Successful surgical treatment of massive pulmonary embolism after coronary bypass surgery

Acute massive pulmonary embolism after cardiac surgery is very rare. Although accurate diagnosis and rapid treatment are crucial to a successful outcome, there is no standard treatment option. Thrombolytic therapy and catheter embolectomy are the usual treatment options, but they are associated with risks, especially in patients who experience massive pulmonary embolism after coronary artery bypass surgery. Open pulmonary embolectomy may be the best choice for treating these patients. This report describes our use of emergency pulmonary embolectomy along with cardiopulmonary bypass as an effective therapeutic approach in 2 cases of massive pulmonary embolism that occurred after on-pump coronary artery bypass grafting.     

Case report: Treatment failure in a case of aquagenic syringeal acrokeratoderma

Aquagenic syringeal acrokeratoderma (ASA) is a rare, acquired, recurrent, and transient type of keratoderma that may occur after a few minutes of exposure to water. Herein, an 18-year-old male patient who had bilateral swelling and whitish plaques on his palms and soles is presented. The lesions on soles and heels developed within short time of immersion in water and resolved after 30 min with drying. In this case, all treatment methods, previously described in the literature in similar cases (i.e., aluminum salts, urea–salicylic acid including ointments, iontophoresis, and botulinum toxin) were ineffective. ASA is a condition that has an adverse effect on life quality. Alternative treatments are needed in ASA cases who are resistant to treatment modalities mentioned in the literature.     

Modulatory effects of Aroclors 1221 and 1254 on bone turnover and vertebral histology in intact and ovariectomized rats

Polychlorinated biphenyls (PCBs) are persistent environmental pollutants. Two PCB mixtures, Aroclors 1221 and 1254 have been suggested to have estrogenic and anti-estrogenic properties, respectively. We have examined whether these PCB mixtures modulate bone turnover and vertebral histology in intact and ovariectomized (ovx) rat models. Thirty-two adult female rats were divided into four groups subcutaneously receiving 4% DMSO (control), A1221 (10 mg/kg), A1254 (10 mg/kg) oestradiol (E2, 30 microg/kg). These compounds were injected to the animals for a period of 6 weeks at two daily intervals. In the second model, rats (n=32) were ovx and allowed to recover for a period of 3 weeks. Control group received vehicle (4% DMSO) alone. Remaining rats were divided into three groups and injected (s.c.) with A1221, A1254 and E2 for 5 weeks. Urine samples were collected prior to end of the experiments. Then, all animals were decapitated. Serum parathyroid hormone (PTH), calcitonin and osteocalcin levels were determined by immunoradiometric method. Serum concentrations of alkaline phosphatase (ALP), calcium and inorganic phosphate were determined by enzymatic-colorimetric method. Urinary deoxypyridinoline (DPD) was measured by ELISA. Lumbar vertebrae (L2) of all animals were dissected out and processed for light microscopy. Levels of urinary DPD were significantly lowered in E2 -treated intact rats (p<0.001). Ovx significantly increased urinary DPD excretion (p<0.01) compared to intact control values. Administration of A1221 and A1254 had no significant effects in intact rats, however, they significantly reduced (p<0.05) and increased (p<0.001) urinary DPD levels in ovx rats, respectively. Neither of the PCB mixtures significantly changed serum osteocalcin and ALP levels in intact or ovx rats (except A1221 increased ALP in intact model, p<0.01). Both PCB mixtures had differential effects on serum PTH, calcitonin, calcium and inorganic phosphate concentrations. Treatment with A1221 reversed the adverse effects of ovariectomy on L2 histology. However, A1254 produced necrotic areas in vertebral bone, and this effect was expanded in ovx animals. Our findings suggest that both Aroclor compounds interfere with bone turnover mechanisms, particularly in ovx rats.     

Ascorbic Acid (Vitamin C) and Iloprost Attenuate the Lung Injury Caused by Ischemia/Reperfusion of the Lower Extremities of Rats

The objectives of this study were to compare the protective effects of ascorbic acid and iloprost on lung injury caused by ischemia reperfusion (I/R) of the lower extremities of rats. Wistar albino rats (n = 34) were divided into five groups. In the I/R group (n = 6), the aorta was cross-clamped for 3 hr, followed by 1 hr of reperfusion. In the vitamin C group (n = 8), animals were pretreated with 100 mg/kg ascorbic acid via the left jugular vein before aortic cross-clamping. In the iloprost group (n = 8), animals were pretreated with 20 ng/(kg · min) iloprost by constant intravenous infusion via the left jugular venous cannula. In the sham group (n = 6), the abdomen was left open at the same period and a juguler venous line was established. In the control group (n = 6), lungs were removed and blood samples taken immediately after sternotomy. No treatment was given in this group. After both lungs were removed, biochemical parameters were measured and histopathological evaluation was made. Although the arterial blood pO₂ and HCO₃ levels were stastistically significantly high in both the vitamin C and iloprost groups compared to the I/R group, plasma malondialdehyde (MDA) levels were significantly low. Meanwhile, the MDA levels in the lung tissue were significantly low in the vitamin C group compared to the I/R group. The MDA level in the lung tissue in the iloprost group was also low compared to the I/R group, but it was not statistically significant. The lungs of the I/R group displayed intense interstitial leukocytic infiltration in histopathological examination compared to the other groups. Pretreatment of animals with iloprost and vitamin C significantly decreased the pulmonary injury characterized by decreased plasma leukocyte sequestration. The results suggest that both vitamin C and iloprost are useful agents for attenuating the lung injury caused by increased oxidative stress and neutrophil accumulation after a period of I/R of the lower extremities.     

Does using the bispectral index (BIS) during craniotomy affect the quality of recovery?

One of the aims of neuroanesthesia is to provide early postoperative recovery and neurologic examination in patients undergoing supratentorial surgery. Our aim was to investigate the role of using the bispectral index (BIS) in recovery from anesthesia and altering drug administration in patients undergoing craniotomy. Fifty American Society of Anesthesiologists' (ASA) physical status I-II patients undergoing craniotomy were included in the study. The patients were randomly divided into two groups, and all patients received standard induction drugs, and 0.8%-1.5% sevoflurane was used for maintenance of anesthesia. In the BIS-guided group, the concentration of sevoflurane was titrated to maintain BIS at 40-60. In the control group, the anesthesiologist was blind to BIS, and the concentration of sevoflurane was changed according to the patients' hemodynamic changes. The hemodynamic data, BIS values, and sevoflurane concentrations were recorded every 15 minutes. In addition, the BIS value was recorded by the primary anesthetist in the BIS-guided group and by another independent anesthetist in the control group. At the end of the study, recovery criteria and Aldrete recovery scores were recorded every 15 minutes. Neurologic assessments were performed when the Aldrete score was 9-10. BIS values were higher, and sevoflurane concentrations (P < 0.05) and total doses of fentanyl (P < 0.01) were lower, in the BIS-guided group. Times to first spontaneous breathing, eye opening, and extubation (P = 0.035, P = 0.001, and P = 0.0001, respectively) were significantly shorter in the BIS-guided group. Time to an Aldrete score of 9-10 and adequate neurologic assessment were similar between the groups. In conclusion, BIS monitoring by supratentorial craniotomy under general anesthesia reduced the maintenance anesthetic concentration and narcotic drug usage and lowered the recovery times from general anesthesia.     

The effects of section thickness on the estimation of liver volume by the Cavalieri principle using computed tomography images

Estimation of liver volume using routine CT scans has been described previously. We have, however, not found a gold standard study which analyzes the effect of section thickness on the estimation of liver volume using CT images. In the present study, five normal livers obtained from cadavers were scanned using a Spiral CT Scanner (Xpress/GX Toshiba, Tocigi-Ken) in the horizontal plane. Consecutive sections at a thickness of 10, 5 and 1mm were used to estimate the total volume of the livers by means of the Cavalieri principle. With a view to evaluating inter-observer differences, liver volume was estimated by three observers. The estimated volume using the classical volume estimation formula did not concur with the actual volume of the livers obtained by the fluid displacement technique. The section thickness has an over- or under-projection effect on the estimated volume. The obtained volume estimation results were, therefore, calibrated using three different approaches. The volume obtained by the calibration formulae did not differ statistically from actual liver volumes (P<0.05). There were also no significant differences between the performers' estimates (P>0.05). Results showed that the effect of section thickness on the volume estimates could not be omitted and the obtained values could be calibrated using the proposed approaches presented in this study.     

Comparison of Bariatric and Non-Bariatric Elective Operations in Morbidly Obese Patients on the Basis of Wound Infection

Background: Wound infection rates after various types of bariatric operations have been well described. The question of whether bariatric surgery increases wound infection rate compared with similar elective surgical procedures in obese patients has not been clearly answered. The purpose of this study was to investigate wound status of morbidly obese patients after elective general surgery. Methods: A prospective evaluation was conducted of 141 morbidly obese patients undergoing bariatric (n=60) and non-bariatric elective general surgery operation of similar invasiveness (n=81) with the ASEPSIS wound surveillance method. Results: Median age of patients undergoing non-bariatric elective surgery (51, 32-68) was significantly higher than patients exposed to bariatric surgery (39, 24-57). Patients undergoing bariatric surgery had higher BMIs (44.0, 35-52.5) compared to the others (38.4, 35-43). All patients enrolled in the study were followed for a 21-day period. At the 7th postoperative day, 9 patients in the bariatric surgery group developed infection (15%), whereas 13 patients (16%) in the non-bariatric surgery group suffered wound infection. Wound infection was still present in 2 patients (3.4%) in the bariatric surgery group and 3 patients (3.7%) in the non-bariatric surgery group at the 21st day. Risk factors for wound infection included history of coronary artery diseases, diabetes, chronic respiratory illness and malignant disease. Conclusion: Bariatric surgery does not cause an additional risk of postoperative wound infection in morbidly obese patients, compared to elective general surgical operations of the same invasiveness.     

Improvement of Vertical Banded Gastroplasty by Strict Dietary Management

Background: Vertical banded gastroplasty (VBG) has been found to reduce BMI significantly during the first postoperative year. However, the same trend in weight loss has not been established thereafter.The purpose of this study was to evaluate the effects of our dietary program on morbidly obese patients treated with VBG. Methods: A prospective evaluation of 40 obese patients (25 female, 15 male) undergoing VBG over a 3-year period was undertaken. Results: The age range was 24-57 (median 38) years, mean weight 133±2 SD kg, and mean BMI 45±6.4 SD kg/m2. After VBG, a special follow-up program was applied to patients. All patients (100%) were available for follow-up. Operative mortality was zero. 4 patients developed an early postoperative complication, and 1 patient was re-operated because of staple-line disruption 8 months after VBG. BMI decreased to 34±3.2 after 12 months, 27±1.3 after 24 months, and 28±1.4 after 36 months. All patients showed weight loss after VBG, and the weight loss continued with the strict follow-up program during a 3-year period, except in 1 patient who regained the weight lost despite an intact staple-line and stoma. Conclusion: Our policy for patients after VBG appears to be effective.