The effect of low flow anesthesia with sevoflurane on oxidative status: A prospective, randomized study.

OBJECTIVES: To assess the impact of low-flow, mid-flow, and high-flow sevoflurane anesthesia on the oxidative state by measuring thiol/disulfide levels in patients undergoing surgery. METHODS: The study included 99 patients randomly assigned to 3 groups. In the low-flow anesthesia group, the fresh gas flow was diminished to 1 L.min-1 for anesthesia maintenance after 6 L.min-1 was administered for the first 10 minutes. In the mid-flow anesthesia group, fresh gas flow was applied as 2 L.min-1. In the high-flow anesthesia group, the fresh gas flow was administered as 4 L.min-1 throughout the operation. Blood samples were obtained before induction, at the 60th minute after induction, and at 2 hours postoperatively. Native thiol, total thiol, disulfide analyzed and disulfide/native thiol percentage, disulfide/total thiol percentage, and native thiol/total thiol percentage were calculated. RESULTS: Disulfide values in mid-flow and low-flow anesthesia were significantly lower at the 60th minute after induction compared to the high-flow anesthesia group. In the group evaluations, intraoperative native thiol levels in the high-flow group were found to be substantialy lower than preoperative values. CONCLUSION: It was sighted that low-flow anesthesia with sevoflurane prohibited oxidative damage. It was concluded that low flow anesthesia can be utilized safely in this respect.

Prognostic effect of red cell distribution width-to-platelet ratio in colorectal cancer according to tumor stage and localization.

INTRODUCTION: Colorectal cancer (CRC) is one of the most common cancers worldwide and survival is still approximately 24 months. Recently, importance of the molecular features, tumor localization, and also inflammatory status is increased, and most of these entities can be used as a predictive marker for colon tumor. However, since most of these tests are expensive and unachievable, there is a need for new prognostic and predictive markers that can be used easily and are inexpensive. AIM: We aimed to investigate the prognostic effect of red cell distribution width (RDW)-to-platelet ratio (RPR) which reflects inflammatory status and can be calculated basically by using center blood count (CBC) parameters on CRC according to tumor stage and localization. METHODS: Newly diagnosed 312 CRC patients between 2010 and 2016 were retrospectively analyzed. Patients' demographics, including survival data and tumor characteristics, were obtained from medical charts. RPR was calculated using CBC parameters at the time of diagnosis. Cutoff value for RPR was set at 0.05 and the patient population was divided into two arms (arm A: RPR ≥0.05 and arm B: RPR <0.05). The patients were stratified according to the tumor stage (early and advanced disease) and tumor localization (right sided and left sided). RESULTS: Totally, 312 patients were enrolled to the study. Nearly 81.9% of the patients were at early stage and 18.1% were at advanced stage at the time of diagnosis. In patients with early-stage disease, no significant disease-free survival and overall survival (OS) was found in both arms (P = 0.88 and P = 0.085, respectively). In arm A, OS was nonsignificantly better in the entire and left-sided advanced tumor compared to arm B. In patients with right-sided advanced cancer, OS was statistically significantly better for arm A compared to arm B (median OS; RPR ≥0.05: 24.8 months vs. <0.05: 13.9 months; P = 0.035). DISCUSSION: RPR can be a useful prognostic marker in CRC, especially in right-sided advanced tumors. CONCLUSION: RPR can be used as a prognostic marker in CRC but should be validated with further investigation.

Association between Her2/neu status in colorectal carcinoma and clinicopathological features: a retrospective study using whole - tissue sections.

The human epidermal growth factor receptor 2 (Her2/neu) signal pathway plays a significant role in the occurance of various solid tumor types. The rate of Her2/neu in colorectal carcinoma (CRC) is not clearly elucidated. In this study, we discuss the association between Her2/neu overexpression and clinicopathological parameters in CRC. Her2/neu immunohistochemical (IHC) staining was performed on whole sections of formalin fixed paraffin embedded tumor tissues of 100 CRC resections. Cases with score 3+ and score 2+ expressions were further evaluated by silver in-situ hybridization (ISH) for the existence of Her2/neu gene amplification. Her2/neu membranous overexpression was observed in 12 of the 100 cases (6 cases with a score 3+ and 6 cases with a score 2+) and 6 of these were heterogenous. There were 10 cases with Her2/neu amplification (6/6 score 3+, 4/6 score 2+). Strong cytoplasmic staining was observed in 5 cases. Membranous scores were either 3+ or 2+ in 3 of these 5 cases. Moreover, there was Her2/neu amplification in 2 of these 3 cases. Her2/neu amplification status and overexpression was not related to clinicopathological parameters and overall survival. More clear results can be obtained from studies with Her2/neu IHC and ISH test on whole sections.

Rectal eversion and double-stapled ileal pouch anal anastomosis in familial adenomatous polyposis syndrome.

INTRODUCTION: Surgery is the only treatment option for familial adenomatous polyposis (FAP). Aim of surgery in FAP is to minimize colorectal cancer risk without need for permanent stoma. There are especially two operation options; Total colectomy with ileorectal anastomosis (IRA) and total proctocolectomy with ileo-pouch anal anastomosis (IPAA). We report here a patient with FAP who had resection via rectal eversion just over the dentate line under direct visualization and ileoanal-J pouch anastomosis by double-stapler technique. PRESENTATION OF CASE: A 40 yr. old female patient with FAP underwent surgery. Firstly, colon and the rectum mobilized completely, and then from the 10 cm. proximal to the ileo-caecal valve to the recto-sigmoid junction total colectomy was performed. Rectum was everted by a grasping forceps which was introduced through the anus and then resection was performed by a linear stapler just over the dentate line. A stapled J-shaped ileal reservoir construction followed by intraluminal stapler-facilitated ileoanal anastomosis. Follow up at six months anal sphincter function was found normal. DISCUSSION: There is only surgical management option for FAP patients up to now. Total colectomy with IRA and restorative proctocolectomy with IPAA is surgical options for FAP patients that avoid the need for a permanent stoma. Anorectal eversion may be used in the surgical treatment of FAP, chronic ulcerative colitis and early stage distal rectal cancer patients. CONCLUSION: J-pouch ileoanal anastomosis can safely be performed by rectal eversion and double stapler technique in FAP patients.

Do repeatedly nondiagnostic fine needle aspirations of thyroid nodules predict malignancy risk?

Fine needle aspiration biopsy (FNAB) is a common, minimally invasive, cost-effective, and rapid method to manage thyroid nodules, but nondiagnostic FNAB (ND-FNAB) is still a common problem due to high prevalence (2%-20%). Our purpose in this study is to investigate risk of malignancy of repeating ND-FNABs and correlation between clinical and ultrasound findings. Our cohort study included 75 patients who had 2 or more times ND-FNABs and, finally, undergone surgical resection. We evaluated demographic, clinical, ultasonographic, and pathologic features. Fifty-seven patients were female, and 22 patients were male. Seventy-five patients' histopathologic results were 76% (n=57) benign and 24% (n=18) malignant. Of malignant nodules, 94.4% (n=17) were papillary carcinoma, whereas 5.6% (n=1) were follicular carcinoma. We did not find any predictive factor for malignancy and any differences associated with clinical and ultrasonographic features between benign and malignant nodules. Reaspiration followed by surgery for appropriate patients is recommended.

Management of fistula of ileal conduit in open abdomen by intra-condoit negative pressure system.

INTRODUCTION: We aimed to present the management of a patient with fistula of ileal conduit in open abdomen by intra-condoid negative pressure in conjunction with VAC Therapy and dynamic wound closure system (ABRA). PRESENTATION OF CASE: 65-Year old man with bladder cancer underwent radical cystectomy and ileal conduit operation. Fistula from uretero-ileostomy anastomosis and ileus occurred. The APACHE II score was 23, Mannheim peritoneal index score was 38 and Björck score was 3. The patient was referred to our clinic with ileus, open abdomen and fistula of ileal conduit. Patient was treated with intra-conduid negative pressure, abdominal VAC therapy and ABRA. DISCUSSION: Management of urine fistula like EAF in the OA may be extremely challenging. Especially three different treatment modalities of EAF are established in recent literature. They are isolation of the enteric effluent from OA, sealing of EAF with fibrin glue or skin flep and resection of intestine including EAF and re-anastomosis. None of these systems were convenient to our case, since urinary fistula was deeply situated in this patient with generalized peritonitis and ileus. CONCLUSION: Application of intra-conduid negative pressure in conjunction with VAC therapy and ABRA is life saving strategies to manage open abdomen with fistula of ileal conduit.

Intrarectal negative pressure system in the management of open abdomen with colorectal fistula: A case report.

INTRODUCTION: To present the management of open abdomen with colorectal fistula by application of intrarectal negative pressure system (NPS) in addition to abdominal NPS. PRESENTATION OF CASE: Twenty-year old man had a history of injuries by a close-range gunshot to the abdomen eight days ago and he had been treated by bowel repairs, resections, jejunal anastomosis and Hartman's procedure. He was referred to our center after deterioration, evisceration with open abdomen and enteric fistula in septic shock. There were edematous, fibrinous bowels and large multiple fistulas from the edematous rectal stump. APACHE II, Mannheim Peritoneal Index and Björck scores were 18, 33 and 3, respectively (expected mortality 100%). After intensive care for 5 days, he was treated by abdominal and intrarectal NPS. NPS repeated for 5 times and the fistula was recovered on day 18 completely. Fascial closure was facilitated with a dynamic abdominal closure system (ABRA) and he was discharged on day 33 uneventfully. There was no herniation and any other problem after 12 months follow-up. DISCUSSION: Management of fistula in OA can be extremely challenging. Floating stoma, fistula VAC, nipple VAC, ring and silo VAC, fistula intubation systems are used for isolation of the enteric effluent from OA. Several biologic dressings such as acellular dermal matrix, pedicled flaps have been used to seal the fistula opening with various success. Resection of the involved enteric loop and a new anastomosis of the intestine is very hard and rarely possible. In all of these reports, usually patients are left to heal with a giant hernia. In contrast to this, there is no hernia in our case during one year follow up period. CONCLUSION: Combination of intra and extra luminal negative pressure systems and ABRA is a safe and successful method to manage open abdomen with colorectal fistula.