The protective effect of alpha-lipoic acid in experimental ovarian ischaemia-reperfusion injury

BACKGROUND: We investigated the effect of alpha-lipoic acid (LA) on reperfusion injury in a rat ovarian torsion-detorsion model. The changes in tissue and plasma levels of malondialdehyde (MDA), end-product of lipid peroxidation, superoxide dismutase (SOD), xanthine oxidase (XO) and nitric oxide (NO), were determined. Ovarian histopathological findings were scored and compared among groups. MATERIALS AND METHODS: Thirty-two female Sprague-Dawley rats were divided into four groups. Sham operation was performed in group I; in group II only ovarian torsion was performed. Group III received intraperitoneal injections of saline, and group IV received LA via intraperitoneal injections (LA group: aqueous solution at 36 mg/kg of body weight per day, saline group: equal volume of saline) 21, nine, and one hour before torsion of the ovary. Rats in the torsion group were killed after 360 degrees clockwise adnexial torsion for three hours, and ovaries were harvested. After three hours of adnexial detorsion, the rats in saline group and LA group were killed and adnexa were surgically removed. RESULTS: Ovarian tissue damage scores were significantly different among groups and were seen to correlate with tissue MDA levels. Ovarian tissue and serum MDA, NO and serum XO levels in the group III were significantly higher than those of the groups I and IV (P<0.05). The serum levels of SOD in the group III were significantly lower than those of the groups I and IV (P<0.05). CONCLUSION: These results suggest that LA pretreatment has beneficial effects in the prevention of ischaemia-reperfusion injury of the ovaries.     

Incidence and Impact of Documented Eradication of Breast Cancer Axillary Lymph Node Metastases Before Surgery in Patients Treated With Neoadjuvant Chemotherapy

OBJECTIVE: To determine the incidence and prognostic significance of documented eradication of breast cancer axillary lymph node (ALN) metastases after neoadjuvant chemotherapy. SUMMARY BACKGROUND DATA: Neoadjuvant chemotherapy is the standard of care for patients with locally advanced breast cancer and is being evaluated in patients with earlier-stage operable disease. METHODS: One hundred ninety-one patients with locally advanced breast cancer and cytologically documented ALN metastases were treated in two prospective trials of doxorubicin-based neoadjuvant chemotherapy. Patients had breast surgery with level I and II axillary dissection followed by additional chemotherapy and radiation treatment. Nodal sections from 43 patients who were originally identified as having negative ALNs at surgery were reevaluated and histologically confirmed to be without metastases. An additional 1112 sections from these lymph node blocks were obtained; half were stained with an anticytokeratin antibody cocktail and analyzed. Survival was calculated using the Kaplan-Meier method. RESULTS: Of 191 patients with positive ALNs at diagnosis, 23% (43 patients) were converted to a negative axillary nodal status on histologic examination (median number of nodes removed = 16). Of the 43 patients with complete axillary conversion, 26% (n = 11) had N1 disease and 74% (n = 32) had N2 disease. On univariate analysis, patients with complete versus incomplete histologic axillary conversion were more likely to have initial estrogen-receptor-negative tumors, smaller primary tumors, and a complete pathologic response in the primary tumor. The 5-year disease-free survival rates were 87% in patients with preoperative eradication of axillary metastases and 51% for patients with residual nodal disease after neoadjuvant chemotherapy. Of the 39 patients with complete histologic conversion for whom nodal blocks were available, occult nodal metastases were found in additional nodal sections in 4 patients (10%). At a median follow-up of 61 months, the 5-year disease-free survival rates were 87% in patients without occult nodal metastases and 75% in patients with occult nodal metastases. CONCLUSIONS: Neoadjuvant chemotherapy can completely clear the axilla of microscopic disease before surgery, and occult metastases are found in only 10% of patients with a histologically negative axilla. The results of this study have implications for the potential use of sentinel lymph node biopsy as an alternative to axillary dissection in patients treated with neoadjuvant chemotherapy.     

Nonoliguric renal failure after transurethral resection of prostate

PURPOSE: To define the relation of nonoliguric renal failure to transurethral resection of the prostate (TURP), its clinical importance, and predictive factors. PATIENTS AND METHODS: The files of 439 patients who had undergone TURP at Hacettepe University School of Medicine, Department of Urology, between January 1991 and 1994 were analyzed. The patients were divided into three groups according to postoperative serum creatinine concentration and the presence of clinical signs and symptoms of TUR syndrome (Group I: patients with preoperative and postoperative creatinine in the normal range; Group II: patients suffering nonoliguric renal failure; and Group III: patients with TUR syndrome). The data of the groups were compared in terms of factors influencing nonoliguric renal failure. RESULTS: The mean postoperative concentrations of sodium, blood urea nitrogen, creatinine, and albumin in Groups II and III were statistically different from those in Group I (P < 0.001). There was a moderate relation between hyponatremia and the occurrence of nonoliguric renal failure (r(s) = -0.56). Capsule perforation increased the risk of nonoliguric renal failure 10.6 fold. All of the patients were managed by a conservative approach, and none of the patients died or progressed to end-stage renal disease. They were all discharged with a mean hospitalization period of 7 days and normal renal function tests. CONCLUSION: Nonoliguric renal failure was thought to be an early step in the pathophysiology of TUR syndrome with acute renal failure. It is an asymptomatic clinical picture that is undiagnosed unless laboratory examinations are performed. A conservative therapeutic approach is enough.     

Epidural neostigmine produces analgesia but also sedation in women after cesarean delivery

BACKGROUND: Intrathecal neostigmine produces analgesia but also nausea, limiting its utility. In contrast, epidural administration of neostigmine has been suggested to produce postoperative analgesia without nausea in nonpregnant patients. The purpose of this study was to examine the dose range for efficacy and side effects of epidural neostigmine in women at cesarean delivery receiving combined spinal-epidural anesthesia. METHODS: After institutional approval and informed consent, 80 patients for elective cesarean delivery were given combined spinal-epidural anesthesia with 8 mg hyperbaric bupivacaine plus 10 microg fentanyl. Patients were randomized to receive either saline or 75, 150, or 300 microg neostigmine (n = 20 per group) in 10 ml saline after cord clamping. Pain, morphine consumption, and side effects were monitored for 24 h. RESULTS: Global pain assessment for the first 24 h was reduced from 5.4 +/- 0.2 in the saline group to 3.0-3.5 +/- 0.3 in the neostigmine groups, dose independently. Correspondingly, global satisfaction with neostigmine was also improved (P < 0.05). Nausea and morphine consumption were similar among groups. Intraoperative shivering and sedation were increased in the 300-microg neostigmine group only (P < 0.05), and postoperative sedation was increased by neostigmine in a dose-independent fashion (P < 0.05). CONCLUSIONS: Epidural neostigmine produced modest analgesia in women after cesarean delivery. In contrast with previous reports, which focused primarily on nausea, these data suggest that epidural neostigmine can also produce mild sedation for several hours. These data suggest a limited role for single bolus-administration epidural neostigmine for analgesia after cesarean delivery. They also support future study of epidural neostigmine for obstetric analgesia.     

Upper cervical vertebrae movement during intubating laryngeal mask, fibreoptic and direct laryngoscopy: a video-fluoroscopic study

BACKGROUND AND OBJECTIVE: Minimizing cervical vertebrae motion during endotracheal intubation is important in patients with cervical instability. The aim of this study was to compare upper cervical spine extension during endotracheal intubation using three different techniques. METHODS: Duration of intubation and movement of upper cervical vertebrae during endotracheal intubation were compared in 33 patients undergoing lumbar laminectomy. Patients requiring tracheal intubation under general anaesthesia and neuromuscular blockade were randomly allocated into three groups - direct laryngoscopy, intubating laryngeal mask (LM) airway and fibreoptic laryngoscopy. The procedure was recorded by video-fluoroscopy and analysed with computer-assisted measurements. The maximum movement of the C1/C2 and C2/C3 vertebrae during intubation were obtained. Data were analysed using one-way analysis of variance with Bonferroni and Kruskal-Wallis tests. RESULTS: We found statistically significant movement between the first and second, but not between the second and third cervical vertebrae. The mean (+/-SD) movement at C1/C2 was 10.2 +/- 7.3 degrees with direct laryngoscopy, 5.0 +/- 6.3 degrees with LM and 1.6 +/- 3.2 degrees with fibreoptic laryngoscopy. This difference was statistically significant (P = 0.01) between the direct and fibreoptic laryngoscopy groups. The maximum movement at C2/C3 was 2.2 +/- 10.1 degrees with direct laryngoscopy, 3.5 +/- 5.1 degrees with LM and 0.5 +/- 3.2 degrees with fibreoptic laryngoscopy. Duration of intubation was significantly longer in the intubating LM group (P < 0.001). CONCLUSION: We conclude that fibreoptic laryngoscopy is the more suitable intubation technique when cervical spine movement is not desired.     

Effects of desflurane and isoflurane on hepatic and renal functions and coagulation profile during donor hepatectomy

We compared the effect of two inhalation anesthetics desflurane and isoflurane on postoperative hepatic and renal functions as well as coagulation profiles in living donors undergoing right hepatectomy. This study was performed on 80 patients who were randomly allocated to group D (desflurane, n = 40) or group I (isoflurane, n = 40) after Faculty Ethics Committee approval. After induction, isoflurane or desflurane was used with air/oxygen for anesthetic maintenance. The isoflurane or desflurane concentration was set at one minimum alveolar concentration (MAC). Remifentanil was infused for analgesia as well as cisatracurium. Aspartate aminotransferase (AST), alanine aminotransferase (ALT), international normalized ratio (INR), albumin, total bilirubin, blood urea nitrogen, creatinine, platelet count, and hemoglobin levels were analyzed preoperatively at end of the operation, and on postoperative days (PODs) 1, 2, 3, 5, 7, and 30. Both AST and ALT differed significantly and continually except on POD 30. AST showed significant elevations from the end of the operation to POD 2 and ALT, from the end of the operation to POD 5 in group I compared with group D. INR was significantly higher from the end of the operation to POD 3 in group I and to POD 2 in group D. At the end of the operation as well as on POD 1 and POD 2, INR was significantly increased in group I compared with group D. Albumin level was significantly lower at the end of the operation in both groups, but it was not different. No patient developed hepatic or renal failure. Our study showed better postoperative hepatic tests and INR using desflurane than isoflurane at equivalent doses of 1 MAC in living donors undergoing right hepatectomy.     

Peritoneal Carcinoembryonic Antigen Level for Predicting Locoregional and Distant Spread of Gastric Cancer

Purpose Peritoneal recurrence is not an uncommon cause of death after surgery for gastric cancer, even after surgery with curative intent. This indicates that there is undetected residual disease in the peritoneal cavity. We conducted this study to determine the value of peritoneal and serum carcinoembryonic antigen (CEA) levels and peritoneal washing cytology in predicting the locoregional and distant spread of gastric cancer. Methods We prospectively evaluated 70 consecutive patients with gastric cancer by measuring peritoneal CEA (pCEA) and serum CEA (sCEA) levels and peritoneal washing cytology results, and studying their effect on the histopathologic properties. The effect of the pCEA level on disease-free survival (DFS) and overall survival (OS) was also evaluated in patients treated with curative intent. Results Twenty-one (30%) patients had sCEA levels >10 ng/ml, whereas 25 patients (35.7%) had pCEA levels >10 ng/g protein and 26 patients (37.1%) had positive cytology. The pCEA levels were significantly higher in patients with hepatic metastases (P = 0.034), or serosal (P = 0.028), and peritoneal (P = 0.026) involvement, whereas the sCEA levels were significantly higher only in patients with hepatic metastases (P = 0.04). Similarly, positive cytology was mainly detected in patients with hepatic metastases (P = 0.004). The pCEA levels significantly affected DFS (P = 0.002) and OS (P = 0.01) in 34 patients treated with curative intent. Conclusion Since pCEA levels are more useful for predicting locoregional recurrence, their measurement during surgery may help plan the most appropriate surgical strategy and adjuvant therapy.     

Comparison of two different techniques for brachial plexus block: infraclavicular versus axillary technique

BACKGROUND: Brachial plexus block via the axillary approach is problematic in patients with limited arm mobility. In such cases, the infraclavicular approach may be a valuable alternative. The purpose of our study was to compare axillary and infraclavicular techniques for brachial plexus block in patients undergoing arm or forearm surgery. METHODS: After institutional approval and informed consent were obtained, 30 patients (ASA physical status I or II) scheduled for forearm and hand surgery under brachial plexus anesthesia were included in the study. Patients were randomly allocated into two groups. Brachial plexus block was performed via the axillary approach in the Group A patients and via the infraclavicular approach in the Group I patients using a peripheral nerve stimulator. All blocks were performed with a total dose of 40 ml 0.375% bupivacaine. RESULTS: In each nerve territory (radial, ulnar, median, and musculocutaneous), the mean values of the degree and the duration of the sensory block and motor block were not significantly different between the two groups (P > 0.05). Inadvertent vessel puncture was significantly more frequent in the axillary approach (P < 0.05). CONCLUSION: Brachial plexus block performed via the infraclavicular approach is as safe and effective as the axillary approach. Infraclavicular approach may be preferred to the axillary approach when the upper arm mobility is impaired or not desired.     

Immediate Continence Rates in RALRP: A Comparison of Three Techniques

Methods:We retrospectively analyzed the patients who underwent RALRP for localized prostate cancer by a single surgeon in our clinic from January 1, 2009–February 1, 2016. Continence was defined as no leakage or use of a safety pad for minimal leakage. The main outcome measure was continence at postoperative week 1 and months 1, 6, and 12.Results:Between 2009 and 2016, 239 patients underwent RALRP for localized prostate disease. Seventy-four patients underwent a standard approach (group 1), 88 had posterior reconstruction (group 2), and 77 had posterior reconstruction with total anatomic restoration (group 3). After 1 week, 24.3% of the patients in group 1 (18/74), 31.8% in group 2 (28/88), and 45.8% in group 3 (33/72) were continent (P = .02). One month after the surgery, continence rates for groups 1, 2, and 3 were 56.7, 67, and 75%, respectively (0.065). After 6 and 12 months, continence rates for groups 1, 2, and 3 were 72.9 and 87.8%, 81.8 and 89.7%, and 84.7 and 91.6%, respectively (P = .178 and .7484).Conclusion:Anatomic restoration improves continence rates in the early period after RALRP. Even though other parameters were higher in the total restoration group, immediate continence (at 1 week) was significantly better.