The Role of Self-Expandable Metallic Stents in the Treatment of Malignant Strictures in all Segments of the Gastrointestinal Tract.

Objectives: Management of malignant gastrointestinal (GI) obstruction presents a significant challenge. Most patients are in a profoundly decompensated state due to underlying malignancy and are not ideal candidates for invasive surgical procedures. Self-expandable metallic stents (SEMSs) are used to provide permanent or temporary patency in all endoscopically accessible stenosis of the GI tract. In this study, it is aimed to analyse the characteristics and the efficacy of patients with malignant stenosis treated with SEMS, in all segments of the GI tract. Material and Methods: The sample consisted of 60 patients who underwent SEMS replacement, between 10 March 2014 and 16 December 2020, to treat malignant-related strictures in the GI tract at the Gastroenterology Department of the Health Sciences University Umraniye Training and Research Hospital. The data of the patients, hospital data processing database and electronic endoscopic database records were retrospectively scanned and recorded. The general characteristics of the patients and the treatment-related features were analysed. Results: The mean age of patients who were placed SEMS was 69.7 ± 13.7 years. Uncovered (15%, n: 9), fully covered (13.3%, n: 8), or partially covered (71.6%, n: 43) SEMS were successfully placed in all patients. Clinical success in patients with SEMS was 85.7% in the esophagus, 100% in the small intestine and 90.9% in the stomach and colon. About 11.4% migration, 14.2% pain, 11.4% overgrowth and 5.7% ingrowth were detected in patients who had SEMS placed in the oesophagus. Pain was detected in 9.1% and ingrowth in 18.2% of patients who had SEMS placed in the stomach. Pain was detected in 18.2% of the patients who had SEMS placed in the colon and migration was found in 9.1%. Conclusion: SEMS implant is a minimally invasive effective method in the palliative treatment of malignant strictures of the GI tract.

Can gastric botulinum toxin A injection be used as minimally invasive procedure in the short-term treatment of obesity?

BACKGROUND/AIM: Gastric botulinum toxin A (BTX-A) injection is a type of endoscopic obesity treatment option that delays gastric emptying. However, there is little and contradictory information concerning the treatment efficacy of BTX-A injection. This study evaluated the treatment efficacy of BTX-A injection in the treatment of obesity. MATERIALS AND METHODS: This was an open-label, prospective study of obese individuals with a body mass index >30 kg/m2 admitted to our clinic. The sample consisted of 72 consecutive treatment-naive patients with obesity divided into age-sex-matched three groups: gastric BTX-A injection (study group), calorie-restricted (15-20 Kcal/kg) diet (control) and bariatric surgery (BS) (control) groups. In the study group, 200 IU BTX-A was injected to the antrum and corpus endoscopically. The study and control groups were compared for their total body weight loss (TBWL) and excess body weight loss (EBWL) at the 6th month. RESULTS: Gastric BTX-A injection therapy was applied to 24 patients. The mean age was 39.1 ± 9.1/years. 54.1% of the patients (n = 13) was female. At the 6th month, the mean TBWL and EBWL of patients were; 10% ±4.1 and 37.2% ±13.9 for gastric BTXA injection group, 5% ±2.3 and 20.2% ±9.3 for diet group, 30.7% ±5.3 and 66.9% ±14.4 for BS group. Patients who underwent gastric BTX-A injection lost weight more effectively than patients who were on diet alone, while BS patients lost weight more effectively than those who had gastric BTX-A injection (P < 0.001). In the gastric BXT-A injection group, the first 3-month delta EBWL and TBWL (change of EBWL and TBWL percentages) were found significantly higher than the 3-6th month and 6-12th month (P = 0.001 and P < 0.001). CONCLUSION: Gastric BTX-A injection is a minimally invasive and short-term effective method that can be used in the treatment of obesity.

Prediction of Prognosis Acute Pancreatitis with Inflammatory Markers and Patient Characteristics Compared to the Scoring System: Real-Life Data.

Objectives: Acute pancreatitis (AP) is an inflammatory disease with a high morbidity and mortality rate. It is one of the most common causes of hospitalization among gastrointestinal system diseases. Inflammatory and other factors that predict the severity of AP are very important for patient management. This study will analyze the factors associated with the severity of AP. Methods: The sample consisted of 514 patients. Demographic characteristics, comorbid diseases, causes of AP, body mass index (BMI), tobacco use, blood at admission, amylase, lipase, leukocyte, neutrophil, lymphocyte, C-reactive protein (CRP), mean platelet volume, red cell distribution width, albumin, calcium, and CRP values at 48th h were recorded. The bedside index of severity in AP (BISAP), Ranson score, neutrophil-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) values was calculated and recorded. The relationship between these parameters and the severity of AP was analyzed according to the Atlanta classification. Results: Participants had a mean age of 55±17.8 years. More than half the participants were women (n=272, 52.9%). Biliary causes were the most common etiological causes (n=299, 58.2%). Most participants had mild pancreatitis (n=416, 80.9%). The severity of AP was associated with tobacco use, high BMI, thrombocytosis, high NLR, high PLR, high 48th h CRP, hypoalbuminemia, hypocalcemia, aspartate aminotransferase/alanine aminotransferase ratio (AST/ALT ratio), and high Ranson and BISAP scores. Conclusion: Biochemical markers that give rapid results in the early period can provide information about the severity of AP. We may develop new scores by combining these parameters.

A Schistosoma Colitis Case Misdiagnosed as Ulcerative Colitis in a Non-Endemic Area: A Case Report.

The differential diagnosis of bloody diarrhea is necessary to specify etiology and plan treatment. Misdiagnosis can lead to catastrophic results with the treatments to be given. In this case report, we present a case of schistosomal colitis mimicking ulcerative colitis in a 26-year-old Guinean male patient diagnosed in 2021.

EUS-FNA and ROSE in solid lesions of the pancreas; have the same diagnostic efficacy compared to pancreatic sites?

OBJECTIVE: Various techniques, needle types, and additional methods such as on-site pathological evaluation (ROSE) are used to increase the sensitivity of endoscopic ultrasound-fine needle aspiration (EUS-FNA), which is used in the diagnosis of pancreatic solid lesions. In this study, diagnosticity of the lesions according to the regions of the pancreas with EUS-FNA and ROSE performed with the slow pull technique using a 22 G needle will be evaluated. METHODS: A total of 82 patients who underwent EUS-FNA between January 2, 2015, and March 14, 2020, were included in the study. General and clinical information of the patients were recorded retrospectively. The patients were diagnosed according to The Papanicolaou Society of Cytopathology System for Reporting Pancreaticobiliary Cytology Classification. If the diagnosis could not be made with EUS-FNA and ROSE, the diagnosis was made with alternative methods of surgery or percutaneous biopsy. Patients diagnosed as benign with EUS-FNA and ROSE were followed for at least 1 year and were accepted as benign. RESULTS: The mean age of the patients was 63.2±10.5 years and 54 (69.6%) of them were male. The mean lesion size was 36.8 mm and the number of needle passes was 2.87. The overall sensitivity was 82.9% and the specificity was 100%. The sensitivity of EUS-FNA and ROSE in solid lesions in the head and body of the pancreas was higher than in lesions in the tail region (p=0.024). CONCLUSION: EUS-FNA and ROSE are an effective method in the diagnosis of pancreatic solid lesions. The use of a 22 G needle may be more diagnostic in the head and body of the pancreas than in the tail region.

Can Bispectral Index Monitoring (EEG) be an Early Predictor of Respiratory Depression under Deep Sedation during Endoscopic Retrograde Cholangiopancreatography?

OBJECTIVES: The more often the endoscopy sedation is performed, the more the risk of adverse events, and therefore, advanced monitoring becomes more and more essential in endoscopy units. The present study aims to evaluate whether the Bispectral Index (BIS) monitoring is an early predictor of respiratory depression and to determine the compliance between commonly used clinical sedation score. METHODS: This study was approved by the ethics committee. The sample consisted of 60 patients aged 18 to 50 years with an American Society of Anesthesiologists (ASA) physical status of I scheduled for endoscopic retrograde cholangiopancreatography (ERCP). All patients received propofol mediated sedation. Ramsay sedation score (RSS) was used as a clinical sedation score to assess the depth of sedation. Participants were attached to a BIS monitor. Perioperative hemodynamics, BIS values, the mean dose of propofol, procedure duration, apnea, frequency of oxygen desaturation and airway-related interventions, as well as demographic parameters, were recorded. BIS scores were blinded to RSS data. RESULTS: The study sample consisted of 60 patients (36 females) aged 18 to 50 years (mean: 36.10±8.02). The mean procedure time and the dose of propofol were 32.70±1.79 min and 287.17±59.66 mg, respectively. The cut-off values for respiratory depression were as follows. At the 15th min of measurement, the BIS score of 60 had 96.2% sensitivity and 42.9% specificity. At the 20th min of measurement, the BIS score of 59.50 had 98.2% sensitivity and 100.0% specificity. At the 25th min of measurement, the BIS score of 59.00 had 98.3% sensitivity and 50.0% specificity. Regression analysis showed that the mean BIS score (p=0.000, 95%CI-0.110-0.043) increased by 0.076 with a unit increase in the RSS. CONCLUSION: BIS was highly correlated with RSS, and therefore, can be used to avoid respiratory depression during sedation.

Outcome Measurements for Pain Relief in Elderly Patients with Spinal Stenosis Undergoing Epidural Steroid Injection: Is Conservative Approach an Option?

AIM: To evaluate the short-term outcomes of epidural steroid injections (ESIs) among elderly patients with lumbar spinal stenosis. MATERIAL AND METHODS: This was a retrospective study. The sample consisted of 44 patients aged 65 or older who underwent epidural steroid injections secondary to lumbar spinal stenosis between 2014 and 2016 at a single center. Data were collected using the Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), and Istanbul Low Back Pain Disability Index (ILBPDI) before and at 3-month follow-up visit. RESULTS: Participants had lower mean scale scores at all times after ESI administration than before. Four patients (9.1%) needed additional injections while two (4.5%) needed operation. No minor or major ESI-related complications were observed. CONCLUSION: Epidural steroid injections are an effective nonsurgical option for pain relief and improvement of physical function in elderly patients. The NRS, ODI, and ILBPDI are reliable and valid scales that can be used to evaluate the outcomes of ESIs in a selected group of elderly patients.

The Application of an Enhanced Recovery After Surgery to Spine Instrumentation.

AIM: To evaluate the clinical and economic outcomes of the adoption of the enhanced recovery after spine surgery (ERSS) program in patients undergoing spine instrumentation. MATERIAL AND METHODS: This study described the introduction of the ERSS program, and we compared 86 consecutive patients who participated in ERSS with a retrospective cohort of 88 patients who underwent the same surgery before the implementation of this program. Groups were compared in terms of age, sex, body mass index (BMI), American Society of Anesthesiologist (ASA) physical scores, operative time, comorbidities, intraoperative blood loss, blood transfusion rate, first oral intake, time of first mobilization, length of hospital stay, preoperative and postoperative pain scores using a numeric pain rating scale, 30-day readmission and complication rates, and total cost. RESULTS: Groups were similar in terms of age, sex, BMI, ASA scores, and comorbidities. Intraoperative blood loss, blood transfusion rate, and length of hospital stay were lower in the ERSS group. First oral intake and first mobilization occurred earlier in the ERSS group. Postoperative pain scores were significantly lower in the ERSS group. Operative time, readmissions, or complications at 30 days did not statistically differ between the two groups. The ERSS group was found to be significantly cost effective. CONCLUSION: ERSS is feasible, comprehensive, and cost effective for spine instrumentation with better perioperative outcomes.

Effects of Anesthesia Protocol on Perioperative Outcomes and Costs of Lumbar Microdiscectomies.

AIM: To compare the effects of spinal anesthesia (SA) and general anesthesia (GA) in lumbar microdiscectomy in terms of their costeffectiveness, and perioperative outcomes. MATERIAL AND METHODS: We randomly allocated 100 consecutive patients who were scheduled to undergo elective lumbar microdiscectomy, into either SA or GA groups. We recorded and evaluated various parameters, including demographic aspects, body mass index (BMI), perioperative hemodynamics, time elapsed from operating room (OR) entry until incision, operative time, time elapsed from application of the surgical dressing to exiting OR, blood loss, post anesthetic care unit (PACU) time, preoperative and postoperative pain scores, postoperative analgesic requirements, first mobilization time, first oral intake, the length of hospital stay, time to return to work, and perioperative anesthetic costs. The patients, anesthesiologists, and neurosurgeons were handed a questionnaire before discharge to determine their satisfaction with the procedure. RESULTS: Several variables were found to be better in the SA group: the mean arterial pressure and heart rate changes were significantly lower, and the time elapsed from OR entry until incision, operative time, time elapsed from application of the surgical dressing to exiting OR, PACU time, the length of hospital stay, and time to return to work were shorter; furthermore, the postoperative pain scores, the analgesic requirements, the intraoperative blood loss, and the cost of anesthesia were all lower. Moreover the first mobilization and oral intake occurred earlier; and most significantly, the satisfaction of the patients and surgeons was higher in the SA group. Furthermore, we encountered no complications. CONCLUSION: Based on our results, we conclude that SA is reliable and clinically successful procedure in lumbar microdiscectomy.

The effects of obesity on sedation-related outcomes of advanced endoscopic procedures.

OBJECTIVE: Current literature covers limited data on the safety of sedation in advanced endoscopic procedures in obese patients. The present study aims to evaluate the association between obesity and the frequency of sedation-related complications in patients who were undergoing advanced endoscopic procedures. METHODS: A retrospective chart analysis of 1172 consecutive patients, meeting the inclusion and exclusion criteria for this study and undergoing intravenous ketamine-propofol (ketofol) sedation for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) procedures were evaluated. The patients were classified into three groups according to their body mass index (BMI) (kg/m2). Group I comprised patients with a BMI between 25 and 30, group II with a BMI between 30 and 35, and group III with a BMI between 35-40. The sedation-related outcomes in the form of adverse events, and airway interventions were compared between the groups. RESULTS: For analysis, out of the 1172 available records, 289 patients had a BMI between 35-40 and were predominantly male patients. The total adverse events were more common in obese patients, with apnea (in 5.5% patients in group I, 5.7% in group II, 22.8% in group III p<0.000), oxygen desaturation (in 7.7% patients in group I, 9.4% in group II, and 27.7% in group III p<0.000), and airway obstruction (in 4.9% patients in group I, 5.4% in group II, 22.8% in group III, p<0.000). Moreover, the obese patients more frequently required airway interventions, including airway placement, suctioning and bag-mask ventilation. CONCLUSION: Higher BMI was associated with an increased frequency of sedation-related complications. However, we concluded that ketofol sedation regimen could be used safely in obese patients during advanced endoscopic procedures by skilled anesthesia providers.

Medical Folk Remedy: Two Cases of Garlic Burns.

Over the years, many cultures have used herbs for serious health problems. Garlic (Allium sativum) pose hypocholesterolemic, fibrinolytic, antidiabetic, and antibiotic actions. However, it has unusual adverse effects such as chemical burns and contact dermatitis when used topically. In this case report, the authors present two cases of topical garlic burn caused after the use of crushed garlic with a bandage for pain relief due to arthritis.

Comparison of Ketamine with Midazolam versus Ketamine with Fentanyl for Pediatric Extracorporeal Shock Wave Lithotripsy Procedure: A Randomized Controlled Study.

OBJECTIVES: To compare the effects of ketamine-fentanyl (KF) and ketamine-midazolam (KM) combinations on hemodynamic parameters, recovery properties, pain, and side effects in pediatric patients undergoing extracorporeal shock wave lithotripsy (ESWL) procedure. METHODOLOGY: In this double-blinded, randomized trial, 60 pediatric patients aged between 1 and 13 years with American Society of Anesthesiologists physical status Classes I and II, who scheduled for ESWL procedure, were included in the study. Patients were randomly divided into two groups: Group KM received 0.1 mg/kg of midazolam +1-1.5 mg/kg of ketamine and Group KF received 1 µg/kg of fentanyl +1-1.5 mg/kg of ketamine intravenously. RESULTS: There were similar demographic properties, recovery, and discharge times between groups. No statistically significant difference was found in peripheral oxygen saturation, mean and diastolic blood pressure, Ramsey sedation scores, modified Aldrete recovery scores, side effects, and recovery times (Group KM, 16.067 ± 1.2 min; Group KF, 19.46 ± 0.86 min) between groups (P > 0.05). CONCLUSION: KF combination offers better hemodynamic properties, less side effects with lower visual analog scores, and face, legs, activity, cry, and consolability scores than KM in the pediatric ESWL procedure.

The Comparison of the Efficacy and Safety of Midazolam, Ketamine, and Midazolam Combined with Ketamine Administered Nasally for Premedication in Children.

BACKGROUND: In this prospective, randomized study, we evaluated the intranasal administration of Midazolam ketamine combination, midazolam, and ketamine in premedication for children. MATERIAL AND METHODS: We studied 60 American Society of Anesthesiology physical status Classes I and II children aged between 1 and 10 years undergoing ear nose throat operations. All cases were premedicated 15 min before operation with intranasal administration of 0.2 mg/kg midazolam in Group M, 5 mg/kg Ketamine in Group K, and 0.1 mg/kg Midazolam + 3 mg/kg ketamine in Group MK. Patients were evaluated for sedation, anxiety scores, respiratory, and hemodynamic effects before premedication, 5 min interval between induction and postoperative period. RESULTS: There was no difference with respect to age, sex, weight, the duration of the operation, and for mask tolerance. Sedation scores were significantly higher in Group MK. There was no statistically difference between the groups for heart rate, oxygen saturation, and respiratory rate. CONCLUSION: We concluded that intranasal MK combination provides sufficient sedation, comfortable anesthesia induction with postoperative recovery for pediatric premedication.

The Effects of the Quincke Spinal Needle Bevel Insertion on Postdural Puncture Headache and Hemodynamics in Obstetric Patients.

AIM: Spinal anesthesia is a widely used procedure in modern anesthesia. Although it is a reliable and frequently used anesthetic procedure, it involves complications, including postdural puncture headache caused by arachnoid punctured, which significantly affects postoperative well-being. In this study, we aimed to observe headache frequency with 26-G Quincke spinal needle in either transverse or sagittal planes. MATERIALS AND METHODS: One hundred patients with American Society of Anesthesiologists status classes I and II who were scheduled for elective cesarean delivery with no contraindications for performing spinal anesthesia were randomly divided into two groups: Group I (transverse n = 50) and Group II (sagittal n = 50). Spinal anesthesia was performed with a 26-G Quincke needle, using 1.5-2.0 ml 0.75% hyperbaric bupivacaine. The anesthesiologists' experience, number of attempts for spinal anesthesia, volume of fluid administered preoperatively and intraoperatively, intervertebral space where spinal anesthesia was administered, and patient movements during the attempts were recorded. Mean arterial pressure and peak heart rates were recorded for 60 min intraoperatively and postoperatively. Headache and back pain complications were observed for 1 week postoperatively. Chi-square tests and statistical comparisons of the rates (statistical significance, P < 0.05) were used for assessments. RESULTS AND CONCLUSIONS: No significant differences were observed with respect to age, height, weight, headache, or incidence of back pain. No significant differences were observed for the number of spinal attempts, intervertebral space where spinal anesthesia was administered, experience of the anesthesiologists, patient movements during the attempts, volumes of fluid administered preoperatively and intraoperatively, or low back pain incidence. Significant reductions in mean arterial pressure were observed between groups after 10, 15, 30, 40, and 50 min. No significant differences were observed in headache or back pain frequency with 26-G Quincke spinal needle in either transverse or sagittal planes. Hypotension was frequently observed in the transverse group.

Subarachnoid Block a Safe Choice for Cesarean Section in Neurofibromatosis Patient with Severe Kyphoscoliosis.

Neurofibromatosis type 1 (NF1) is an autosomal-dominant neuroectodermal hereditary disorder, in which spinal skeletal deformities are one of the manifestations. Pectus carinatum, temporomandibular joint dysfunction, and kyphoscoliosis can be seen with this genetic disorder which can lead to cardiorespiratory system problems and can cause difficulty in airway management. We present the anesthetic management of a NF1 patient with a sharp thoracolumbar dystrophic kyphoscoliosis who have been posted for emergency cesarean section as a result of fetal distress. The operation was successfully performed with subarachnoid block. This case highlights the anesthetic challenges and the significance of early planning anesthetic technique.

Anesthetic Management in Corpus Callosum Agenesis.

Corpus callosum agenesis develops when the band which connects the two hemispheres of the brain does not occur in utero. It is associated with prenatal infections, genetic factors, toxic exposures, metabolic disorders, and chromosome errors. Mostly seen clinical features are macrocephaly, microcephaly, seizures, motor retardation, hypotonia, eye anomalies, and facial dysmorphisms. Here, we report a case of corpus callosum agenesis syndrome undergoing upper endoscopy under deep sedation with dexmedetomidine. The main anesthetic concerns are difficulty in airway, respiratory problems, gastric reflux, and interaction of the seizures therapy with general anesthetics.

Anesthetic Management in Pediatric Patient for Percutaneous Endoscopic Gastrostomy with Mitochondrial Myopathy: Leigh Syndrome.

Leigh syndrome (LS) is a rare disease mainly affecting the central nervous system due to the abnormalities of mitochondrial energy generation and seen in early childhood with progressive loss of movement, mental abilities, seizures, nystagmus, ophthalmoparesis, optic atrophy, ataxia, dystonia, or respiratory failure. Anesthesia and surgery exacerbate the risks of aspiration, wheezing, and breathing difficulties. Tracheal irritability can be stimulated with the efforts of intubation. We report the anesthetic management of a rare case of an 11-year-old boy with a severe form of LS for percutaneous endoscopic gastrostomy insertion. The patient was closely monitored during the procedure and the postoperative period. Carefully chosen anesthetic agents, good pain control, and close monitoring are essential.

Anosmia after Caudal Epidural Steroid Injection.

There are no reports for anosmia after caudal epidural steroid injections (CESIs). General anesthesia is among the reasons, but the reports up to date are extremely limited. There are no identifiable factors contributing to anosmia after epidural injection, so it is worth discussing. We present the case of a 50-year-old woman with no previous history of any sensory deficits. She experienced anosmia after CESI that had been performed due to her chronic low back pain and lasted for 4 months. Clinical and imaging studies did not reveal any pathology. After 4 months, the olfactory dysfunction demonstrated a significant improvement. Disorders of the olfactory system are unknown after regional anesthesia. The onset of the dysfunction in correlation with the imaging findings may indicate that anesthetics can affect the olfactory dysfunction. Further studies are needed.

Unexpected Complication after Caudal Epidural Steroid Injection: Hiccup.

Persistent hiccup is uncommon, and the mechanism is poorly understood. We present the case of a 43-year-old male patient referred to the Algology department due to chronic back pain who developed what we believe a rare case of persistent hiccup secondary to caudal epidural steroid injection (CESI). The causes of hiccup are many and include electrolyte derangement, nutritional deficiencies, gastrointestinal disorders and instrumentation, cardiovascular disorders, renal impairment, central nervous system disorders, and drugs; however, the cause may be unknown. CESI is one of the treatments of back pain, in addition to various other modalities including surgical interventions. CESI has gained rapid and widespread acceptance for the treatment of lumbar and lower extremity pain. However, there are only a few well-designed, randomized, controlled studies on the effectiveness of steroid injections. Consequently, side effects should be considered. We aimed to present a persistent hiccup after CESI for chronic low back pain.

A Safe Regional Technique in a High-risk Patient: Cervical Plexus Blockage.

Regional anesthesia in the form of combined cervical plexus block is gaining popularity as a technique of choice for cervical spine surgeries, especially for urgent ones. An important advantage is that it allows continuous monitoring of patient's neurological status. The success of the block often depends on accurate placement of the local anesthetic. Landmarks for the block are therefore of great importance. In this case, we aimed to present a 74-year-old man with C4-5 odontoid fracture. We planned to perform a unilateral combined cervical plexus block for anterior cervical instrumentation and fusion (ACIF) operation because of his associated high-risk comorbid disorders.