Alper Findikcioglu

A different application method of talc pleurodesis for the treatment of persistent air leak.

Persistent air leak is a serious problem that may cause empyema, hypoxia, respiratory insufficiency, and other life‐threatening complications. Chemical pleurodesis may be carried out for the treatment of persistent air leak if the lung is fully expanded. However, the standard method of chemical pleurodesis entails clamping the chest tube for a period of time after instillation of the agent. In patients with massive air leak, this would result in a tension pneumothorax. Therefore, standard chemical pleurodesis for persistent air leak is not an appropriate treatment for these patients. In this study, we carried out talc pleurodesis in six patients using an inverted U‐shaped chest tube elevated to 60u2003cm that did not result in tension pneumothorax and mediastinal shift. No recurrence was observed during a mean follow up of 16.2u2003months.

Isolated mediastinal lymph node false positivity of [18F]-fluorodeoxyglucose-positron emission tomography/computed tomography in patients with cervical cancer.

Objective This study aimed to evaluate the degree of mediastinal involvement in patients with cervical cancer with isolated mediastinal [18F]-fluorodeoxyglucose–positron emission tomography (FDG-PET) positivity as verified by histopathologic examination. Methods Two hundred twenty-eight patients with newly diagnosed cervical cancer and who underwent FDG-PET imaging were analyzed. Twenty-nine patients (17%) had disseminated disease detected with PET/computed tomography (CT). Only 10 patients (4%) had increased FDG uptake in mediastinal lymph nodes alone. Of the 10 patients with mediastinal disease, 2 refused surgical mediastinal lymph node biopsy and did not receive any treatment. Patients with suspected paratracheal or subcarinal lymph node metastasis detected on PET/CT underwent mediastinoscopy, and those with hilar metastasis had video-assisted mediastinal lymphadenectomy. Treatment was delivered according to final staging based on histopathologic confirmation of mediastinal lymph node involvement. Results The mean (SD) maximum standardized uptake values for primary cervical tumor and mediastinal lymph nodes were 19.7 (10.3) and 7.5 (1.6), respectively. Of 8 patients who underwent mediastinal lymph node confirmation, 6 (75%) were tumor free, demonstrating granulomatous changes, and were treated curatively. No patients had residual or recurrent disease at the primary site, and all but 1 were alive without disease. Two patients with confirmed mediastinal lymph node metastasis were treated palliatively and died between 9 and 11 months after diagnosis. Conclusions Positron emission tomography/CT is an important tool for lymphatic staging and evaluation of distant metastases in cervical cancer. However, PET/CT should be interpreted cautiously for isolated mediastinal involvement; surgical evaluation is required for accurate staging and appropriate treatment decisions to achieve better outcomes.

Factors affecting morbidity and mortality in flail chest: comparison of anterior and lateral location.

OBJECTIVEnFlail chest is most often accompanied by significant underlying pulmonary parenchymal injuries and may constitute a life-threatening thoracic injury. In this study we evaluated the treatment modalities for flail chest depending on the effect of trauma localization on mortality and morbidity.nnnMETHODSnBetween 2003 and 2008, 23 patients (20 males/3 females) were treated for flail chest. Location of the trauma in the chest wall, mechanical ventilation support, prognosis and injury severity score (ISS) were recorded for all patients. Mechanical ventilation support was given in 14 patients (60.8 %), and 12 of these 14 patients required subsequent tracheostomy. Internal fixation was used in 3 patients.nnnRESULTSnThe major cause of flail chest was a car crash in 18 of 23 patients (76 %). Median ISS was 62.8 for all patients. The patients with flail chest who had bilateral costochondral separation (anterior chest location) (group I, n = 10) had a significantly higher ISS than those with single-side posterolateral flail chest (group II, n = 13; ISS: 70/55; P = 0.02). The need for mechanical ventilation support was also higher in the group with bilateral costochondral separation. Morbidity was higher in group I than in group II ( P = 0.198), and mortality was also significantly higher in group I ( P = 0.08). Patients with a cranial trauma and flail chest had a higher mortality (19 %) than patients with only flail chest (no mortality). The mean ISS was 75 for patients with cranial trauma and flail chest and 55.7 ( P = 0.001) for patients with only flail chest. Sepsis and subarachnoid bleeding were the major causes of mortality. The mean ISS was 54.5 for patients under the age of 55 (n = 14) whereas it was 69.4 in those aged 55 and over (n = 9; P = 0.034). Mortality in the older group was also higher (33 % versus 7 %; P = 0.02).nnnCONCLUSIONnEarly intubation and mechanical ventilation is of paramount importance in patients with flail chest. However, prolonged mechanical ventilation is associated with a poor outcome. Tracheotomy and frequent flexible bronchoscopy are an effective pulmonary toilet. Advanced age was a major risk factor for flail chest trauma mortality, together with the severity of the injury. When cranial trauma was accompanied by flail chest, mortality and morbidity rates increased. Bilateral costochondral separation also increased the risk of morbidity and the need for mechanical ventilation in patients with flail chest.

MANAGEMENT OF COMPLICATED HYDATID CYST OF THE THORAX

Background:u2003 Complicated hydatid cyst of the thorax is important to the clinical approaches and treatment methods in hytadid disease. The aim of this study was to evaluate the problems of complicated pulmonary hytatid cyst, including choice of surgical methods, diagnostic clues and to discuss the inherent risks of medical theraphy and the delay of surgical treatment in pulmonary hydatid disease.

Is clipping superior to cauterization in the treatment of palmar hyperhidrosis

BACKGROUNDnEndoscopic thoracic sympathectomy has been accepted as the most effective treatment for palmar hyperhidrosis (PH). However, there is a debate regarding the surgical techniques in terms of effectiveness, recurrence, and reversibility. In this study, sympathetic chain disruptions were compared in terms of whether the clipping or ablation technique had an effect on the long-term outcomes of patients who underwent thoracic sympathectomy for primary PH.nnnPATIENTS AND METHODSnAll patients who underwent video-thoracoscopic sympathectomy for PH between May 2008 and October 2011 were included. Single-port bilateral sympathectomy was performed depending on the sweat distribution. As a standard approach, rib-based terminology was used to describe the blockade level of the sympathetic ganglia, and single-level R3 sympathectomy (between R3 and R4) was performed in all patients. The type of sympathectomy was changed. Monopolar electrocautery was first performed and 5-mm clips were then used for nerve disruption. Both techniques were evaluated and compared in terms of effectiveness, reversibility, and recurrence.nnnRESULTSnCauterization of the sympathetic chain was applied in 28 (47%) (Group A) patients and clipping in 32 (53%) patients (Group B). CH was the most common adverse effect and was observed in 43 (71.6%) patients (Group A, 71.4%; Group B, 71.8%; pu2009=u20090.8). The success rate was 93% for Group A and 100% for Group B (pu2009=u20090.15). The satisfaction rate for Group A was 83% and for Group B was 86% (pu2009=u20090.77). In Group A two patients (7%), and in Group B three patients (9%) requested reversibility because of severe compensatory hyperhidrosis. Overly dry hands were the other most common side effect and were identified in 12 (25%) patients. Recurrences were observed in 11 patients in Group A and 4 patients in Group B (19 vs. 6%; pu2009=u20090.01). The mean follow-up time was 33u2009±u200910.5 months (range, 13-53 months).nnnCONCLUSIONnBoth clipping and cauterization are highly effective for the treatment of PH. The methods are comparable in terms of effectiveness and side effects despite the fact that the recurrence rate was higher in the cauterization group. Potential reversibility of compensatory sweating was not observed in our series. Identification of ideal candidates for surgery and education of patients about the permanent side effects of sympathectomy might make these techniques more convenient.

Thoracic Epidural Anesthesia and Analgesia During the Perioperative Period of Thoracic Surgery: Levobupivacaine Versus Bupivacaine

OBJECTIVESnTo compare the effects of thoracic epidural anesthesia with levobupivacaine or bupivacaine on block features, intraoperative hemodynamics, and postoperative analgesia for thoracic surgery.nnnDESIGNnA prospective, randomized, and double-blind study.nnnSETTINGnA university hospital.nnnPARTICIPANTSnFifty patients undergoing thoracic surgery.nnnINTERVENTIONSnPatients received thoracic epidural catheterization either with levobupivacaine or bupivacaine. A bolus of 0.1 mL/kg of 0.25% levobupivacaine or 0.25% bupivacaine was administered, and infusion of the same drug with 0.25% concentration was started at 0.1 mL/kg/h. General anesthesia was induced after assessing the sensory block and maintained with 0.3% to 0.8% isoflurane and 50% O(2) in air. Epidural patient-controlled analgesia with the same agent was started at the end of the operation for 48 hours postoperatively.nnnMEASUREMENTS AND MAIN RESULTSnSensory block features such as onset time and spread were assessed for the next 20 minutes after the bolus dose. Heart rate and systolic, diastolic, and mean arterial blood pressures were recorded intraoperatively and postoperatively. Pain at rest and activity was evaluated by the visual analog scale (VAS) for 48 hours after the operation. All patients were comparable with respect to the demographic data. Onset time of the block and the number of blocked dermatomes and hemodynamic parameters were similar in both groups. All VAS assessments were comparable between groups except VAS at the 36th hour postoperative, which was higher in the levobupivacaine group (p = 0.039).nnnCONCLUSIONSnThoracic epidural anesthesia with either levobupivacaine or bupivacaine provided comparable sensory block features, intraoperative hemodynamics, and postoperative analgesia for thoracic surgery.

Video-Assisted Thoracoscopic Surgery to Treat Hydatid Disease of the Thorax in Adults: Is It Feasible?

BACKGROUNDnOptimal treatment of intrathoracic hydatid diseases in adults involves complete removal of the cyst with parenchyma-preserving surgery. In current practice, thoracotomy remains the standard surgical approach for pulmonary hydatid cysts, so surgical experience is limited, particularly with regard to video-assisted thoracoscopic surgery (VATS).nnnSUBJECTS AND METHODSnBetween June 2007 and May 2011, a selected series of 12 adult patients presenting with intrathoracic hydatid cysts underwent VATS. The cysts were completely removed using a three-trocar technique.nnnRESULTSnComplete removal of the cysts was successful in all patients. All cysts were diagnosed by computerized tomography, and 6 (50%) patients had a history of hydatid disease in the liver or lung. No serious postoperative complications were observed. Patients with thoracoscopic excision were discharged after a median of 2.9 days (range, 2-6 days). No recurrences or complications were observed during a mean follow-up of 29 months.nnnCONCLUSIONSnConsidering the conversion and complication rates in our series, VATS should be the primary therapeutic choice for adults with thoracic hydatid cysts. Open surgical interventions in patients with large and uncomplicated cysts appear optional.

Concurrent Chemoradiotherapy with Vinorelbine plus Split-Dose Cisplatin may be an Option in Inoperable Stage III Non-Small Cell Lung Cancer: A Single-Center Experience

Background Concurrent chemoradiotherapy is the current standard treatment for inoperable stage III non-small cell lung cancer (NSCLC). In this study we aimed to investigate the efficacy and toxicity of CCRT with split dose of cisplatin (30 mg/m2) and vinorelbine (20 mg/m2) in patients with inoperable stage III NSCLC followed in our oncology clinic. Material/Methods Medical records of 97 patients with inoperable stage III NSCLC treated with concurrent chemoradiotherapy with cisplatin-vinorelbine were retrospectively analyzed. Cisplatin (30 mg/m2) and vinorelbine (20 mg/m2) were administered on days 1, 8, 22, and 29 during radiotherapy. Two cycles of consolidation chemotherapy were given. All patient data, including pathological, clinical, radiological, biochemical, and hematological data, were assessed retrospectively using our database system. Results Our study included 97 unresectable stage III NSCLC patients who were treated with CCRT. Median age was 58 years old (range 39–75) and 87 (89.7%) of the patients were men. ECOG performance score was 0–1 in 93 patients (95.9%). Squamous histology, the most common histology, was diagnosed in 46 patients (47.4%). Median follow-up time was 23.8 months. Median progression-free survival (PFS) and median overall survival time (OS) were 10.3 months and 17.8 months, respectively. Objective response rate and clinical benefit rate were 75.3% and 83.5%, respectively. Distant and local relapse rate were 57.1% and 42.9%, respectively. Hematological and non-hematological grade 3–4 toxicities were seen in 13 (13.4%) and 16 (16.5%) patients, respectively. Six (6.1%) patients died due to toxicity. Conclusions The results of this study suggest that split-dose cisplatin may offer fewer grade III–IV toxicities without sacrificing efficacy and could be an option in patients with inoperable stage III NSCLC during CCRT. Similar to past studies, despite high response rate during CCRT, distant relapse is the major parameter that influences patient survival in long-term in NSCLC.

A thoracic surgeon's perspective on the elastofibroma dorsi: A benign tumor of the deep infrascapular region

Background:u2002 An elastofibroma is a benign, soft‐tissue tumor and is important in the differential diagnosis of thoracic wall masses. Here, patients with elastofibromas who underwent thoracic surgery were retrospectively reviewed to elucidate elastofibroma formation and to facilitate the differential diagnosis.

Elastofibroma dorsi incidentally detected by 18 F-FDG PET/CT imaging

ObjectiveElastofibroma dorsi (ED) is a rare pseudotumor of the soft tissues that can also show 18F-fluorodeoxyglucose (18F-FDG) uptake on positron emission tomography combined with computed tomography (PET/CT) imaging. The aim of this retrospectively study was to describe the metabolic characteristics of ED incidentally detected by 18F-FDG PET/CT imaging.Materials and MethodsBetween November 2009 and August 2013 at our institution, 10,350 consecutive PET/CT examinations were retrospectively investigated. In 176 of these patients, ED was recorded as an incidental finding. Fifty-five of 176 patients also had follow-up scans after chemoradiotherapy. A total of 231 scans with ED in 176 patients were identified. To determine the metabolic activity of ED, the maximum standardized uptake value (SUVmax) was calculated semiquantitatively. For measurement size of ED, the longest axis of transaxial CT images was used. Seven of the 176 patients underwent surgery due to suspected metastases and/or invasion of primary malignancy and/or symptoms or incidental during surgery.ResultsThe prevalence of ED in our series was 1.7xa0%. The lesions were located in the subscapular region in all patients, except in one case with a lesion in the infrascapular region. A total of 419 ED lesions in 231 scan of 176 patients were evaluated. Meanxa0±xa0SD SUVmax and long axis values for these 419 lesions were 2.31xa0±xa00.61 (range 1.0–4.30) and 56.78xa0±xa017.01xa0mm (range 19–112xa0mm), respectively. Of these 176 patients, 141 (80.1xa0%) had bilateral lesions and 35 (19.9xa0%) had unilateral lesions. There were statistically significant differences in the SUVmax and long axis values between the right and left side in the bilateral lesions (pxa0=xa00.001). No significant differences in the SUVmax and long axis values of the lesion were found between pre- and posttreatment in the patients with follow-up scans.ConclusionElastofibroma dorsi located in the scapular region is usually bilateral, asymmetric and with mild or moderate metabolic activity on PET/CT imaging. In addition, the metabolic activity and size of ED remained stable after chemoradiotherapy. Awareness of these metabolic characteristics of ED is important for preventing misinterpretation during 18F-FDG PET/CT studies.