Evaluation of laparoscopic transperitoneal adrenalectomy: is it feasible for large masses?

AIM: The aim of this paper was to determine whether laparoscopic adrenalectomy (LA) is a safe and effective treatment for the management of large adrenal tumors. METHODS: We retrospectively evaluated the data of patients who underwent LA at our institution between September 2002 and September 2012. Seventy-six transperitoneal LA were performed by the same surgical team. Patients with invasive tumors to adjacent organs or distant metastasis were excluded from the study. All patients were operated using the 450 oblique position as transperitoneal approach. RESULTS: The mean age of the patients was 48.3 years (range 20-68 years). The mean tumor size was 5.37 cm (range 2-15 cm). Sixteen patients had tumor size over 8 cm. The mean tumor weight was 31.2 gr (range 2-156 g). The lesions were localized on the right side in 42 (55%) patients and on the left side in 34 (45%) patients. The mean intraoperative blood loss was 114 mL (range 20-400 mL) and the mean operative time was 112 min (range 55-300 min). Six patients (7%) required conversion to open procedure. The mean hospitalization time was 2.5 days (range 1-4 days). Five patients (6%) had post-operative minor complications. There were no incidents of capsular invasion or adverse cardiovascular events. CONCLUSION: LA is safe and feasible for both malign and benign adrenal lesions. Good preoperative assessment, surgical skills, team work and adherence to anatomical and surgical principles are the key to success for large adrenal masses.

Homocysteine levels after nitrous oxide anesthesia for living-related donor renal transplantation: a randomized, controlled, double-blind study.

BACKGROUND: Nitrous oxide anesthesia increases postoperative homocysteine concentrations. Renal transplantation candidates present with higher homocysteine levels than patients with no renal disease. We designed this study to investigate if homocysteine levels are higher in subjects receiving nitrous oxide for renal transplantation compared with subjects undergoing nitrous oxide free anesthesia. METHODS: Data from 59 patients scheduled for living-related donor renal transplantation surgery were analyzed in this randomized, controlled, blinded, parallel-group, longitudinal trial. Patients were assigned to receive general anesthesia with (flowmeter was set at 2 L/min nitrous oxide and 1 L/min oxygen) or without nitrous oxide (2 L/min air and 1 L/min oxygen). We evaluated levels of total homocysteine and known determinants, including creatinine, folate, vitamin B12, albumin, and lipids. We evaluated factor V and von Willebrand factor (vWF) to determine endothelial dysfunction and creatinine kinase myocardial band (CKMB)-mass, troponin T to show myocardial ischemia preoperatively in the holding area (T1), after discontinuation of anesthetic gases (T2), and 24 hours after induction (T3). RESULTS: Compared with baseline, homocysteine concentrations significantly decreased both in the nitrous oxide (22.3 ± 16.3 vs 11.8 ± 9.9; P < .00001) and nitrous oxide-free groups (21.5 ± 15.3 vs 8.0 ± 5.7; P < .0001) at postoperative hour 24. The nitrous oxide group had significantly higher mean plasma homocysteine concentrations than the nitrous oxide-free group (P = .021). The actual homocysteine difference between groups was 3.8 µmol/L. CONCLUSION: This study shows that homocysteine levels markedly decrease within 24 hours after living-related donor kidney transplantation. Patients receiving nitrous oxide have a lesser reduction, but this finding is unlikely to have a clinical relevance.

The effects of opioids, local anesthetics and adjuvants on isolated pregnant rat uterine muscles.

Local anaesthetics, opioids and adjuvants are often used for managing labor pain. Some others of these agents are reported to cause alterations on uterine contractility during labor. However, there are controversies and the effects of some others are unknown. In the present study, we aimed to elucidate the effects of opioids such as alfentanyl, meperidine, remifentanyl; local anesthetics such as mepivacaine, ropivacaine, bupivacaine; and adjuvants such as clonidine and midazolam on isolated pregnant rat uterine muscle. Strips of longitudinal uterine smooth muscle obtained from rats pregnant for 18-21 days were suspended in 20 ml organ baths. Isometric tension was continuously measured with an isometric force transducer connected to a computer-based data acquisition system. The effects of cumulative concentrations of alfentanyl, meperidine, remifentanyl, mepivacaine, ropivacaine, bupivacaine, clonidine and midazolam (10(-8) - 10(-4) M, for all) on contractions induced by oxytocin (1 mU/ml) were studied. Alfentanyl (10(-5) M), meperidine (10(-5) M), remifentanyl (10(-4) M), bupivacaine (10(-4) M), ropivacaine (10(-4) M) and midazolam (3 x 10(-5) M) caused significant decreases in contractile responses of uterine strips to oxytocin. Contrastingly, mepivacaine increased (33.1% +/- 7.2%) oxytocin-induced contractions of uterine strips while clonidine exerted no significant effect. The sensitivity of myometrial preparations to tested local anesthetics or opioids did not differ significantly. The findings of the present study demonstrated that some local anesthetics, opioids and adjuvants caused significant and agent-specific alterations on contractility of the pregnant rat myometrium. Therefore, they seemed to have a potential to influence uterine contractility during clinical management of pain during labor. However, further research is needed to extrapolate these finding to clinical practice.

The effects of bupivacaine, ropivacaine and mepivacaine on the contractility of rat myometrium.

Local anesthetic agents are commonly used for obstetric anesthesia and analgesia. We determined the effects of bupivacaine, ropivacaine and mepivacaine on the contractility of isolated pregnant rat uterine muscle strips. Uterine specimens were obtained from 18- to 21-day pregnant Wistar rats (n = 28). Myometrial strips were obtained from the uterine horns after removing the fetuses and non-uterine tissue, incubated in organ baths and contractions stimulated with oxytocin. When contractions became regular, strips were exposed to increasing concentrations of the study drugs. Mepivacaine (n = 8), ropivacaine (n = 10) and bupivacaine (n = 10) were used at cumulative doses from 10(-8) to 10(-4) mol/L. Two of the local anesthetics, bupivacaine most, ropivacaine least, caused a dose-dependent inhibition of uterine contractility. In contrast, mepivacaine significantly increased uterine contractility. Bupivacaine, ropivacaine and mepivacaine were found to have no effect on frequency of uterine contractions. These results demonstrate that bupivacaine and ropivacaine may inhibit myometrium contractility.

Acute subdural haematoma after accidental dural puncture during epidural anaesthesia.

A case is reported of acute intracranial subdural haematoma following accidental dural puncture during epidural anaesthesia. A 36-year-old primigravida with a gestation of 37 weeks and 3 days underwent caesarean section for which epidural anaesthesia was initially planned. An 18-gauge Tuohy needle was inserted into the L3-4 interspace but accidental dural puncture occurred. The needle was removed and general anaesthesia was initiated for surgery. On the second day post partum, the patient described a headache in both occipital area and neck that was relieved by lying down. On the seventh post-partum day she suffered tonic-clonic convulsions and underwent computerised tomography (CT). Despite different analgesic treatments and a normal CT, the patient suffered severe headaches in the following days. Magnetic resonance imaging revealed a 4-mm subdural hematoma in the right frontal area. The persisting headache decreased on day 12 and disappeared on day 14. The patient was discharged from hospital on day 15. The presence of post dural puncture headache complicated by atypical neurological deterioration following epidural anaesthesia should prompt the anaesthetist to consider the existence of intracranial complications and to seek immediate clinical and radiological diagnosis.

Orbital Doppler sonography findings in cases of brain death.

In this study, we investigated the blood flow velocity changes in orbital arteries by using Doppler sonography in eight patients with brain death. Peak-systolic and end-diastolic velocities and resistive indices of the ophthalmic and central retinal arteries were evaluated. We observed the absence or reversal of end-diastolic blood flow in these arteries. To our knowledge, this finding has not been previously reported to be associated with brain death.