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Objective: To present a multidisciplinary open surgical treatment under cardiopulmonary bypass (CPB) for a renal cell carcinoma (RCC) with Mayo level 4 inferior vena cava (IVC) thrombus extending into the right atrium. Patient and Surgical Procedure: A 57 years old man with macrohematuria was diagnosed 8.5 cm left kidney tumor with venous tumor thrombus (VTT) from left renal vein along IVC extending into right atrium. The patient was clinically staged as cT3cN0M0. Normal cardiac ejection fraction and no additional cardiac risk was detected by echocardiography and coronary arterial angiography. The patient underwent ‘Left Radical Nephrectomy (RN) + Excision of VTT in IVC and Right Atrium under CPB’ by a multidisciplinary team consisting of Urologic Oncology Division at Urology Department, Cardio-Vascular Surgery and Hepatobiliary Surgery. A video of operative details was submitted as supplement of the article. Results: The duration of operation, CPB, myocardial ischemia, renal and hepatic ischemia were 650, 42, 23 and 17 minutes, respectively. The estimated blood loss was 2000 cc., and it was replaced intraoperatively by transfusion of 5 unit erythrocyte suspensions and 2 unit fresh frozen plasmas. The patient was discharged at postoperative 10 days after being monitored at intensive care unit for 3 days and at urology service for 7 days. The pathology was WHO/ISUP Grade 3 clear cell RCC staged as pT3cN0M0. The patient received adjuvant sunitinib treatment for 12 months, and he is alive with no evidence of tumor progression for 48 months after surgery. Conclusions: Radical Nephrectomy and thrombectomy is the standard treatment in non-metastatic RCC with Mayo level 4 IVC thrombus extending into right atrium. The multidisciplinary approach is the key factor determining decreased perioperative morbidity and mortality, and increased survival outcomes. Preoperative planning with experiences on urologic oncology, cardiopulmonary bypass surgery and hepatobiliary surgery are hallmarks of success in this complex surgery.

Background and objectives: Postoperative cognitive dysfunction is common after cardiac surgery. Adequate cerebral perfusion is essential and near infrared spectroscopy (NIRS) can measure cerebral oxygenation. Aim of this study is to compare incidence of early and late postoperative cognitive dysfunction in elderly patients treated with conventional or near infrared spectroscopy monitoring. Methods: Patients undergoing coronary surgery above 60 years, were included and randomized to 2 groups; control and NIRS groups. Peroperative management was NIRS guided in GN; and with conventional approach in control group. Test battery was performed before surgery, at first week and 3rd month postoperatively. The battery comprised clock drawing, memory, word list generation, digit spam and visuospatial skills subtests. Postoperative cognitive dysfunction was defined as drop of 1 SD (standard deviation) from baseline on two or more tests. Mann-Whitney U test was used for comparison of quantitative measurements; Chi-square exact test to compare quantitative data. Results: Twenty-one patients in control group and 19 in NIRS group completed study. Demographic and operative data were similar. At first week postoperative cognitive dysfunction were present in 9 (45%) and 7 (41%) of patients in control group and NIRS group respectively. At third month 10 patients (50%) were assessed as postoperative cognitive dysfunction; incidence was 4 (24%) in NIRS group (p:0.055). Early and late postoperative cognitive dysfunction group had significantly longer ICU stay (1.74 + 0.56 vs. 2.94 + 0.95; p

Introduction: Postoperative cognitive dysfunction (POCD) is an adverse outcome of surgery that is more common after open heart procedures. The aim of this study is to investigate the role of tightly controlled blood glucose levels during coronary artery surgery on early and late cognitive decline. Methods: 40 patients older than 50 years undergoing elective coronary surgery were randomized into two groups. In the “Tight Control” group (GI), the glycemia was maintained between 80 and 120 mg dL−1 while in the “Liberal” group (GII), it ranged between 80–180 mg dL−1. A neuropsychological test battery was performed three times: baseline before surgery and follow-up first and 12th weeks, postoperatively. POCD was defined as a drop of one standard deviation from baseline on two or more tests. Results: At the postoperative first week, neurocognitive tests showed that 10 patients in the GI and 11 patients in GII had POCD. The incidence of early POCD was similar between groups. However the late assessment revealed that cognitive dysfunction persisted in five patients in the GII whereas none was rated as cognitively impaired in GI (p = 0.047). Conclusion: We suggest that tight perioperative glycemic control in coronary surgery may play a role in preventing persistent cognitive impairment. Resumo: Introdução: A disfunção cognitiva pós-operatória (DCPO) é um resultado adverso cirúrgico que é mais comum após cirurgias cardíacas abertas. O objetivo deste estudo foi investigar o papel dos níveis de glicose no sangue rigorosamente controlados durante a cirurgia coronariana no declínio cognitivo precoce e tardio. Métodos: Quarenta pacientes com idades acima de 50 anos e submetidos à cirurgia coronariana eletiva foram randomizados em dois grupos. No grupo “controle rigoroso” (GI), a glicemia foi mantida entre 80-120 mg.dL−1; enquanto no grupo “liberal” (GII), variou entre 80-180 mg.dL−1. A bateria de testes neuropsicológicos foi realizada três vezes: fase basal, antes da cirurgia e na primeira e décima segunda semana de acompanhamento no pós-operatório. DCPO foi definida como uma queda de um desvio padrão da fase basal em dois ou mais testes. Resultados: Na primeira semana de pós-operatório, os testes neurocognitivos mostraram que 10 pacientes no GI e 11 pacientes no GII apresentaram DCPO. A incidência de DCPO precoce foi semelhante entre os grupos. No entanto, a avaliação tardia revelou que a disfunção cognitiva persistiu em cinco pacientes no GII, enquanto nenhum paciente foi classificado como cognitivamente prejudicado no GI (p = 0,047). Conclusão: Sugerimos que o controle glicêmico rigoroso no perioperatório de cirurgia coronariana pode desempenhar um papel na prevenção da deterioração cognitiva persistente. Keywords: Glucose control, Cognitive dysfunction, Coronary artery bypass surgery, Palavras-chave: Controle glicêmico, Disfunção cognitiva, Cirurgia de revascularização do miocárdio

Background and objectives: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. Methods: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients’ internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5 min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4) min. Results: There was a significant decrease between T0 and T1 in heart rate (80.5 ± 11.6 vs. 75.9 ± 14.4 beats/min), MAP (105.8 ± 21.9 vs. 78.9 ± 18.4 mmHg) and PSI (88.5 ± 8.3 vs. 30.3 ± 9.7) (all p