Evaluation of the Renal Arteries of 2,144 Living Kidney Donors Using Computed Tomography Angiography and Comparison with Intraoperative Findings.

OBJECTIVES: A carefully chosen and suitably prepared kidney donor is essential in living-donor kidney transplantation. Computed tomography angiography (CTA) is an effective imaging method for evaluating the renovascular morphology of donor candidates. The aim of this study was to evaluate renal artery variations in kidney donors using CTA and compare the findings with the number of arteries detected during laparoscopic donor nephrectomy. MATERIALS AND METHODS: The study included 2,144 living donors who underwent pretransplant renovascular assessment using CTA and laparoscopic donor nephrectomy in our center between August 2012 and October 2018. The number of renal arteries to the donor kidney detected on CTA was compared with the number of arteries discovered intraoperatively. RESULTS: The mean age of the 2,144 living kidney donors included in the study was 47.19 ± 13.3 (18-87) years. According to CTA findings, 81.1% (n = 1,738) had a single renal artery, 17.2% (n = 369) had double renal arteries, 1.6% (n = 35) had triple renal arteries, and 0.1% (n = 2) had quadruple renal arteries. The same number of renal arteries were detected by CTA and in laparoscopic donor nephrectomy in 97.9% (n = 2,099) of the donors. In the other 2.1% (n = 45), fewer renal arteries were detected intraoperatively compared to their CTA findings. None of the donors included in the study had a greater number of renal arteries discovered during nephrectomy than by CTA. CONCLUSION: CTA is a highly accurate method for the evaluation of renovascular variations in donor candidates for living-donor kidney transplantation. However, it must be kept in mind that double or multiple renal artery variations may be detected on CTA in 18.9% of donor candidates.

The relationship between placental transfusion, and thymic size and neonatal morbidities in premature infants - A Randomized Control Trial

OBJECTIVE: To compare the effect of umbilical cord milking and early cord clamping on thymic size, and neonatal mortality and morbidity in preterm infants. METHODS: This single-center, prospective, double-blind, randomised controlled study was conducted at Baskent University, Konya Education and Research Centre, Konya, Turkey, between October 2015 and April 2016. Pregnant women who delivered before 32 weeks of gestation were randomised to receive umbilical cord milking (group 1) or early cord clamping (group 2). Ultrasonographic evaluation was performed in each newborn by an experienced radiologist within the first 24 hours of life. Thymic si ze was estimated in l ine with literatu re. SPSS 15 was u sed for a ll data analyses. RESULTS: There were 38 subjects in group 1 and 37 in group 2. There were as many infants in the two groups (p>0.05) The haemoglobin levels was higher in group 1, but not significantly (p=0.213). The absolute neutrophil count in group 1 was significantly lower (p= 0.017) than group 2. In terms of neonatal mortaility and morbidity, there were no significant differences between the groups (p>0.05). CONCLUSIONS: Umbilical cord milking was not associated with thymic size during the the first 24h of life.

Laparoscopic gastrostomy under awake thoracic epidural anesthesia: A successful experience.

General anesthesia is the first choice as an anesthesia method particularly for abdominal operations. However, because neuromuscular blockade induced during general anesthesia will increase atelectasis in a patient with pulmonary disease, it will also increase postoperative ventilator dependence, which will be even more apparent in cases of chronic obstructive pulmonary disease (COPD) that pose a risk, particularly for postoperative complications. Herein, thoracic epidural anesthesia (TEA) was found to be a better option for our patient with severe COPD and stage IV lung cancer, as it provided sufficient anesthesia and better postoperative care for laparoscopic gastrostomy.

A Novel Technique in the Treatment of Lymphoceles After Renal Transplantation: C-Arm Cone Beam CT-Guided Percutaneous Embolization of Lymphatic Leakage After Lymphangiography.

BACKGROUND: We aimed to evaluate the efficacy of percutaneous embolization after lymphangiography using C-arm cone-beam computed tomography (CBCT) performed at the site of lymphatic leakage in patients with postrenal transplant lymphocele. METHODS: Between July 2014 and August 2017, 13 patients not responding to percutaneous ethanol sclerotherapy and conservative treatment for recurrent lymphocele after renal transplant were included. The mean age of the patients was 56.38 ± 9.91 (range, 36-70) years, and it comprised 9 men and 4 women. All patients underwent intranodal lymphangiography. C-arm CBCT-guided percutaneous embolization was performed in patients with confirmed lymphatic leakage. Patients who had no lymphatic leakage underwent drainage with fibrin glue injection. RESULTS: Lymphatic leakage was observed in 9 patients after lymphangiography, and they underwent CBCT-guided percutaneous N-butyl-2-cyanoacrylate embolization. The volume of lymphatic drainage reduced to less than 10 mL in 8 patients. One patient who was not responding to embolization was treated surgically, after percutaneous drainage and fibrin glue injection. Lymphatic leakage was not observed in 4 patients after lymphangiography. Of these, 3 patients showed a reduction in the amount of lymphatic drainage after lymphangiography. All 4 patients underwent percutaneous drainage and fibrin glue injection. One patient did not respond to the treatment and was treated surgically. Prelymphangiography and postlymphangiography and embolization, the volume of lymphatic drainage was 113.07 ± 21.75 mL, and 53.84 ± 30.96 mL, respectively, and statistically significant decrease was detected (P < 0.005). CONCLUSIONS: Lymphangiography and CBCT-guided percutaneous embolization procedures might be an effective treatment method for patients with lymphocele refractory to treatment.

Evaluation of retrobulbar blood flow and choroidal thickness in patients with rheumatoid arthritis.

PURPOSE: To evaluate whether retrobulbar blood flow and choroidal thickness (CT) are affected in patients with rheumatoid arthritis (RA), and the relationship between these values. METHODS: We evaluated 40 eyes of 20 RA patients and 40 eyes of 20 healthy controls. The enhanced depth imaging optical coherence tomography, color Doppler imaging, was held. Statistical analysis was performed. RESULTS: Peak systolic velocity (PSV) of ophthalmic (OA) and central retinal artery (CRA) were significantly higher in RA. No significant difference was observed when end-diastolic velocity (EDV) of OA and CRA was compared between the groups. The resistivity index (RI) of OA and CRA was higher in RA. Perifoveal/subfoveal CT was lower in RA. Negative correlation was detected between the RI of OA and the perifoveal CT, and a positive correlation was detected between RI of CRA and CT. CONCLUSIONS: Ocular hemodynamics is effected by RA and can exaggerate ocular complications of various vascular diseases such as diabetes mellitus, hypertension, retinal vascular occlusions.

Higher dose intra-arterial milrinone and intra-arterial combined milrinone-nimodipine infusion as a rescue therapy for refractory cerebral vasospasm.

Background Cerebral vasospasm (CV) is a major cause of delayed morbidity and mortality in patients with subarachnoid hemorrhage (SAH). Various cerebral protectants have been tested in patients with aneurysmal SAH. We aimed to research the success rate of treatment of CV via intra-arterial milrinone injection and aggressive pharmacological therapy for refractory CV. Methods A total of 25 consecutive patients who received intra-arterial milrinone and nimodipine treatment for CV following SAH between 2014 and 2017 were included in the study. Patients who underwent surgical clipping were excluded. Refractory vasospasm was defined as patients with CV refractory to therapies requiring ≥3 endovascular interventions. Overall, six patients had refractory CV. Long-term neurological outcome was assessed 6-18 months after SAH using a modified Rankin score and Barthel index. Results The median modified Rankin scores were 1 (min: 0, max: 3) and Barthel index scores were 85 (min: 70, max: 100) From each vasospastic territory maximal 10-16 mg milrinone was given to patients; a maximum of 24 mg milrinone was given to each patient in a session and a maximum of 42 mg milrinone was given to a patient in a day. Both milrinone and nimodipine were given to three patients. There was a large vessel diameter increase after milrinone and nimodipine injections. No patient died due to CV; only one patient had motor dysfunction on the right lower extremity. Conclusion Higher doses of milrinone can be used effectively to control refractory CV. For exceptional patients with refractory CV, high dose intra-arterial nimodipine and milrinone infusion can be used as a rescue therapy.

High Prolactin Level as a Predictor of Vasospasm in Aneurysmal Subarachnoidal Hemorrhage.

BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is a destructive syndrome with a mortality rate of 50%. Recent studies have also suggested a high pervasiveness of hypothalamic-pituitary insufficiency in up to 45% of patients after aSAH. Prolactin has been associated with the pathogenesis of hypertensive irregularities that are linked to pregnancy. MATERIAL AND METHODS We identified a group of 141 patients with spontaneous SAH due to a ruptured cerebral aneurysm; these patients were operated on at our institution's Neurosurgery and Interventional Radiology Department between 2011 and June 2015. All of the data were obtained retrospectively from medical records. RESULTS The hormonal abnormalities observed in the initial 24 h after ictus in subjects with subarachnoid SAH were caused by stressful stimulation aggravated by intracranial bleeding. CONCLUSIONS The elevated prolactin levels that occur in patients with aSAH can be used in conjunction with other auxiliary factors that we believe may be beneficial to vasospasm.

Is there a Real Correlation between Red Cell Distribution Width and Peripheral Arterial Disease?

BACKGROUND: Few data is available concerning the association between peripheral arterial disease (PAD) and red cell distribution width (RDW). In this study, we analyzed the relationship between RDW and atherosclerosis of the vessels other than coronary arteries in patients who had undergone digital substraction angiography (DSA). METHODS: This study included 730 patients who had undergone DSA. Patients were divided into two groups according to their angiographic images. The association between RDW and atherosclerosis of peripheral arteries was analyzed. The relationship between atherosclerosis and smoking, hypertension (HT), diabetes mellitus (DM), hs-CRP, hemoglobin, white blood cell (WBC), triglyceride, total cholesterol, HDL and LDL cholesterol levels was assessed. RESULTS: Atherosclerosis was observed more common in male and patients with older age, HT, DM and smoking (p<0.001). hs-CRP and WBC levels were both in significantly positive association with atherosclerosis (p<0.05). However, there were no significant differences in the RDW levels, hemoglobin, triglyceride, total cholesterol, LDL and HDL cholesterol levels in the groups (p>0.05). CONCLUSION: Our results seem to demonstrate that older age, male gender, HT, DM and smoking are powerful risk factors for PAD. In contrast to the previous reports, RDW levels are found not to be associated with atherosclerosis of peripheral arteries.

Endovascular Treatment of Wide Necked Ruptured Saccular Aneurysms with Flow-Diverter Stent.

AIM: Flow diverter (FD) stents have been used in the treatment of unruptured intracranial aneurysms. There are a few studies that report the use of these devices in ruptured blister-like aneurysms. We present 5 consecutive patients, who had ruptured intracranial wide necked or side branch close to the neck of saccular aneurysms, with no other treatment options, treated with FD stents and coil embolization. MATERIAL AND METHODS: Between September 2012 and April 2015, 139 ruptured aneurysms of 133 consequent patients were treated. Of these, 48 were surgically treated aneurysms. Five of the remaining 85 aneurysms treated with FD stents. Three aneurysms were in the posterior communicating artery, and 2 were in the supraclinoid internal carotid artery (ICA). Partial coil embolization was performed in addition to FD stents in three patients. All patients were treated in the first 3 days after bleeding. RESULTS: Technical success was 100%. Inappropriate deployment of silk stent and partial thrombus formation occurred in one patient due to the jailed micro-catheter. Inappropriate apposition of stent was corrected with a balloon, and the thrombus resolved with tirofiban, tissue plasminogen activator (t-PA) injections. No other complication or death occurred related to the procedure. One patient who had a giant ICA aneurysm and Fisher grade 4 bleeding died due to vasospasm, cerebral edema and sepsis on the postoperative 13 < sup > th < /sup > day. The other patients were followed-up uneventfully with computed tomography angiography (CTA) at 6th month and digital subtraction angiography (DSA) at 12 < sup > th < /sup > month. CONCLUSION: FD stents can be used in the treatment of ruptured large wide necked or side branch close to the neck of saccular aneurysms when other treatment options can not be used.

Association Between Brain Venous Drainage, Cerebral Aneurysm Formation and Aneurysm Rupture.

AIM: The brain venous drainage dominance is generally divided into three groups; right or left dominance and co-dominance. There is no study in the literature examining the link between brain venous drainage and aneurysm formation or rupture. Our aim was to evaluate the association between venous dominancy, aneurysm formation and rupture. MATERIAL AND METHODS: Eighty-six patients, who underwent cerebral digital subtraction angiography and who had cerebral aneurysms, were included in the study. The angiographic images, patient charts, and tomography images were scanned retrospectively. We recorded the aneurysm"s location, size, dome to neck ratio (D/N); the patient"s gender, age, whether there was a ruptured aneurysm, smoking history, and/or hypertension; dominance of venous drainage, aneurysm side, Fisher scores and the World Federation of Neurosurgical Societies (WFNS) Grading System for Subarachnoid Hemorrhage scores for patients who had a ruptured aneurysm. We assessed whether or not venous drainage was associated with rupture of the aneurysm and if venous dominance was a predisposing factor for aneurysm formation like location, size, and hypertension. RESULTS: There was a statistically significant association between venous dominance and side of aneurysm; and also a statistically significant association between venous dominance and rupture. There was a positive correlation between hypertension and rupture. The most common aneurysm location was the anterior communicating artery, followed by the middle cerebral artery. CONCLUSION: Brain venous drainage dominance may be a predisposing factor for aneurysm formation and it can be predictive for rupture.

Percutaneous Placement of Pancreatico-biliary Drainage Catheter for the Treatment of Complicated Pancreatic Anastomotic Leakage: an Alternative Treatment Option.

A 58-year-old female patient who had anastomotic leakage after a Whipple operation was treated with a percutaneously placed pancreatico-biliary drainage catheter. Complete secondary healing of the anastomotic defect and leakage was seen on control cholangiography examination on the 35th postoperative day, and the pancreatico-biliary drainage catheter was removed. She was discharged on the 39th postoperative day uneventfully. Percutaneous pancreatico-biliary drainage should be kept in mind as an alternative treatment option of complicated pancreatic anastomotic leakage after a Whipple operation.

The effect of pneumoperitoneum on the cross-sectional areas of internal jugular vein and subclavian vein in laparoscopic cholecystectomy operation.

BACKGROUND: Increased central venous pressure secondary to an increase in intraabdominal pressure has been reported during laparoscopic surgery. However, no study has yet determined the effect of pneumoperitoneum on cross-sectional area (CSA) of central veins by ultrasonography during laparoscopic cholecystectomy. Herein, we aimed to quantify changes in CSAs of internal jugular (IJV) and subclavian veins (SCV) by ultrasonography during this surgery. METHODS: This study included 60 ASA I-II patients scheduled for laparoscopic cholecystectomy surgery under general anesthesia. Pneumoperitoneum was performed with CO2 at 12 mmHg. The CSAs of right IJV and right SCV were measured using a 6 Mhz ultrasonography transducer in supine and neutral positions before anesthesia induction (T1), 5 min after connecting to mechanical ventilator (T2), 5 min after creation of pneumoperitoneum (T3), at the end of pneumoperitoneum (T4), and 5 min after desufflation and before extubation (T5) both at end-expiration and end-inspiration. RESULTS: The comparison of IJV CSA at inspiration showed significant increase in T3 value compared to T2 value (p < 0.001). Similarly the expiratory measurements of IJV CSA demonstrated significant increase in T3 value compared to T2 value (p < 0.001). The comparison of inspiratory CSA measurements of SCV showed significantly increased in T3 (p = 0.009) than T2 value. In expiratory measurements there was a significant increase in T3 (p = 0.032) value compared to T2. All measurements of IJV and SCV SCAs both end-inspiration and end-expiration T5 values significantly decreased compared to T4 values (p < 0.001). CONCLUSIONS: Pneumoperitoneum with an intraabdominal pressure of 12 mmHg produces significant increases in IJV and SCV CSAs during laparoscopic cholecystectomy procedure. We believe that this finding may enhance our understanding of pneumoperitoneum-induced hemodynamic changes and facilitate catheterization attempts. TRIAL REGISTRATION: Date of registration 21/07/2016, ISRCTN Registry ( No: ISRCTN15164056 , registered retrospectively).

Severe hypernatremia associated catheter malposition in an intensive care patient.

We present a catheter related severe hypernatremia in a 2-month-old baby who was admitted to the pediatric intensive care. Imbalance of plasma sodium is commonly seen in pediatric intensive care patients. The water and sodium balance is a complex process. Especially, brain and kidneys are the most important organs that affect the water and sodium balance. Other mechanisms of the cellular structure include osmoreceptors, Na-K ATPase systems, and vasopressin. Hypernatremia is usually an iatrogenic condition in hospitalized patients due to mismanagement of water electrolyte imbalance. Central venous catheterization is frequently used in pediatric intensive care patients. Complications of central venous catheter placement still continue despite the usage of ultrasound guidance. Malposition of central venous catheter in the brain veins should be kept in mind as a rare cause of iatrogenic hypernatremia.

Abducens Nerve Palsy and Ipsilateral Horner Syndrome in a Patient With Carotid-Cavernous Fistula.

The combination of abducens nerve palsy and ipsilateral Horner syndrome was first described by Parkinson and considered as a localizing sign of posterior cavernous sinus lesions. The authors present a case with right abducens nerve palsy with ipsilateral Horner syndrome in a patient with carotid-cavernous fistula because of head trauma. The patient was referred to the ophthalmology clinic with diplopia complaint after suffering a head trauma during a motorcycle accident. Cerebral angiography showed low-flow carotid-cavernous fistula.

The effect of laser wavelength on postoperative pain score in the endovenous ablation of saphenous vein insufficiency.

PURPOSE: Endovenous laser ablation has replaced surgical methods in the treatment of saphenous insufficiency. The aims of this study were to compare the effectiveness of 1470- and 980-nm wavelength (WL) laser systems, to compare the postoperative complication rates, and to determine the effect of laser WL on postoperative pain scores. MATERIALS AND METHODS: Between October 2010 and November 2011, 79 consecutive patients with saphenous vein insufficiency were examined. The patients who received the 980-nm treatment were defined as Group 1; 54 extremities of 47 patients were treated in this group. The patients who received the 1470-nm treatment were defined as Group 2; 36 extremities of 32 patients were treated in this group. RESULTS: Early technical success was 100% in both groups. Both major and minor complications were seen in Group 2. The complications in Group 1 were mostly major; however, three minor complications were reported in this group. The complication rates of the two groups were not significantly different. There was no statistically significant difference between the pain scores of the two groups. CONCLUSION: Early postoperative pain was the major factor that impaired quality of life. There was no relationship between the postoperative pain scores and laser WL or energy density. The laser WL did not affect technical success or occurrence of complications. Use of a suitable energy density resulted in complete occlusion in all patients with saphenous vein insufficiency.