Endobronchial metastasis is generally a late finding of primary tumor or may be determined before the diagnosis of primary tumor. We present a rare case of primary transitional and signet-ring cell carcinoma of the urinary bladder that occurred with malignant pleural effusion and endobronchial metastasis. A 71-year-old man complained of dyspnea and hematuria. He was admitted to the intensive care unit (ICU) with a prediagnosis of acute respiratory failure. He had decreased respiratory sounds and fine rales bilaterally at the lung bases. Respiratory failure worsened, and he was placed on mechanical ventilation. Radiograph and computed tomogram revealed bilateral effusion and metastatic nodules in the lung parenchyma. Subsequent abdominal computed tomogram revealed a mass in the urinary bladder, and transurethral biopsy indicated transitional epithelial carcinoma (modified Bergvist grade IIIB, and World Health Organization/International Society of Urological Pathology higher-grade urothelial papillary carcinoma) and signet-ring cell carcinoma, with lymphovascular invasion, consistent with the pathology findings. Our treatment plan was radical cysto-prostatectomy, followed by chemotherapy and radiotherapy, but because of his very poor medical status, the operation was not performed. On the 5th ICU day he died from severe respiratory failure, despite intensive supportive therapy. This case highlights the need to rule out malignancies in other organs in patients admitted with severe respiratory symptoms.

Congenital factor VII deficiency is a rare autosomal-recessive disorder and surgery in patients with factor VII deficiency has been reported to be endangered by intraoperative or postoperative bleeding, unless a replacement therapy is used. In this paper, we report a successful prophylaxis with single and low dose rFVIIa (12.5 microg kg(-1)) in a 22-year-old homozygote factor VII deficient patient who underwent laparoscopic gynecologic surgery. Minimally invasive surgeries, such as laparoscopic surgery, could be safely performed in patients with congenital factor VII using single and low dose rFVIIa combined with vigilant clinical observation and laboratory examination.

Background/aim: Acute mesenteric ischemia (AMI), one of the gastrointestinal system complications, which occurs following cardiac surgery, is challenged in the literature with a diminished incidence of AMI by heart surgery without cardiopulmonary bypass (CPB) or with pulsatile CPB. This study aims to compare the incidence and mortality rate of mesenteric ischemia in a series of consecutive patients undergoing coronary artery bypass grafting (CABG) through on-pump and off-pump techniques. Materials and methods: This study included patients who underwent CABG between 1 January 2010 and 31 June 2016. All patients were divided into two groups: Group 1 comprised 6396 CABG patients operated on with the off-pump technique. Group 2 included 1210 patients who received CABG with the on-pump technique. Preoperative data were collected on the studied variables. Postoperative data included the development of intestinal ischemia and in-hospital mortality. Results: Of 7606 consecutive CABG patients, a total of 31 (0.4%) developed intestinal ischemia. The incidence of postoperative mesenteric ischemia was 0.28% in Group 1 and 1.07% in Group 2 (P = 0.000). The survival rates after AMI were 61.1% in Group 1 (offpump) and 7.7% in Group 2 (on-pump) (P = 0.003). Time from the first occurrence of nonspecific GI complaints to laparotomy was similar in the off-pump and on-pump groups and had no effect on mortality. Conclusions: With regard to the incidence of mesenteric ischemia and survival after laparotomy, off-pump CABG patients revealed significant improvement compared with those operated on with the on-pump technique.

We read with great interest the article by Hoshi et al. [1] dealing with the recovery time from neuromuscular blockade induced by rocuronium combined with sugammadex versus succinylcholine during electroconvulsive therapy (ECT). Sugammadex has recently been introduced as a fast-acting, selective relaxant-binding agent that was specifically designed to rapidly reverse rocuroniuminduced neuromuscular blockade. This study is interesting for anesthesiologists who frequently encounter ECT sessions in their operating rooms and are waiting for safe agents that rapidly reverse neuromuscular blockade in this subgroup of patients. The authors revealed that recovery time of T1 to 10 and 90% in the rocuronium-sugammadex group was shorter than in the succinylcholine group although the difference was not statistically significant. The authors also revealed that seizure duration with succinylcholine (33 ± 8 s) was shorter than that with rocuroniumsugammadex (39 ± 4 s) and reported a potential benefit of the use of rocuronium-sugammadex as an alternative to succinylcholine for muscle relaxation during ECT [1]. In our opinion, some points of this work are not sufficiently clear.The authors reported a tendency to shorter time to recovery of T1 to 10 and 90% with rocuronium-sugammadex compared with succinylcholine but the difference was not statistically significant (p = 0.26, p = 0.07) and no significant differences in time to first spontaneous breath and eye opening in response to verbal commands were found with either muscle relaxant (p = 0.94, p = 0.48). Absence of such a statistically significant difference might be because of the small sample size (n = 5 in this clinical report) and/or increased variability of the time to recovery of T1 to 10 and 90% and the time to the first spontaneous breath between the first case and the remaining group. Not only the absence of statistically significant differences between the two medicationspossibly-for methodological reasons, but also the increased percentage of elderly ([65 years) subjects (2/5: 40%) weakens the findings of this report, because reversal of rocuronium neuromuscular blockade with sugammadex was found to be slightly slower in elderly patients [2].Further large-scale prospective studies on sugammadex are mandatory, especially for patients with contraindications to the use of succinylcholine, although the cost of sugammadex may preclude such trials. References1. Hoshi H, Kadoi Y, Kamiyama J, Nishida A, Saito H, Taguchi M, Saito S. Use of rocuronium-sugammadex, an alternative to succinylcholine, as a muscle relaxant during electroconvulsive therapy. J Anesth. 2011;25:286-90. 2. McDonagh DL, Benedict PE, Kovac AL, Drover DR, Brister NW, Morte JB, Monk TG. Efficacy, safety, and pharmacokinetics of sugammadex for the reversal of rocuronium-induced neuromuscular blockade in elderly patients. Anesthesiology. 2011;

A AB BS ST TR RA AC CT T O Ob bj je ec ct ti iv ve e: : This study aimed to investigate the total oxidant status (TOS), total antioxidant status (TAS), oxidative stress index (OSI) and the paraoxonase and arylesterase activities of patients with gallstones and compare them with healthy individuals as well as to assess the impact of sevoflurane and desflurane on oxidative stress markers in laparoscopic surgery. M Ma at te er ri ia al l a an nd d M Me et th ho od ds s: : Forty patients scheduled for laparoscopic surgery (Patient Group) and 30 healthy volunteers as control subjects (Control Group) were enrolled in the study. The patient group was randomized to desflurane group (n= 0) and sevoflurane group (n= 20). Blood samples were collected preoperatively and at postoperative 6 hours in order to measure the levels of TAS, TOS, OSI, and paraoxonase and arylesterase activities. Preoperative and postoperative laboratory findings of sevoflurane and desflurane group were compared with the Mann Whitney U test between groups and the Wilcoxon test within a group. R Re es su ul lt ts s: : Preoperative TOS, OSI levels in the patient group were significantly increased and arylesterase activities were significantly decreased compared to the control group (p<0.05) [(TOS (µmol H2O2 equiv/L), 19.64 ± 2.16 vs. 14.25 ± 1.83), (OSI 1.85 ± 0.53 vs. 0.98 ± 0.24), (Arylesterase (U/L), 45.19 ± 6.82 vs. 49.66 ± 4.78)]. There was no statistically significant difference between sevoflurane and desflurane group in laboratory findings of the preoperative and the postoperative period (p> 0.05). Preoperative and postoperative TAS, TOS, OSI results and activities of paraoxonase and arylesterase were not significantly different in the sevoflurane group (p> 0.05). Although the preoperative and postoperative levels of TAS and TOS and paraoxonase and arylesterase activities in the desflurane group was not significantly different, postoperative OSI was significantly increased (p< 0.05) (OSI 1.80 ± 0.57 vs 2.20 ± 0.67). C Co on nc cl lu us si io on n: : Patients with gallstone are exposed to a potent oxidative stress influencing TOS, OSI levels and arylesterase activities. Sevoflurane and desflurane had similar effects on oxidative stress during laporoscopic surgery in this patient group; however, OSI was increased in the desflurane group in the postoperative period compared to preoperative levels (p< 0.05).K Ke ey y W Wo or rd ds s: : Gallstones; laparoscopy; sevoflurane; desflurane; oxidative stress Ö ÖZ ZE ET T A Am ma aç ç: : Bu çalışmada, safra taşı olan hastalarda total oksidan seviye (TOS), total antioksidan seviye (TAS), oksidatif stres indeksi (OSİ) seviyelerinin ve paraoksonaz, arilesteraz aktivitelerinin, sağlıklı bireylerdeki parametrelerle karşılaştırılması ve laparoskopik cerrahide oluşan oksidatif stres üzerinde sevofluran ve desfluranın etkilerinin araştırılması amaçlandı. G Ge er re eç ç v ve e Y Yö ön nt te em ml le er r: : Laparoskopik cerrahi planlanan 40 hasta (hasta grubu) ve 30 sağlıklı gönüllü (kontrol grubu) çalışmaya dâhil...