Laparoscopic Sleeve Gastrectomy Outcomes of 750 Patients: A 2.5-Year Experience at a Bariatric Center of Excellence.

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity worldwide. This retrospective cohort study evaluated the outcomes of a large cohort of patients with obesity who underwent LSG in a Bariatric Center of Excellence. All consecutive patients who underwent LSG between July 2013 and April 2016 were identified retrospectively. Preoperative and postoperative variables and comorbidities were recorded. The study consisted of 750 patients. Their mean age was 37.4 years; 72% were women, and the mean body mass index was 42.8 kg/m. The most common preoperative comorbidities were diabetes (23.3%), hyperlipidemia (21.9%), hypertension (21.1%), and obstructive sleep apnea (21.1%). The rates of comorbidity resolution during follow-up were 80.6%, 74.4%, 82.9%, and 94.3%, respectively. The percentage average excess weight loss 1, 3, and 6 months and 1 and 2 years after surgery was 29.4%±11.3%, 54.4%±17.7%, 76.9%±20.9%, 85.5%±23.6%, and 89.7%±27.6%, respectively. There was no mortality. LSG effectively and safely induced weight loss and comorbidity resolution.

Airtraq, LMA CTrach and Macintosh Laryngoscopes in Tracheal Intubation Training: A Randomized Comparative Manikin Study.

OBJECTIVE: Training students on simulators before allowing their direct contact with patients is well accepted. There is no clinical or manikin-based simulation study in the literature comparing tracheal intubation with Airtraq, laryngeal mask airway (LMA) CTrach and Macintosh laryngoscopes performed by medical students having no prior intubation experience. METHODS: After obtaining written informed consents, 123 participants were included in the study. The participants were asked to intubate the manikin five times with each device randomly. After all the participants had completed their fifth intubations, the measurements were performed. The primary outcome variables were the first-attempt success rate and the time for a successful intubation, while the secondary outcome variables were to determine the scores of dental trauma, the difficulty visual analogue scale and the optimization manoeuvres. RESULTS: The LMA CTrach group revealed a significantly higher number of intubation attempts. The mean time for a successful intubation was the longest in the LMA CTrach group (17.66±8.22 s, p<0.05). Students defined the Airtraq as the easiest to use and the Macintosh laryngoscope as the most difficult device to use and learn. Dental trauma severity was significantly lower in the Airtraq group than in the other groups (p<0.05), and it was found to be 0 in 81.1% in the Airtraq group. The head extension optimization manoeuvre rate was significantly higher with the Macintosh laryngoscope than with the Airtraq laryngoscope (p<0.05). CONCLUSION: This study, in which different types of laryngoscopes were compared, revealed that the Airtraq laryngoscope has advantages, such as shorter intubation duration, less additional optimization manoeuvres, less dental trauma intensity and is easier to learn compared with the LMA CTrach and Macintosh laryngoscopes.

Comparison of neostigmine and sugammadex for hemodynamic parameters in cardiac patients undergoing noncardiac surgery.

STUDY OBJECTIVE: The aim of this study is to compare the hemodynamic effects of neostigmine-atropine combination and sugammadex in patients with cardiac problems undergoing noncardiac surgery. DESIGN: Prospective randomized study. SETTING: In the operating room. PATIENTS: Ninety patients with a class 2 or 3 cardiovascular disease according to the New York Heart Association classification and aged between 18 and 75 years undergoing noncardiac surgery were randomized. INTERVENTIONS: Group N (n = 45) received 0.03 mg/kg IV neostigmine when T2 appeared as measured with a nerve muscle stimulator. When heart rate was 5 beats/min (±10 beats/min) lower than the heart rate before administration of the medication, 0.5 mg IV atropine sulfate was given. Group S (n = 45) received 3 mg/kg IV sugammadex when T2 appeared as measured with a nerve muscle stimulator. MEASUREMENTS: Heart rate, mean systolic and diastolic blood pressures, and electrocardiographic alterations including the QTc (QT Fredericia and QT Bazett) were recorded. MAIN RESULTS: There were no significant differences between and within the groups in terms of QTc values. Sugammadex group had a significant decrease on heart rate 1 minute after the medication when compared to the measurement before the medication (P < .05). Heart rate and systolic blood pressure increased in neostigmine group 3 minutes after the medication and during postoperative measurements (P < .05). Sugammadex group had lower systolic, diastolic, and mean blood pressures and heart rate when compared to neostigmine group (P < .05). CONCLUSIONS: We suggest that sugammadex might be preferred as it provides more hemodynamic stability compared to neostigmine-atropine combination to reverse rocuronium-induced neuromuscular blockage in cardiac patients undergoing noncardiac surgery.

The Professional Experience of Anaesthesiologists in Proper Inflation of Laryngeal Mask and Endotracheal Tube Cuff.

OBJECTIVE: Cuffs inflated to inappropriately high pressures cause ischemia, reducing tracheal mucosal blood flow, while cuffs inflated at lower pressure than necessary give rise to inadequate ventilation, aspiration of gastric contents, or extubation due to air leakage. In this study, we aimed to investigate the effect of the experience of anaesthesia staff on endotracheal tube and laryngeal mask airway cuff inflation. METHODS: The study included 348 elective patients scheduled to undergo surgery under general anaesthesia, with 34 anaesthesia technicians, 16 anaesthesia residents, and 12 anaesthesiologists with different years of professional experience. The participants were told to inflate the cuff balloon with air to the level of the pressure that was appropriate for them. No information was provided to the participants about the values of the cuff pressure pending the completion of all measurements. After placement of the laryngeal mask airway and endotracheal tube, the success of the procedure was checked by monitoring square-wave capnograph tracing and thoracoabdominal motion. Each participant performed the procedures on three patients, and the mean cuff pressures were measured. RESULTS: There was no significant correlation between duration of experience of technicians, residents, and experts in using laryngeal mask airway pressure (r=-0.192/p=0.278, r=0.225/p=0.402, r=-0.476/p=0.118, respectively) and endotracheal tube (r=-0.306/p=0.079, r=-0.060/p=0.826, r=-0.478/0.116, respectively). CONCLUSION: It has been concluded that professional experience does not contribute to achieving normal cuff pressure without monitoring. Introduction of the cuff manometer into routine anaesthesia practice will be useful, irrespective of anaesthesiologists' experience.

Parental Satisfaction Assessment After Paediatric Procedural Sedation: There Are Still Issues to Address.

OBJECTIVE: As paediatric sedation practices are becoming safer and more feasible everyday, they have been widely used for diagnostic and therapeutic procedures. This study intended to determine the relation between parental satisfaction and the branches applying procedures and demographic data of the patients and their families, physicians, nurses, and the healthcare personnel in the room. METHODS: In total, 223 successive patients under 18 years of age and ASA I-II undergoing diagnostic or therapeutic procedures in paediatric pulmonary disease, gastroenterology, cardiology, and invasive radiology units were included in the study. The satisfaction level of the patients' parents was determined through a questionnaire of 22 questions. RESULTS: Average satisfaction scores for paediatric bronchoscopy and endoscopic interventions varied between 8.06 and 9.30, while the satisfaction scores of the interventions for the cardiovascular system, hepatic system, and renal system, as well as the invasive radiologic interventions, varied between 7.5 and 9.6. There was a statistically significant negative correlation between the age of parents and children and the necessity for a playground in the waiting area (p<0.05). A significant correlation was found between the age of children and the adequacy of the anaesthetist's behaviors (p<0.05). CONCLUSION: Satisfaction levels of the parents were high at the units where paediatric sedation was applied. However, the expectations of young patients and their parents were higher. When the physical conditions and communication with patients and their relatives are improved and the process schedules are followed more precisely, the clinical results will increase in a positive way.

Testicular germ cell tumor metastatic to the right atrium.

We describe a right atrial metastasis of a testicular germ cell tumor, which was successfully removed from the tricuspid valve and subvalvular apparatus without the need for valve replacement.

Effect of intraarticular injection of lornoxicam on the articular cartilage & synovium in rat.

BACKGROUND & OBJECTIVE: Intraarticular (i.a) drug application is consider to be a new therapeutic approach for the treatment of postoperative pain after arthroscopic knee surgery without any systemic adverse effects. Lornoxicam, a nonsteroid anti-inflammatory drug is a short acting agent, and its anti-inflammatory and analgesic activity may be effective in the postoperative pain management in minor surgery. In this study, the effects of intraarticular administration of lornoxicam on the synovium and articular cartilage in the rat knee joint were investigated. METHODS: Lornoxicam (0.25 ml) was given as an injection into the right knee joint and 0.25 ml of 0.9 per cent saline solution by injection into the left knee joint as a control in 25 rats. Groups of five rats were sacrificed by a lethal injection of ketamine 1st, 2nd, 7th, 14th and 21st days after lornoxicam administration. Knee joints were detached, fixed in 10 per cent buffered formalin and decalcified. Serial sections of 5 microm were stained with haematoxylin-eosin and evaluated for the presence of inflammation in the articular, periarticular regions and synovium. Inflammatory changes in the joints were graded according to a five-point scale, histologically. RESULTS: There were no significant differences in inflammation and cartilage degeneration, between control and lornoxicam applied knees. Grade 3 inflammatory changes occurred only in one knee in lornoxicam group, at 24 h after injection. No pathological changes were observed in both groups at any time point. INTERPRETATION & CONCLUSION: Lornoxicam did not show significant effect on inflammation on rat synovia in knee joint. Further studies including in human need to be done before any recommendations are made for i.a. administration of lornoxicam.

The efficacy of ketamine for the treatment of postoperative shivering.

BACKGROUND: There are few reports on the utility of ketamine for the prevention of postoperative shivering. We thus established the efficacy of two doses of ketamine compared with meperidine for the treatment of postoperative shivering. METHODS: This is a prospective, randomized double-blind study involving 90 ASA I-II patients after general anesthesia. Patients with shivering grade 3-4 were allocated to receive either meperidine 25 mg, ketamine 0.5 mg/kg, or ketamine 0.75 mg/kg IV. Shivering and side effects were monitored at set time intervals. RESULTS: Shivering grades for the first 4 min after treatment were lower in the ketamine groups; however, nystagmus and feeling like "walking in space" was experienced with both doses of ketamine. CONCLUSION: Ketamine 0.5-0.75 mg/kg is more rapid than meperidine (25 mg) for the reduction of postoperative shivering, but the side effect profile may limit its usefulness.

Effect of hypotensive anesthesia on cognitive functions. A comparison of esmolol and remifentanil during tympanoplasty.

OBJECTIVE: To compare the effects of esmolol and remifentanil, used as adjuncts for induced hypotension on surgical conditions and short-term cognitive functions, during tympanoplasty. METHODS: The study was conducted in Hacettepe University, School of Medicine, Ankara, Turkey between January 2005 and December 2006 following Institutional Ethical Committee approval, 40 ASA I-II patients, between 18 and 60 years of age were included in this study. With the induction of anesthesia, for group E, an esmolol infusion of 50-250 ug.kg-1.min-1 was titrated, following a bolus of 0.5 mgxkg-1; for group R, a remifentanil infusion of 0.2-0.5 ugxkg-1xmin-1 was titrated; to achieve a mean blood pressure (BP) of 55-65 mm Hg. Arterial BP were recorded continuously throughout the operation. Mini Mental State Test (MMS) was performed at the preoperative 30th minute (MMSP), postoperative 30th minute (MMS30), 60th minute (MMS60) and 24th hour (MMS24). Surgical field was evaluated by the blinded surgeon, using a 6 point category scale. RESULTS: Patient demographics were similar in both groups. Sustained controlled hypotension was sufficient in all of the groups throughout surgery. Surgical field scores were lower in group R (p<0.05), although the scores were

Comparative assessment of induction efficacy of propofol preparations.

OBJECTIVE: To compare the hypnotic effects (using Bispectral Index [BIS]), hemodynamic parameters, injection pain and quality of anesthesia during induction of anesthesia of the 3 commercial propofol preparations (Abbott Propofol, Abbott Laboratories), Pofol (Dongkook Pharm. Co. Ltd.), and Propofol 1% Fresenius (Fresenius Kabi). METHODS: After Ethics Committee Approval, a prospective, randomized, double-blind study was designed in Hacettepe University Hospitals Operating Theaters in 2005. The patients aged 18-65 years, American Society of Anesthesiologists (ASA) grades I and II scheduled for elective surgery under general anesthesia with orotracheal intubation. Ninety patients were randomized into 3 groups with 30 patients in each group. Propofol infusion rate was 2.5 mg. seconds(-1). Induction time and doses to reach BIS level of 50+/-10, injection pain, BIS values and hemodynamic parameters were recorded every minutes for the first 7 minutes and than every 2 minutes for 15 minutes. We used a special chart to assess the induction quality. RESULTS: Demographical parameters and ASA Physical status were similar in all groups. There were no significant differences in induction quality, induction time and doses, injection pain, BIS values and hemodynamic parameters. CONCLUSION: Abbott Propofol, Pofol and Propofol 1% Fresenius have similar effects on anesthesia induction quality and the cost should be taken into consideration when choosing the type of commercial formulation propofol emulsions.

The efficacy of intravenous or peritonsillar infiltration of ketamine for postoperative pain relief in children following adenotonsillectomy.

BACKGROUND: A few previous studies have suggested the efficacy of i.v. ketamine for postoperative pain relief in children after adenotonsillectomy, but none has investigated the efficacy of peritonsillar infiltration of ketamine in these children. METHODS: This randomized, placebo-controlled study evaluated the effects of peritonsillar infiltration of ketamine in children undergoing adenotonsillectomy. Ninety ASA I-II children were randomized three groups of 30 each. Group I received: 2 ml i.v. saline, group II received i.v. ketamine (0.5 mgxkg(-1)) and group III received a local peritonsillar infiltration of ketamine (0.5 mgxkg(-1)). All medications were 2 ml in volume which was applied 1 ml per tonsil 3 min prior to tonsillectomy. Modified Hannallah pain scale [observational pain scores (OPS)], nausea, vomiting, bleeding, rescue analgesia, sedation and Aldrete scores were recorded at first, 15th, 30th and 60th min postoperatively. Patients were interviewed on the day after surgery to assess the postoperative pain, nightmares, hallucinations, vomiting and bleeding. RESULTS: Group I had higher OPS scores than group II and group III. Group II and group III had comparable scores, which were not statistically significant (P > 0.05). Group II had higher sedation score at 15th min (P = 0.015). Thirty-two children, 19 of whom were in group I had rescue analgesia in postanesthesia care unit (P < 0.05) and the time to first analgesic requirement was significantly shorter in group I than the other groups (P = 0.006). Group II and group III also had less pain than group I at home (P = 0.023). CONCLUSIONS: Low dose ketamine given i.v. or by peritonsillar infiltration perioperatively provides efficient pain relief without side-effects in children undergoing adenotonsillectomy.

Intracerebral hemorrhage following enucleation: a result of surgery or anesthesia?--A case report.

Choroidal melanoma is the most common primary intraocular cancer in adults. A sixty-nine years old, hypertensive male with a choroidal melanoma underwent enucleation. After extubation he woke up confused and unconscious. An emergent computed tomographic (CT) scan demonstrated intracerebral hematoma. The underwent repeat surgery in the postoperative first hour, because of left parietotemporal intracerebral hematoma. His neurological state became worse and he died in the eighth postoperative day. Sympathetic stimulation due to extubation, causing increase in the intracranial pressure or uncontrolled hypertension, may be reasons precipitating intracranial hemorrhage. In patients, who undergo intracranial or intraorbital surgery, had risk factors of intracranial hemorrhage or showed labile blood pressure perioperatively and were confused or unconscious in the postoperatively or had delayed emergence, intracranial hematoma must be suspected.

Spinal anesthesia in Kartageners syndrome.

Kartageners syndrome, an autosomal recessive disorder is a combination of dextrocardia situs inversus, bronchiectasis and sinusitis. We report a 22-year-old woman with this syndrome scheduled for appendectomy. Spinal anesthesia was preferred for the patient with this rare disorder due to the relative advantages of the regional technique over general anesthesia.

Ketamine sedation during spinal anesthesia for arthroscopic knee surgery reduced the ischemia-reperfusion injury markers.

We studied the effect of ketamine sedation on oxidative stress during arthroscopic knee surgery with tourniquet application by determining blood and tissue malonyldialdehyde (MDA) and hypoxanthine (HPX) levels. Thirty ASA I-II patients undergoing arthroscopic knee surgery with tourniquet were randomly divided into two groups. Spinal anesthesia induced with 12.5 mg bupivacaine was administered to all patients. In the ketamine group, after IV administration of 0.01 mg/kg midazolam, a continuous infusion of ketamine (0.5 mg . kg(-1) . h(-1)) was used until the end of surgery whereas the placebo group received a volume-equivalent placebo infusion. Ramsey Sedation Scale (RSS) was used for assessing the sedation level. Venous blood and synovial membrane tissue samples were obtained before ketamine infusion, at 30 min of tourniquet ischemia, and at 5 min after tourniquet deflation for MDA and HPX measurements. Tissue MDA and HPX levels were significantly less in the ketamine group than the control group after reperfusion. RSS scores were higher in the ketamine group without any adverse effect. We conclude that ketamine sedation attenuates lipid peroxidation markers in arthroscopic knee surgery with tourniquet application.

Airway management of mucopolysaccharidosis with cervical spine involvement.

Mucopolysaccharidoses are a group of inherited disorders occasionally accompanied by cervical spine involvement complicating tracheal intubation. In this study, we review and discuss 5 cases of mucopolysaccharidosis with cervical spinal involvement.

The efficacy of intra-articular ketamine for postoperative analgesia in outpatient arthroscopic surgery.

PURPOSE: The purpose of this study was to compare the postoperative analgesic effects of intra-articularly administered ketamine, neostigmine, and bupivacaine after outpatient arthroscopic surgery. TYPE OF STUDY: Prospective, randomized, double-blind, clinical study. METHODS: In this study, 60 patients undergoing arthroscopic surgery other than ligament reconstruction were evaluated for postoperative pain. Ketamine, neostigmine, and bupivacaine were administered intra-articularly. The period of effective analgesia, recorded in minutes, was measured between time 0 and first usage of patient-controlled anesthesia (PCA) by the patients. The visual analog scale (VAS) was used to describe the pain level of the patient. RESULTS: VAS values were lower for the 3 medication groups compared with the placebo at rest and 90 degrees knee flexion. Intra-articular administration of 0.5 mg/kg ketamine provided longer duration of analgesia as defined by the first PCA use time (P <.05). The total amount of pethidine and analgesia time were longer for the 3 medication groups. CONCLUSIONS: Our basic finding was reduction in postoperative pain and consumption of adequate analgesic drugs with intra-articular ketamine, bupivacaine, or neostigmine use. We have not seen any psychomimetic side effects, particularly as seen with higher doses or systemic use. This study may conclude that intra-articular administration of ketamine provides long-lasting and effective analgesia, similar to neostigmine but less effective than bupivacaine after knee arthroscopy without any adverse effects. LEVEL OF EVEIDENCE: Level I.