Atilla Gürses

Management of traumatic diaphragmatic rupture.

PurposeDiaphragmatic rupture following trauma is often an associated and missed injury. This report documents our experience of treating traumatic diaphragmatic rupture (TDR).MethodsWe retrospectively analyzed 18 patients who presented between 1993 and 2000 with TDR, caused by blunt injuries in 14 and by penetrating injuries in 4.ResultsThe average age of the patients was 32 years and the female to male ratio was 4 : 14. The TDR was right-sided in 5 patients and left-sided in 13. The diagnosis was made by chest X-ray, thorax and upper abdominal computed tomography, and upper gastrointestinal contrast studies. The most common herniated organs were the omentum (n = 11), stomach (n = 10), spleen and colon (n = 9), and liver (n = 2). Sixteen diaphragmatic injuries were repaired primarily, and two were repaired using a prolene mesh graft. The mortality rate was 5.5% (n = 1).ConclusionsA high index of suspicion and early surgical treatment determine the successful management of TDR, with or without the herniation of abdominal organs. The surgical approach to TDR is individualized. Acute left-sided injuries are best approached through the abdomen, although we prefer the chest approach, adding laparotomy when necessary. Acute right-sided injuries and chronic injuries should be approached through the chest.

Bilateral elastofibroma dorsi

Elastofibroma dorsi was diagnosed in a 48-year-old woman with bilateral subscapular tumor masses diagnosed asynchronously in an interval of 4 months in spite of presence of another lesion at first admittance. She underwent subsequent resections of the lesions. They were diagnosed as elastofibroma. Reevaluation of the initial computerized tomography of thorax indicated an omitted small lesion with a 2-cm diameter and 25.2-day doubling time. Although the real neoplastic nature of elastofibroma is unknown, bilateral presence of the masses with different sizes and relatively short doubling times of the lesions must be kept in mind.

Comparison of clinical and surgical-pathologic staging of the patients with non-small cell lung carcinoma

OBJECTIVE Clinical staging of non-small cell lung cancer helps to determine the extent of disease and separate patients with potentially resectable disease from those that are unresectable. Since, clinical staging is based on radiologic and bronchoscopic findings, overstaging or understaging may occur comparing to the final surgical-pathologic evaluation. We aimed to analyze preoperative and postoperative stagings in order to evaluate stage migrations and our surgical strategy for marginally resectable patients. METHODS We did a retrospective analysis of 180 patients with non-small cell lung cancer who underwent resectional surgery between 1994 and 2000. In all patients, a thoracic computerized tomography and bronchoscopy were performed to define clinical staging (cTNM). RESULTS In 86 patients (47.7%) clinical and surgical-pathologic staging concurred. When comparing T subsets alone, correct staging, overstaging and understaging occurred in 133 (73.9%), 28 (15.5%), 47 (26.1%) patients, respectively. Only 13 of 21 patients (61.9%) who were thought to have T4 tumor preoperatively were found to have pT4. Also six patients with cT2 and five patients with cT3 were subsequently found to have T4 disease according to pathology. Clinical staging overestimated the nodal staging in 35 patients (19.4%), while underestimated the lymph node involvement in 45 patients (25%). CONCLUSION Construction of cTNM stage remains a crude evaluation, preoperative mediastinoscopy in every patient must be performed. Preoperative limited T4 disease is not to deny surgery to patients since a considerable number of patients with cT4 are to be understaged following surgery.

Nonanatomic prognostic factors in resected nonsmall cell lung carcinoma: The importance of perineural invasion as a new prognostic marker

BACKGROUND A number of prognostic factors have been reported for resected nonsmall cell lung carcinoma. Although none of them reported to have greater prognostic impact than the TNM staging system, which is based on anatomical descriptions of tumors, the prognoses of a significant number of patients are not in agreement with real survival of the patients. Moreover, certain histopathologic properties of the tumor (such as lymphatic and vascular invasion) could help to predict the survival of the patients. METHODS A retrospective study was conducted on 82 surgically resected nonsmall cell lung carcinomas, and the following prognostic factors were evaluated in univariate analysis: age, gender, clinical and surgical-pathologic T and N status, histologic type of tumor, grade of differentiation, lymphatic invasion, vascular invasion, and perineural invasion. RESULTS Lymphatic invasion and perineural invasion of the tumor were found to be significant prognostic factors (p = 0.02 and p = 0004). Blood vessel invasion (venous or arterial involvement) had no prognostic impact (p > 0.05). According to multivariate analyses, three factors were selected as prognostic indicators: (1) clinical N status (p = 0.027), (2) lymphatic invasion (p = 0.027) and (3) perineural invasion (p = 0.0148). By combining these factors we identified a poor prognostic subgroup of patients with stage I disease. CONCLUSIONS Our study showed that lymphatic vessel and perineural invasion of the tumor could be prognostic factors, along with anatomical determinants such as cN and surgical-pathologic stage of the pulmonary carcinoma.

Prognostic Significance of Surgical-Pathologic N1 Lymph Node Involvement in Non-Small Cell Lung Cancer

BACKGROUND Patients with N1 non-small cell lung cancer represent a heterogeneous population with varying long-term survival. To better define the importance of N1 disease and its subgroups in non-small cell lung cancer staging, we analyzed patients with N1 disease using the sixth edition and proposed seventh edition TNM classifications. METHODS From January 1995 to November 2006, 540 patients with N1 non-small cell lung cancer who had at least lobectomy with systematic mediastinal lymphadenectomy were analyzed retrospectively. RESULTS For completely resected patients, the median survival rate and 5-year survival rate were 63 months and 50.3%, respectively. The 5-year survival rates for patients with hilar N1 (station 10), interlobar (station 11), and peripheral N1 (stations 12 to 14) involvement were 39%, 51%, and 53%, respectively. Patients with hilar lymph node metastasis showed a shorter survival period than patients with peripheral lymph node involvement (p = 0.02). Patients with hilar zone N1 (stations 10 and 11) involvement tended to show poorer survival than patients with peripheral zone N1 (12 to 14) metastasis (p = 0.08). Multiple-station lymph node metastasis indicated a poorer prognosis than single-station involvement (5-year survival 39% versus 51%, respectively, p = 0.01). Patients with multiple-zone N1 involvement showed poorer survival than patients with single-zone N1 metastasis (p = 0.04). A significant survival difference was observed between N1 patients with T1a versus T1b tumors (p = 0.02). Multivariate analysis revealed that only multiple-station lymph node metastasis was predictive of poor prognosis (p = 0.05). CONCLUSIONS Multiple-station versus single-station N1 disease and multiple-zone versus single-zone N1 involvement indicate poorer survival rate. Patients with hilar lymph node involvement had lower survival rates than patients with peripheral N1. The impact of T factor seemed to be veiled by the heterogenous nature of N1 disease. Further studies of adjusted postoperative strategies for different N1 subgroups are warranted.

Surgical treatment and prognosis of primitive neuroectodermal tumors of the thorax.

Introduction: Primitive neuroectodermal tumors (PNETs) are rare, rapidly progressive, small- round cell tumors with a poor prognosis despite multimodal therapy, including surgery and chemoradiotherapy. The treatment of choice was unknown since no clinical series with surgical therapy had been reported. We evaluated the impact of multimodal treatment in patients with PNETs located in the thoracic region. Methods: Between 1998 and 2006, 25 patients with PNETs in the thoracic region were treated in 3 tertiary-care hospitals. The patients consisted of 15 males and 10 females with a mean age of 27.2 years (range, 6-60). The tumor was in the chest wall in 20 (involving the costovertebral junction in 9), the lung in four, and the heart in one patient. Twelve patients received neoadjuvant chemotherapy (54.5%), and 22 of 25 patients underwent surgery. Results: In patients who received neoadjuvant treatment, the mean regression rate was 65.4% (range, 30-100%). Eighteen (82%) patients underwent chest wall resection, while 7 (32%) had vertebral resections, and the remaining 4 (16%) had pulmonary resections. A complete resection was possible in 18 of 22 patients (82%). Patients with incomplete and complete resections had 25% and 56% 5-year survival rates, respectively (p = 0.13). The progression-free 3-year survival rate was 36% and the median survival time was 13 months. The complete resection rate was significantly higher in patients receiving neoadjuvant therapy (p = 0.027). The 5-year survival rate of the patients with or without neoadjuvant therapy was 77% and 37%, respectively (p = 0.22) although it prolonged the disease-free survival (p = 0.01). The 5-year survival rate of patients without costovertebral junction involvement was 66%, whereas patients with PNETs involving the costovertebral junction had a 21% 3-year survival. The difference was statistically significant (p = 0.01). The 5-year progression-free survival rate of patients without costovertebral junction involvement was 58%, whereas patients with PNETs involving the costovertebral junction had a 14% 1-year progression-free survival (p = 0.004). Conclusions: PNET is an aggressive malignancy that often requires multimodal therapy. Induction chemotherapy leads to a greater complete resection rate and better disease-free survival, while involvement of the costovertebral junction indicates a poorer survival.

Extended cervical mediastinoscopy in the diagnosis of anterior mediastinal masses

BACKGROUND Although transthoracic needle biopsy (TNB) has been the preferred method for the diagnosis of anterior mediastinal masses, it has inherent limitations in accuracy. In particular, lymphoma and thymoma are diagnosed less reliably using needle biopsy. Videothoracoscopy has been advocated as an alternative method for diagnosis. Our goal was to assess the usefulness of extended cervical mediastinoscopy (ECM) in the diagnosis of anterior mediastinal masses. METHODS The ECM technique was performed in 9 patients in whom TNB and Tru-cut biopsies had been inefficient for histologic diagnosis. All lesions were in the anterior mediastinum. Extended cervical mediastinoscopy was carried out using the same incision as in a standard cervical mediastinoscopy and dissection was performed behind the sternum as previously published. Mean operative time was 50 minutes (range 40 to 70 minutes) and mean hospital stay was 8 hours (range 5 to 36 hours). RESULTS Diagnosis of lymphoma in 4 cases, thymoma in 3 cases, and thymic hyperplasia in 2 cases were obtained by ECM. In 1 of 2 patients with suspected thymoma who underwent resectional surgical procedures, final histologic diagnosis was non-small cell lung carcinoma. There was no surgical mortality or intraoperative complication. One patient had minimal pneumothorax requiring no intervention. CONCLUSIONS We conclude that ECM in the diagnosis of anterior mediastinal masses is technically feasible and provides an alternative to the conventional approaches in patients with paraaortic or aortopulmonary masses.

Prompt surgery for massive hemoptysis: more acceptable than it was reported.

We read with interest the article by Jougon et al. [1] concerning the treatment of massive hemoptysis. The authors reported a mortality rate of 23% in patients who were operated on immediately close to bleeding crise. There were six pneumonectomies and six lobectomies in this group. In massive hemoptysis patients, prompt lateralization, localization and appropriate surgical intervention are of pivotal importance and may lead to acceptable mortality rates. We reviewed our experience in 29 patients with massive hemoptysis (.600 ml/24 h). We performed 17 lobectomies (58.6%), five pneumonectomies (17.2%), three segmentectomies and three bilobectomies and one physiologic lung exclusion. Two patients had been resuscitated and intubated in the emergency department. Following rigid bronchoscopy and aspiration of blood clotting and fresh blood, emergency intubation and lung isolation using onelung intubation or double-lumen intubation tube were accomplished. During the operation, the lung or part of the lung (lobe or segment) from which the intrabronchial hemorrhage originated could be localized in 27 patients (93.1%), by a localized radiologic appearance, emergency endoscopy or combination of these techniques and could be confirmed by bronchotomy to the bronchus of the suspected part of the lung (segment or lobe) or lung itself (i.e. bronchus first method). Probably due to having known the localization of the bleeding site in most patients, we only experienced 11.5% of mortality (i.e. three patients). We also believe that, delay in the surgical treatment (in tomographic examination, observation) of the patients with massive hemoptysis leads to exanguination and higher mortality and morbidity rates. Previously, when the initial treatment of massive hemoptysis has been believed to be medical, the mortality rate was reported to be as high as 50–85% [2]. Similarly, the authors found the mortality rate of non-surgically treated patients (i.e. Group 3) to be 26% which could be considered to be fairly high. In their series, a suboptimal effort to localize the bleeding site and delay in emergency surgery possibly due to the computerized tomography (CT) and pulmonary function test analyses might lead to the higher mortality rate (i.e. 23%) in the immediate surgery group (i.e. Group 1). Gourin and Garzon recommended prompt surgical resection for any individual who has bled more than 600 ml in 24 h or less [3]. This approach also decreases the number of pneumonectomies since rigid bronchoscopic evaluation during active bleeding provides better localization of hemorrhage in the lung. In patients in whom the site of bleeding was seen but the exact involved lobe was not identified using rigid bronchoscopy, bleeding lobe can be found via a small bronchotomy near to the suspected lobar carina. In our series we also found that, the advantage of immediate surgery outweighed the risk of not knowing the pulmonary function test and computed tomographic image of the lungs since the airway obstruction and exanguination of the patient are the major lethal elements in patients with massive hemoptysis. The authors recommended an immediate operation in case of pulmonary vessels hemorrhage and they also stated the difficulty in discrimination between pulmonary and bronchial vessel bleeding. In our series, all patients except six were followed-up for at least 1-year (range, 1–6 years) and we recorded only one patient with recurrence that required a completion pneumonectomy. We believe that, emergency surgical pulmonary resection following rigid bronchoscopy is a life-saving procedure with acceptable mortality and morbidity rate in all patients with massive hemoptysis.

Physiological exclusion for massive hemoptysis: when?

We read with interest the article by Dhaliwal and associates [1] describing the role of physiological lung exclusion in difficult lung resections for massive hemoptysis. Their conclusions “physiological lung exclusion is a safe and effective method for control of massive hemoptysis in cases where lung resection is technically hazardous or difficult” were assiduitied by us. We would like to share our experience about massive hemoptysis with the readers of the Journal. We have performed 27 lung resections in the past 8 years (one pneumonectomy, 26 lobectomies) in whom the blood loss was more than 600 ml/24 h. We excluded the percutaneous bronchial embolization patients. Diagnostic evaluation of these patients was done with a chest roentgenogram and computerized tomography of the thorax. Rigid bronchoscopy was performed in 24 of them before operation. Two patients (7.40%) died in the postoperative period, one patient required mechanical ventilation for 62 days and three patients (11.11%; including a mechanically ventilated patient) developed postlobectomy empyema and bronchopleural fistula. The pathological records demonstrated pulmonary tuberculosis in ten patients (three of them were multidrug resistant), pulmonary hemorrhagic syndrome in seven patients, bronchiectasis in three patients, pulmonary vasculitis in three patients, aspergillosis in three patients and lung cancer in one patient. We performed a physiological lung exclusion considering the experience of Dr Dhaliwal and associates. The patient was a 38-year-old man who had been treated for pulmonary tuberculosis. Acid resistant bacteria were present in the sputum. He had hemoptysis of 1400 ml/day. He was hemodynamically unstable (hematocrit, 20%; T/A, 80–40 mmHg; pulse was arrhythmic, 120/min) and desaturated (saturation, 84%). Rigid bronchoscopy revealed that the bleeding was from the origin of the right upper lobe bronchus. A posterolateral thoracotomy was performed, very tight calcific pleural adhesions were noticed. It would have taken a long time to mobilize the lung and hilus. Posteriorly, we identified the upper lobe bronchus and stapled. We prepared the fissure and ligated the major pulmonary arterial vessels to right upper bronchus. During these maneuvers, 4 units of blood were transfused and the Htc was still 18%. It would have been dangerous to mobilize the fixed upper lobe to the apex of the thorax. Two standard pleural drainages were employed and the thoracotomy was closed. He was mechanically ventilated for 6 h. The patient had an uneventful postoperative course and was discharged on postoperative day 10. Radiologically, a shrunk lobe was present in the apical region. We do not offer such an operation for a standard massive hemoptysis patient. However, we believe that physiological exclusion of the lung could be applicable in cases of: (1), really tight pleural adhesions which would increase the operating time and would cause more bleeding; (2), desaturated patients; (3), hemodynamically unstable patients. We strictly do not offer such an operation for lung cancer patients, stable patients and technically feasible resections. Non-surgical candidates could have bronchial embolization. Physiological lung exclusion for massive hemoptysis should be kept in mind as an alternative.

Radical resection of a giant recurrent chondrosarcoma of the anterior chest wall

A 63-year-old woman presented with a giant anterior chest wall tumor. She had undergone an operation 5 years previously for sternal chondrosarcoma at another medical center. Here, the patient underwent further surgery: a radical en bloc resection of an 18 × 18 cm portion of her anterior chest wall was performed, including the proximal ends of both clavicles, the first three costochondral joints bilaterally, and the tumor mass. The large chest wall defect was reconstructed in two layers: the first with a polypropylene mesh and a pedicled latissimus dorsi muscle flap as the second. She is healthy 20 months postoperatively.