pH between groups. CONCLUSION: Propofol and sevoflurane anesthesia were associated with similar degrees of myocardial injury, indicating comparable cardioprotection. Myocardial injury was related directly to the duration of cardioplegic arrest.

Clinical significance of prophylactic central compartment neck dissection in the treatment of clinically node-negative papillary thyroid cancer patients.

BACKGROUND: Lymph nodal involvement is very common in differentiated thyroid cancer, and in addition, cervical lymph node micrometastases are observed in up to 80 % of papillary thyroid cancers. During the last decades, the role of routine central lymph node dissection (RCLD) in the treatment of papillary thyroid cancer (PTC) has been an object of research, and it is now still controversial. Nevertheless, many scientific societies and referral authors have definitely stated that even if in expert hands, RCLD is not associated to higher morbidity; it should be indicated only in selected cases. MAIN BODY: In order to better analyze the current role of prophylactic neck dissection in the surgical treatment of papillary thyroid cancers, an analysis of the most recent literature data was performed. Prophylactic or therapeutic lymph node dissection, selective, lateral or central lymph node dissection, modified radical neck dissection, and papillary thyroid cancer were used by the authors as keywords performing a PubMed database research. Literature reviews, PTCs large clinical series and the most recent guidelines of different referral endocrine societies, inhering neck dissection for papillary thyroid cancers, were also specifically evaluated. A higher PTC incidence was nowadays reported in differentiated thyroid cancer (DTC) clinical series. In addition, ultrasound guided fine-needle aspiration citology allowed a more precocious diagnosis in the early phases of disease. The role of prophylactic neck dissection in papillary thyroid cancer management remains controversial especially regarding indications, approach, and surgical extension. Even if morbidity rates seem to be similar to those reported after total thyroidectomy alone, RCLD impact on local recurrence and long-term survival is still a matter of research. Nevertheless, only a selective use in high-risk cases is supported by more and more scientific data. CONCLUSIONS: In the last years, higher papillary thyroid cancer incidence and more precocious diagnoses were worldwide reported. Among endocrine and neck surgeons, there is agreement about indications to prophylactic treatment of node-negative "high-risk" patients. A recent trend toward RCLD avoiding radioactive treatment is still debated, but nevertheless, prophylactic dissections in low-risk cases should be avoided. Prospective randomized trials are needed to evaluate the benefits of different approaches and allow to drawn definitive conclusions.

The role of Del Nido Cardioplegia in reducing postoperative atrial fibrillation after cardiac surgery in patients with impaired cardiac function.

BACKGROUND: Postoperative atrial fibrillation (POAF) occurs in 20% to 40% of patients who underwent cardiac surgery and can compromise the postoperative course, especially in those with reduced left ventricular ejection fraction. The most common causes are related to surgical trauma and the high variations in volemic and electrolyte balance in the postoperative period. OBJECTIVES: As cardioplegic solutions can significantly impact both these factors, the study aimed to assess the role of Del Nido (DN) cardioplegia on the onset of POAF. METHODS: A retrospective single-center analysis was carried out on 93 patients undergoing coronary artery bypass graft surgery where cardioplegia was used. The patients were divided into two groups according to the cardioplegic solution (Cold Blood vs Del Nido), and perioperative outcomes were compared. RESULTS: POAF occurred in 21.5% of patients; the patients treated with cold blood cardioplegia (CBC) showed a 3-times higher rate of POAF compared to the DN group (OR: 3.44; 95% CI: 1.1 to 10.5; p = 0.029). The CBC group showed higher serum potassium levels both after the cross-clamp removal (p<0.001), at the ICU admission (p = 0.007), and during the first 3 postoperative days (p = 0.009). The defibrillation rate at cross-clamp removal (p = 0.003), the dose of postoperative epinephrine (p<0.001), and the peak of serum troponin (p = 0.01), were lower in the DN Group. CONCLUSION: DN cardioplegia showed significantly reduced POAF rates after cardiac surgery by acting on the electrolyte balance, myocardial protection and on the need for postoperative inotropic support.

[Thoracotomy enucleation of a giant leiomyoma of the upper oesophagus. Case report and review of the literature]. / Enucleazione toracotomica di un leiomioma gigante dell'esofago toracico superiore. Caso clinico e revisione della letteratura.

The authors report on a case of fibro-leiomyoma of the upper oesophagus. The patient presented dysphagia and oppressive retrosternal pain. Computed tomography and magnetic resonance of the thorax revealed a solid voluminous formation at the level of the posterior upper mediastinum. The US-endoscopy showed that this was a tumour originating from the esophageal wall with macroscopic characteristics of benignity, suggestive of a leiomyoma. The patient was treated by thoracotomy enucleation of the large tumour after sectioning the azygous vein on the same side as the lesion. Histological examination of the surgical resection confirmed that the tumour was a fibro-leiomyoma of the esophagus with a conspicuous vascular component and an interstitial inflammatory focus. The patient now appears to be asymptomatic and illness-free.

Role of parathyroidectomy on anemia control and erythropoiesis-stimulating agent need in secondary hyperparathyroidism of chronic kidney disease. A retrospective study in 30 hemodialysis patients.

BACKGROUND: Parathyroidectomy (Ptx) ameliorates anemia (A) and reduces postoperative erythropoiesis-stimulating agent (ESA) requirement. The authors retrospectively evaluated the effects of successful Ptx on chronic A and ESA need in 30 2HPT patients. METHODS: From 2004 to 2009,30 anemic hemodialysis (HD) patients, affected by severe 2HPT, underwent Ptx -15 total parathyroidectomy (TP) and 15 TP + subcutaneous autoimplantation (TPai). Patients were evaluated for iPTH, hemoglobin (Hb) levels, erythrocyte count, hematocrit and erythropoietin dosing before and at 6, and 12 months after surgery. RESULTS: In every case, Ptx achieved a dramatic reduction of iPTH levels. In 26/30 cases(86.6%) an improvement of Hb levels was observed,and 27/30 (90%) patients did not need postoperative ESA treatment,irrespective of the type of surgical procedure carried out (TP or TPai). CONCLUSIONS: Successful Ptx for 2HPT of CKD determined a considerable improvement of A,reducing exogenous ESA need.In 2HPT of HD patients A is a secondary indication to surgical treatment,but we propose that this condition should be taken into more careful account, given the high costs of ESA therapy.