Bayram Altuntas

Morgagni Hernia: Transabdominal or Transthoracic Approach ?

Abstract Background : Morgagni hernias are rare and constitute less than 2% of all diaphragmatic hernias. Treatment is primarily surgical and transthoracic or transabdominal route approach methods are amenable. In this study, we compared the results of our Morgagni hernia cases, which underwent either transabdominal or transthoracic method of surgery. Methods : We retrospectively analyzed the records of 20 patients we operated on for Morgagni hernias between 1997 and 2011 in our clinic. Age, sex, presenting symptoms, lesion location, diagnoses, applied surgical method, duration of the hospital stay, morbidity and mortality rates were reviewed. Six of the cases were (30%) approached via thoracotomy and 14 (70%) were laparotomy. The hernial sac was resected in all cases. Diaphragmatic defects were repaired using nonabsorbable sutures in all cases except in one case where prolen mesh used. Results : Thirteen cases (65%) were female and seven (35%) were male. Mean age was 44.1 ± 25.3 years (1–73 years). Hernias were located on the right side in 18 cases, the left side in one, and bilaterally located in one case. Herniated organs were: omentum in 19 (95%), transverse colon in 18 (90%), small bowel in 4 (20%), stomach in 3 (15%), and left lobe of the liver in one (5%) case. No complication was observed in patients who underwent laparotomy, and wound infection occurred in one patient who underwent thoracotomy. Hospital stays in thoracotomy and laparotomy groups are 7 and 6.2 days, respectively. There were no mortalities observed. There was no recurrence during the follow-up of 36.4 months (10–116 months). Conclusion : Our findings showed that both surgical methods have similar and satisfactory results. Although transthoracic approach was preferred in previous cases, the transabdominal approach was preferred in later ones because we assumed that the later procedure is less invasive for the patient. We prefer and propose the abdominal approach for the surgical management of Morgagni hernias.

Complications of tracheobronchial foreign bodies.

BACKGROUND/AIM Tracheobronchial foreign bodies may cause several complications in the respiratory system. We aimed to present the complications of tracheobronchial foreign bodies. MATERIALS AND METHODS Between January 1990 and March 2015, 813 patients with suspected tracheobronchial foreign body aspiration were hospitalized in our department. Patients with complications related to foreign bodies in airways were included in this study. We retrospectively evaluated the records of patients according to symptoms, foreign body type, localizations, and complications. RESULTS A foreign body was found in 701 of 813 patients (86.2%). Complications related to foreign bodies settled in airways were seen in 96 patients (13.7%). The most common complications were atelectasis and pneumonia in 36 (5.1%) and 26 (3.7%) patients, respectively. Other complications were bronchiectasis (n = 12, 1.7%), cardiopulmonary arrest (n = 11, 1.6%), bronchostenosis (n = 3, 0.4%), death (n = 2, 0.3%), migration of foreign body (n = 2, 0.3%), pneumomediastinum (n = 2, 0.3%), tracheal perforation (n = 1, 0.15%), pneumothorax (n = 1, 0.15%), and hemoptysis (n = 1, 0.15%). Coughing (n = 74, 77.1%) and diminished respiratory sounds (59.3%, n = 57) were the most common findings. CONCLUSION Careful evaluation and rapid intervention are life-saving methods in tracheobronchial foreign body aspirations.

Primary Endoscopic Repair of a Large Tracheal Rupture Through Tracheal Stoma.

We describe the case of an 83-year-old man who presented with a large trauma to the membranous wall of the trachea and was treated with endoscopic primary repair of the tracheal wall through a preexisting tracheal stoma. Assessment with an optical telescope through the tracheal stoma revealed a 5-cm laceration in the membranous wall of the trachea starting immediately above the carina. The laceration was closed using continuous 4-0 monofilament polydioxanone sutures with direct visualization of tissues through a fiberoptic telescope. This approach is particularly effective in cases of traumatic rupture of the membranous trachea.

Role of Prolene Mesh in Late Postpneumonectomy Empyema: Esophageal Pleural Fistula

Apatient, who had undergone left pneumonectomy for bronchial carcinoma 6 years previously, presented to our clinic with halitosis, fever, loss of appetite, and weight loss that had occurred within the last 3 months. A chest roentgenogram showed air-fluid level in the pneumonectomy space (Fig 1). Thoracic computed tomography revealed fluid in the pneumonectomy space and a mass on the lateral thoracic wall. The patient underwent chest puncture, through which a purulent fluid sample was obtained. A chest tube was then placed and purulent fluid was drained. A chest roentgenogram obtained after the drainage clearly showed the presence of a mass on the left chest wall. These findings suggested the presence of bronchopleural fistula in the pneumonectomy pouch and tumor recurrence. On bronchoscopy, the bronchial stump had a normal appearance and there was no tumor recurrence and fistula. After confirmation of the absence of bronchopleural fistula, empyema was treated using daily active irrigation by chest tube. After the regression of infectious signs, a single-port videoassisted thoracoscopic surgical procedure was performed and examination of the pneumonectomy space, debride-

Video-Assisted Thoracoscopic Surgery Is Safe and Effective in the Treatment of Pulmonary Hydatid Cyst

We thank Dr Korun for his comments [1] and are largely in agreement. Perhaps our effort at brevity and efficiency in the discussion section [2] failed to disclose why the analysis suggested by Dr Korun was not reported in the article. At the outset, our goal was to evaluate a cohort defined exclusively by intrauterine growth restriction (IUGR) status. Our challenge of course was how best to select a control group. We considered a consecutive series of patients encompassing the IUGR cohort and the use of multivariate analysis, controlling for several potentially important variables as well as weight at operation. Such an approach may have enabled the type of analysis suggested by Dr Korun. This of course introduced certain practical constraints given the period spanned by the IUGR cohort and the inclusion of all consecutive non-IUGR patients during this period (a tremendous amount of data) versus some method of exclusion of certain control patients and hence the potential introduction of bias based on the exclusion process. The matched cohort approach seemed to be a reasonable solution. However, to maintain rigor in the statistical analysis, we judged it important to adhere to the planned design and applicable statistical constraints. Nevertheless, we informally attempted to discern the effects of prematurity and weight through several post hoc analyses. Our biostatisticians expressed concern about reporting these for 2 reasons: (1) intrinsic weakness of post hoc analyses and (2) probably more importantly, the limited numbers of patients in given strata and concern that a significant or nonsignificant result may simply be incorrect and lead to transmission of false information. We therefore limited our comments to the speculation that IUGR likely has an independent effect, perhaps with diminishing impact at the lower extremes of prematurity and weight. Discerning the independent effects of IUGR, prematurity, and low weight will undoubtedly require a much larger cohort and a study designed specifically for this goal.

A Minimally Invasive Surgery for Thoracic Esophageal Diverticula

We read with great interest the case series by Macke and colleagues [1], who retrospectively reported the results of 57 patients with thoracic esophageal diverticula. Esophageal diverticulum is not a common problem, so experience with the minimal approach to its management has been slow to accumulate. Their case series has provided an important contribution to the literature. We congratulate the authors for their excellent article. First, in this largest experience reported to date in 57 cases, there were six leaks, and a 10.5% leakage rate is higher than in the series with open surgery. Despite improvements in surgical technique, we believe this rate is still high. We wonder what can be done to reduce the leakage rate. It is also important to cover the staple line with reapproximation of muscle or pleura over the diverticulectomy site; this may reduce the leak rate. Second, there seems to be a move away from the thoracoscopic approach to the laparoscopic approach for a distal third diverticulum. We wonder whether the authors have experience in this procedure. Which approach was the majority? The technique of operation (video-assisted thoracoscopic surgery, laparoscopy, or combined) should be detailed in this report. Third, all patients in the present series were symptomatic. Asymptomatic patients with small diverticula can be closely observed, but large diverticula and associated motor dysfunction should be considered for surgery. Serious complications, such as tracheal fistula, hemorrhage, vocal cord paralysis, and retained foreign body, may occur. Fourth, the association of cancer and diverticula has been described. Carcinogenesis in an esophageal diverticulum is probably linked to stasis, similar to achalasia, which has a comparable index of malignant degeneration. The risk of malignant degeneration may be taken into account for the therapeutic decision as the diverticulum is not resected. We could not find any information about malignancy in this article. Is there any report analyzing whether the patient has any malignancy in the preoperative or postoperative period? Was histopathologic examination performed on the removed diverticulum? We recommend longterm follow-up in treated and untreated patients for malignancy. A minimally invasive approach for esophageal diverticula offers reduced operative mortality, decreased length of hospital stay, and relief of similar symptoms compared with open surgery performed by experienced hands.

Azygous Vein Flap Is a Good Alternative for Bronchial Stump Reinforcement

We read with great interest the case report by Wilson and colleagues [1] of a patient in whom the right inferior pole of the thymus was used to prevent bronchopleural fistula after upper lobectomy. Bronchopleural fistula is 1 of the most important causes of mortality after lung resections. The bronchial stump can be supported by various tissues such as intercostal and latissimus muscles, parietal pleura, diaphragm, pericardial fat pad, thymus, and azygous vein flap to prevent bronchopleural fistula. An azygous vein flap is a good alternative for this purpose when other tissues are useless, especially after right upper lobectomy because the azygous vein is just above the right upper lobe bronchus, and its dissection and preparation is very easy [2]. The authors’ report has provided an important contribution to the literature about bronchial stump reinforcement. Although a thymic flap seems a good alternative for bronchial stump reinforcement after lobectomy, it usually has been used after pneumonectomy [3]. In this case, we think that an azygous vein flap is a better option than the thymic flap because its preparation is simpler, and the tissue closest to the upper lobe bronchus is the azygous vein. Furthermore, we have some concerns about whether this tissue is completely thymic tissue. Because thymic tissue is largely replaced by adipose tissue in elderly individuals, the bronchial stump may be supported by mediastinal adipose tissue rather than thymic tissue.

Simultaneous Esophageal and Tracheal Fistulization Resulting From Pott’s Abscess

We describe a case of a 30-year-old woman who presented with a complaint of coughing while drinking water, which began 2 months earlier and was treated with surgical repair of esophageal and tracheal fistulization that resulted from a Potts abscess. The patient had been diagnosed with pulmonary tuberculosis 4 years previously and had been treated for 6 months. Esophageal and tracheal fistulization of the abscess cavity was observed both radiologically and intraoperatively. The fistulas were closed through separate operations for the trachea and the esophagus. Simultaneous esophageal and tracheal fistulization of a Potts abscess is a serious complication of spinal tuberculosis that has not been previously reported in the literature.

Complete Right Main Bronchus Rupture in a Child: Report of a Case

DOI: 10.4328/JCAM.1056 Received: 30.04.2012 Accepted: 15.05.2012 Printed: 01.05.2015 J Clin Anal Med 2015;6(3): 387-8 Corresponding Author: Bayram Altuntas, Regional Education and Reserach Hospital, Department of Thoracic Surgery 25000, Erzurum, Turkey. E-Mail: draltuntas@hotmail.com Ozet Ana brons rupturu ile sonuclanan kunt gogus travmalari oldukca nadirdir ve muhtemelen yuksek bir hastane oncesi mortaliteye sahiptir.. Bu yaralanmalar, solunum zorlugu ve eslik eden yaralanmalardan dolayi yuksek oranda mortaliteye sahiptir. Alti yasinda erkek cocugu, kunt toraks travmasindan dolayi klinigimize kabul edildi. Baska bir merkezde sag pnomotoraks nedeniyle tup torakostomi uygulanan hasta yetersiz akciger ekspansiyonu nedeniyle klinigimize refere edilmis. Fizik muayenede orta duzeyde interkostal retraksiyon, tasipne ve siyanoz mevcuttu. Gelis anindaki direkt akciger grafisinde sagda total pnomotoraks vardi ve hilus inferiora yer degistirmisti. Hastaya rijid bronkoskopi yapildi ve sag ana bronsta total ruptur goruldu. Hastaya sleeve ust lobektomi yapildi. Brons rupturlerinde erken tani ve tedavinin onemini vurgulamayi amacladik.