Abid Demircan

The efficacy of self-expanding metal stents for palliation of malignant esophageal strictures and fistulas

OBJECTIVES Esophageal strictures and esophagorespiratory fistulas are complications of malignant esophageal tumors, which are difficult to manage. The efficacy of self-expanding metal stents (SEMS) for palliation of malignant esophageal strictures and fistulas was investigated prospectively. METHODS Forty-three SEMS were inserted in 41 patients with malignant esophageal stricture or fistula. Our series included 32 men and nine women, of whom median age was 61.4 years. Twenty nine stents were inserted for stricture, ten for esophago-tracheal fistula, and four esophago-pleural fistula. Stents were inserted endoscopically under fluoroscopic control. RESULTS SEMS implantation was technically successful in 40 of 41 patients. A second stenting was needed in two patients. Median dysphagia score improved from 3.4 to 1.3. The covered SEMS was succesful in completely sealing 85.7% of the fistulas. Complication occurred in 11 (26.8%) patients. Especially in the case of tumor stenoses in the distal esophagus, complication rate was higher (44%). In total six patients (14.6%) died after stent placement during early postoperative period. Procedure-related mortality was 4.8% (2/41). CONCLUSIONS We conclude that treatment of malignant esophageal obstructions, including esophagorespiratory fistulas, with SEMS is an alternative palliative procedure. Furthermore SEMS implantation seems more safe in the case of tumor stenoses locating in the middle esophagus.

Prospective, randomized, placebo-controlled study of the effect of TENS on postthoracotomy pain and pulmonary function

We investigated the efficacy of transcutaneous electrical nerve stimulation (TENS) for postthoracotomy pain control in a prospective, randomized, double-blind, placebo-controlled study. We studied two groups of patients undergoing posterolateral thoracotomy. In group 1, TENS was used postoperatively on 60 patients for 5 days. Group 2 contained 56 patients without TENS. In both groups a visual analog scale (VAS) was used to indicate if analgesia was needed. When the VAS was higher than 4, an analgesic was administered. We observed the forced expiratory volume in 1 second (FEV1), the forced vital capacity (FVC), partial arterial oxygen pressure (PaO2), partial arterial carbon dioxide pressure (PaCO2), and how many doses of analgesia were given at postoperative 0 (extubation time), 2, 6, 12, 24, 48, 72, and 120 hours. TENS was not employed in patients with cardiac or neurologic disease. In group 1, TENS reduced the need to administer opioids during the 5-day postoperative period. This result is statistically significant (P = 0.013). Additionally, following the sixth postoperative hour, TENS increased the spirometric breath function. The FEV1, FVC, and PaO2 were high and PaCO2 was low when the first group is compared to the second. All these results are statistically significant (P = 0.012, P = 0.01, P = 0.024, and P = 0.02 respectively). We observed that TENS produced no evidence of side effects or intolerance in the patients of group 1. TENS is thus beneficial for pain relief following thoracotomy and has no side effects. Consequently, the routine use of TENS following thoracic surgery is recommended.

Differential expression of VASP in normal lung tissue and lung adenocarcinomas

Background: Vasodilator stimulated phosphoprotein (VASP) is associated with focal adhesions and is thought to have an important role in actin filament assembly and cell motility. We hypothesise that an increase in the expression of VASP is involved in the progression and invasion of lung adenocarcinomas in parallel to tumour progression. A study was undertaken to analyse VASP expression in normal lung tissue and lung adenocarcinomas. Methods: Human lung tissues with adenocarcinomas (n = 26) were used. Normal lung tissue specimens (n = 14) were taken from areas a standard distance (3 cm) from resected adenocarcinomas of patients who underwent surgical lung resection. Adenocarcinomas were classified according to pathological staging and histopathological grades. Tissues were stained for VASP using immunohistochemistry. Results: Normal lung pneumocytes showed no VASP expression while alveolar macrophages had the strongest immunoreactivity for VASP. Bronchial epithelium (surface epithelium, goblet cells) and bronchial gland cells had a very weak immunoreactivity for VASP. Adenocarcinomas had significantly greater VASP expression than normal epithelium (p<0.001). Moreover, VASP expression in adenocarcinomas increased significantly with more advanced tumour stage (p<0.001). Conclusions: The spatial and differential expression of VASP in normal lung tissue and lung adenocarcinomas suggests that it is likely to be involved in the differentiation of normal lung cells to adenocarcinomas. The significant increase in the expression of VASP in adenocarcinomas in parallel to pathological staging suggests that it may regulate the invasive behaviour of lung adenocarcinomas as adenocarcinoma invasion is increased in more advanced tumours.

Methods of surgical therapy in pulmonary hydatid disease: is capitonnage advantageous?

Background:  Hydatid disease of the lungs is still a serious health problem for some Mediterranean countries. The best surgical therapy for the treatment of this disease is still unclear. In this clinical retrospective study, we aimed to investigate whether capitonnage is an effective therapy method for a pulmonary hydatid cyst or not.

Cytogenetic Findings in Thirty Lung Carcinoma Patients

Primary tissue cultures of human lung tumors were prepared from 30 cases of which 16 were diagnosed as squamous cell carcinoma, six adenocarcinoma, four adenosquamous cell carcinoma, three large cell carcinoma, and one small cell lung carcinoma. Chromosomal abnormalities were observed in 26 cases by cytogenetic studies with a GTG banding technique. Specific chromosome bands frequently involved in structural abnormalities were seen on 1p11, 1q11, 2p10, 6p10, 7q11, 7q22, 7q32, 8q22, 9q22, 11q11, 21q10, and Xq24. We assumed that especially i(2)(p10), i(9)(p10), i(21)(q10), t(11;12), t(14;15), del(X)(q24), and loss of the Y chromosome may play a role in the development of lung cancer as secondary changes. In this way, our cytogenetic findings provide evidence that multiple genetic lesions are associated with the pathogenesis of lung cancer.

Intrathoracic migration of Steinman wire

We report two cases of intrathoracic migration of Steinman wire used for the treatment of the fracture and shoulder dislocation. The migrations were symptomatic with back pain in our cases. The treatment involved removing of the pin via thoracotomy. The postoperative course was uneventful. Intrathoracic migration of Steinman wires should be expected in fixation of the shoulder problems. To avoid this complication, threaded pins have to be used in surgery of the shoulder region.

One-stage transthoracic operation for the treatment of right lung and liver hydatid cysts.

In this study we reviewed our experience of hydatid disease of the lung and the liver and discussed the safety and the follow-up results of the one-stage operation. Between 1990 and 2004, 142 patients with pulmonary hydatid disease underwent operation in our clinic. Of these, 27 (19%) patients had cysts located on the dome of the liver, treated with phrenotomy through a right thoracotomy. Hydatid cysts located in the lungs were managed by means of cystotomy. For liver cysts, cystotomy and the inversion of the cavity with sutures was the surgical method of choice, and a drain was left in place. The pulmonary cysts of 12 (8.4%) patients were bilateral and 5 (3.5%) patients had prior surgical treatment of hepatic (n = 1) or pulmonary (n = 4) hydatid cysts. The liver cysts were approached transdiaphragmatically after the lung cysts were excised in 27 (19%) patients. In patients with pulmonary cysts, cystotomy, with or without capitonnage was performed on 123 (86.6%) patients, and wedge resection was performed on 11 (7.7%), segmentectomy was performed on 6 patients (4.2%), and lobectomy was performed on 2 (1.4%) patients. There was no mortality, and only a small number of complications were encountered: empyema in 3, excessive biliary drainage in 2, and bronchopleural fistula in only 1. We suggest that the extraction of pulmonary and hepatic cysts simultaneously through the transthoracic route is a useful and safe surgical technique. This technique also prevents the need for a second operation.

Significance of tumor length as prognostic factor for esophageal cancer.

Our study indicated the relationship between tumor length and clinicopathologic characteristics as well as long-term survival in esophageal cancer. A total of 116 patients who underwent curative surgery for thoracic esophageal cancer with standard lymphadenectomy in 2 fields between 2000 and 2010 were included in the study. The medical records of these patients were retrospectively reviewed. The patients with tumor length 3 cm had a highly significant difference in the involvement of adventitia and lymph node stations. The patients with tumor length 3 cm had significantly lower rates of involvement of the adventitia and lymph node stations. Tumor length could have a significant impact on both the overall survival and disease-free survival of patients with resected esophageal carcinomas and may provide additional prognostic value to the current tumor, node, and metastasis staging system before patients receive any cancer-specific treatment.

Vascular endothelial growth factor expression and neovascularization in non--small cell lung carcinoma.

The prognostic significance of microvascular density (MVD) and vascular endothelial growth factor (VEGF) expression were investigated in 15 patients with adenocarcinoma (AC) and 15 patients with squamous cell carcinoma (SCC). Immunohistochemically, VEGF and factor VIII were applied. The average microvessel counts were given as MVD, and VEGF expression was given as VEGF percentage area and VEGF staining degree. Higher values of MVD were obtained in patients with AC (11.47 ± 3.48) when compared with patients with SCC (7.47 ± 2.50; P = .001) and also in patients at early stages of disease (10.77 ± 3.24) when compared with patients at advanced stages (8.47 ± 3.64; P = .050). A significant correlation was shown between MVD and VEGF percentage area (P = .006) and between VEGF percentage area and VEGF staining degree (P = .000). No significant difference was found in VEGF percentage area between patients with SCC and AC and between patients at early and advanced stages. In conclusion, VEGF or MVD should not be regarded as a solitary prognostic factor but should be supported by other prognostic factors.

Metachronous triple cancer: esophageal carcinoma 4 years later the synchronous bilateral bronchogenic carcinoma

A 65-year-old man with bilaterally synchronous stage Ib bronchogenic carcinoma had undergone bilaterally upper lobectomy by right and left thorachotomy, respectively. The pathologic diagnoses of both tumors were squamous cell carcinoma. Four years later, he presented with progressive dysphagia. Oesophagoscopy and biopsy showed an esophageal squamous cell carcinoma. Oesophagectomy and cervical oesophagogastrostomy were performed because of the metachronous triple stage III oesophageal carcinoma (Figs. 1 and 2).