Bedrettin Yildizeli

Sleeve Lobectomy for Bronchogenic Cancers: Factors Affecting Survival

BACKGROUNDnSleeve lobectomy is a parenchyma-sparing procedure that is particularly valuable in patients with cardiac or pulmonary contraindications to pneumonectomy. The purpose of this study is to report our experience with sleeve lobectomy for bronchogenic cancer and to investigate factors associated with long-term survival.nnnMETHODSnBetween January 1981 and June 2001, 169 patients underwent sleeve lobectomy for non-small-cell lung cancer (n = 139) or carcinoid tumor (n = 30), including 61 with a preoperative contraindication to pneumonectomy. Mean age was 59 +/- 14 years (range, 19 to 82 years). Vascular sleeve resection was performed in 11 patients. The remaining bronchial stump contained microscopic disease in 7 patients.nnnRESULTSnMajor bronchial anastomotic complications occurred in 6 (3.6%) patients: one was fatal postoperatively, three required reoperation, and two were managed conservatively. In the non-small-cell lung cancer group, operative mortality was 2.9% (4 of 139), and overall 5-year and 10-year survival rates were 52% and 28%, respectively. Six patients experienced local recurrence after complete resection. By multivariate analysis, two factors significantly and independently influenced survival: nodal status (N0 or N1 versus N2; p = 0.01) and microscopic invasion of the bronchial stump (p = 0.02). In the carcinoid tumor group, there were no operative deaths, and overall 5-year and 10-year survival rates were 100% and 92%, respectively.nnnCONCLUSIONSnSleeve lobectomy achieves local tumor control and is associated with low mortality and bronchial anastomotic complication rates. Long-term survival is excellent for carcinoid tumors. For patients with non-small-cell lung cancer, N2 disease or incomplete resection is associated with a worse prognosis; outcome is not affected by presence of a preoperative contraindication to pneumonectomy.

Complications and management of long-term central venous access catheters and ports.

Purpose Although prolonged venous access devices (PVADs) are used in case prolonged intravenous therapy is required, implantation and use of these devices is associated with complications. The purpose of this study was to evaluate perioperative and long-term complications associated with PVADs and the management of these complications. Methods A retrospective review was undertaken of 225 PVADs implanted in 217 patients from February 1993 to June 2004. This included 144 single-lumen port infusion systems, 49 single-lumen Hickman® catheters and 32 double-lumen Groshong® catheters. The PVADs were inserted using either the percutaneous Seldinger method (n=183) or cutdown access to the subclavian vein (n=42). Indications for placement were as follows: chemotherapy in 66.2% of patients, drug-infusion treatment in 31.6% of patients and total parenteral nutrition in 2.2% of patients. Results Perioperative complications occurred in 13 patients (5.7%): catheter malposition in seven patients (3.1%), pneumothorax in three patients (1.3%), hemorrhage in two patients (0.9%) and catheter embolization in one patient (0.4%). Long-term complications appeared in 15 patients (6.6%): infection in five patients (2.2%), thrombosis in three patients (1.3%), extravasation in three patients (1.3%), and catheter fracture in four patients (1.8%). The fractured fragments were removed by the Amplatz® snare device. In 10 patients (4.4%) only were PVADs removed prior to completion of the intended therapy. Indications for removal were catheter infection in five patients (2.2%) and catheter fracture in five patients (2.2%). Conclusions PVAD implantation is associated with some risk of serious perioperative and long-term complications. Care of the catheter and the patient should be maintained with the proper and immediate evaluation of the perioperative and long-term complications.

Results of Primary Surgery With T4 Non–Small Cell Lung Cancer During a 25-Year Period in a Single Center: The Benefit is Worth the Risk

BACKGROUNDnThe purpose of this study was to assess operative mortality, morbidity, and long-term results of patients with surgically resected T4 non-small cell lung carcinoma.nnnMETHODSnA retrospective review of 271 patients with T4 non-small cell lung carcinoma between 1981 and 2006 was undertaken. They were divided into four subgroups: 126 patients with superior sulcus tumors, 92 with carinal involvement, 39 with superior vena cava replacement, and 14 with the tumor invading other mediastinal structures. There were 221 men and 50 women with a mean age of 56.3 years. Resection was complete in 249 (92%) patients. The pathologic N status was N0/N1 in 208 and N2/N3/M1 in 63 patients.nnnRESULTSnOperative mortality and morbidity rates were 4% and 35%, respectively. Overall 5-year survival rate was 38.4%. It was 36.6% for superior sulcus tumor, 42.5% for carinal involvement, 29.4% for superior vena cava replacement, and 61.2% for mediastinal group. By multivariate analysis, only three factors influenced survival: nodal status (N0/N1 versus N2/3/M1; 43% versus 17.7% at 5 years, respectively; p = 0.01), complete resection (R0 versus R1; 40.4% versus 15,9%, respectively; p = 0.006), and invasion of the subclavian artery (with versus without invasion; 24.9% versus 41.7%, respectively, p = 0.02).nnnCONCLUSIONSnIn highly qualified centers, radical surgery of T4 N0/N1 non-small cell lung carcinoma can be performed with a 4% mortality rate and may yield a 43% 5-year survival rate. These results seem to indicate primary surgery as the treatment of choice for T4 non-small cell lung carcinoma, whenever a complete resection is thought to be technically feasible and the patients condition is compatible with the extent of the planned surgery.

Trimodality Treatment of Malignant Pleural Mesothelioma

Introduction: Multimodality treatment has achieved significant success in local control and treatment of early-stage malignant pleural mesothelioma patients. However, its favorable effect on survival is questionable. Methods: We have instituted a trimodality treatment protocol consisting of extrapleural pneumonectomy, adjuvant high-dose (54 Gy) hemithoracic irradiation, and platin-based chemotherapy in a multi-institutional setting. Preoperative pulmonary function tests, echocardiogram, chest computed tomography, and magnetic resonance imaging scans were performed in all patients. Twenty patients have been treated with this protocol during 2003–2007. Seventeen had a history of environmental asbestos/erionite exposure. Clinical stages were T1-3N0-2. Results: Median age was 56 (41–70, 8 female). There was one postoperative mortality (% 5) due to ARDS. Morbidity occurred in 11 patients (% 55). Histology was epithelial in 17, mixed in 2, and sarcomatoid in 1. Sixteen patients underwent extrapleural pneumonectomy. Microscopic margin positivity was present in 14 patients with macroscopic complete resection. Twelve patients completed all three treatments. Median follow-up was 16 months (1–43). Overall median survival was 17 months (24% at 2 years). Eight patients had extrapleural lymph node involvement (internal mammary [n = 3], subcarinal [n = 2], pulmonary ligament [n = 1], diaphragmatic [n = 1], subaortic [n = 1]). There was better survival in patients without lymph node metastasis (24 versus 13 months median survival, p = 0.052). Currently, 7 patients are alive, 6 without recurrence, and 2 patients at 40 and 45 months. Conclusions: Trimodality treatment in malignant pleural mesothelioma seems to prolong survival in patients without lymph node metastasis. Novel techniques are needed for preoperative assessment of extrapleural lymph nodes.

Factors affecting early and long-term outcomes after completion pneumonectomy

OBJECTIVEnTo identify factors that affect operative mortality and morbidity and long-term survival after completion pneumonectomy.nnnMETHODSnWe retrospectively reviewed the charts of consecutive patients who underwent completion pneumonectomy at our cardiothoracic surgery department from January 1996 to December 2005.nnnRESULTSnWe identified 69 patients, who accounted for 17.8% of all pneumonectomies during the study period; 22 had benign disease and 47 malignant disease (second primary lung cancer, n=19; local recurrence, n=17; or metastasis, n=11). There were 50 males and 19 females with a mean age of 60 years (range, 29-80 years). Postoperative mortality was 12% and postoperative morbidity 41%. Factors associated with postoperative mortality included obesity (p=0.005), coronary artery disease (p=0.03), removal of the right lung (p=0.02), advanced age (p=0.02), and renal failure (p<0.0001). Preoperative renal failure was the only significant risk factor for mortality by multivariate analysis (p=0.036). Bronchopleural fistula developed in seven patients (10%), with risk factors being removal of the right lung (p=0.04) and mechanical stump closure (p=0.03). Overall survival was 65% after 3 years and 46% after 5 years. Long-term survival was not affected by the reason for completion pneumonectomy.nnnCONCLUSIONnAlthough long-term survival was acceptable, postoperative mortality and morbidity rates remained high, confirming the reputation of completion pneumonectomy as a challenging procedure. Significant comorbidities and removal of the right lung were the main risk factors for postoperative mortality. Improved patient selection and better management of preoperative renal failure may improve the postoperative outcomes of this procedure, which offers a chance for prolonged survival.

Isolated primary chylopericardium.

Isolated primary chylopericardum is known to be a rare clinical entity. A 17-year-old girl was diagnosed as isolated primary chylopericardium. She was unresponsive to conservative treatment with pericardial tube drainage and medium chain triglyceride diet. At 2 weeks after the conservative treatment, ligation and resection of the thoracic duct with establishment of a pericardial window through a left thoracotomy was performed. At 6 months, follow-up showed no accumulation of the pericardial fluid. This case also supports that ligation and resection of the thoracic duct with establishment of a pericardial window is the treatment of choice in isolated primary chylopericardium.

Histopathologic effects of lipid content of enteral solutions after pulmonary aspiration in rats

OBJECTIVEnWe compared the pulmonary histopathologic effects of different enteral formulas with various lipid contents during the subacute period of aspiration in rats.nnnMETHODSnFifty Wistar albino rats, weighing 180 to 300 g, were randomly assigned to one of five groups (n = 10). Anesthesia was induced with an intraperitoneal injection of 100 mg/kg of ketamine hydrochloride, rats were intubated endotracheally with a 16-gauge angiocatheter, and 0.9% saline (group 1, control), Impact (group 2), Jevity (group 3), Biosorb Energy Plus (group 4), or Pulmocare (group 5) with a lipid content of 0, 28, 39.3, 58, or 93.3 g/L, respectively, was injected into the lungs in a volume of 3 mL/kg. Seven days later, rats were killed, and lungs with trachea were removed en bloc for histopathologic examination. For histopathologic assessment, slides were examined for the presence of peribronchial inflammatory cell infiltration, alveolar septal infiltration, alveolar edema, alveolar exudate, alveolar histiocytes, interstitial fibrosis, granuloma, and necrosis formation. The degree of severity was assessed by using a 4-point scale. One-way analysis of variance and Student-Newman-Keuls test were used for statistical analysis.nnnRESULTSnPeribronchial inflammatory cell infiltration was present in all groups but was significantly more severe in group 2 than in groups 1, 4, and 5 (P < 0.05). Alveolar edema was statistically higher in group 2 than in group 1 (P < 0.05). Alveolar septal infiltration was statistically higher in group 4 than in group 1. Alveolar histiocytes were statistically higher in groups 2 and 3 (P < 0.01) and groups 4 and 5 (P < 0.05) than in group 1. Alveolar exudate, interstitial fibrosis, granuloma, and necrosis formation were absent in all groups.nnnCONCLUSIONnThe pulmonary histopathologic effects of aspiration of Impact were severe peribronchial inflammatory cell infiltration (greater than aspiration of Biosorb and Pulmocare), abundant alveolar histiocytes, and alveolar edema in comparison with aspiration of saline, even though Impact had the lowest lipid content of all studied formulas. We concluded that the tissue damage occurring after pulmonary aspiration of Impact is more severe than after aspiration of Pulmocare.

Effect of the amount of intraoperative fluid administration on postoperative pulmonary complications following anatomic lung resections

OBJECTIVEnExcessive fluid administration during lung resections is a risk for pulmonary injury. We analyzed the effect of intraoperative fluids on postoperative pulmonary complications (PCs).nnnMETHODSnPatients who underwent anatomic pulmonary resections during 2012 to 2013 were included. Age, weight, pulmonary function data, smoking (pack-years), the infusion rate and the total amount of intraoperative fluids (including crystalloid, colloid, and blood products), duration of anesthesia, hospital stay, PCs, and mortality were recorded. PCs were defined as acute respiratory distress syndrome, need for intubation, bronchoscopy, atelectasis, pneumonia, prolonged air leak, and failure to expand. Univariate analyses and multivariate logistic regression were performed. A Lowess curve was drawn for intraoperative fluid threshold.nnnRESULTSnIn 139 patients, types of resections were segmentectomy-lobectomy (nxa0=xa069; extended nxa0=xa037; video-assisted thoracoscopic surgery nxa0=xa019) and pneumonectomy (nxa0=xa09; extended nxa0=xa05). One hundred sixty-one PCs were observed in 76 patients (acute respiratory distress syndrome [nxa0=xa05], need for intubation [nxa0=xa09], atelectasis [nxa0=xa060], need for bronchoscopy [nxa0=xa019], pneumonia [nxa0=xa026], prolonged air leak [nxa0=xa019], and failure to expand [nxa0=xa023]). Overall mortality was 4.3% (6 out of 139 patients). Mean hospital stay was 8.5 ± 4.8xa0days. Univariate analyses showed that smoking, intraoperative total amount of fluids, crystalloids, blood products, and infusion rate as well as total amount of crystalloids and infusion rate during the postoperative first 48xa0hours were significant for PCs (Pxa0=xa0.033, Pxa0<xa0.0001, Pxa0=xa0.001, Pxa0=xa0.03, Pxa0<xa0.0001, Pxa0=xa0.002, and Pxa0<xa0.0001, respectively). In multivariate logistic regression analysis intraoperative infusion rate (Pxa0<xa0.0001) and smoking were significant (Pxa0=xa0.023). An infusion rate of 6 mL/kg/h was found to be the threshold.nnnCONCLUSIONSnThe occurrence of postoperative PCs is seen more frequently if the intraoperative infusion rate of fluids exceeds 6 mL/kg/h.

Adoption of pleurectomy and decortication for malignant mesothelioma leads to similar survival as extrapleural pneumonectomy

OBJECTIVEnWe changed our surgical approach to malignant pleural mesothelioma (MPM) in August 2011 and adopted pleurectomy and decortication (PD) instead of extrapleural pneumonectomy (EPP). In this study, we analyzed our perioperative and survival results during the 2 periods.nnnMETHODSnAll patients who underwent surgical intervention for MPM during 2003-2014 were included. Data were retrospectively analyzed from a prospective database. Before August 2011, patients underwent evaluation for EPP and adjuvant chemoradiation (group 1). After August 2011, patients were evaluated for PD and adjuvant chemotherapy and/or radiation (group 2). Demographic characteristics, surgical technique, histology, side, completeness of resection, and types of treatments were recorded. Statistics was performed using Student t test, χ(2) tests, uni- and multivariate regression, and Kaplan-Meier survival analysis.nnnRESULTSnThe same surgical team operated on 130 patients. Median age was 55.7 years (range, 26-80 years) and 76 were men. EPP and extended PD was performed in 72 patients. Ninety-day mortality was 10%. Median survival was 17.8 months with a 5-year survival rate of 14%. Uni- and multivariate analyses showed that epithelioid histology, stage N0, and trimodality treatment were associated with better survival (P = .039, P = .012, and P < .001, respectively). Demographic variables and overall survival (15.6 vs 19.6 months, respectively) were similar between the groups, whereas nonepithelioid histology, use of preoperative chemotherapy, and incomplete resections were more frequent in group 2 (P < .001, P < .001, and P = .006, respectively). Follow-up was shorter in group 2 (22.5 ± 20.6 vs 16.4 ± 10.9 months; P < .001).nnnCONCLUSIONSnAdoption of PD as the main surgical approach is not associated with survival disadvantage in the surgical treatment of MPM.

Epithelioid hemangioendothelioma with multiple organ involvement

Epithelioid hemangioendothelioma is a rare vascular neoplasm of uncertain malignant potential. Various reports document metastatic or concurrent epithelioid hemangioendothelioma in several sites, most commonly with combined lung and liver involvement. The concurrent involvement of multiple sites at presentation may cause diagnostic problems because epithelioid hemangioendothelioma can mimic other neoplastic processes. Although it is a chemoresistant disease, chemotherapy is usually advised for patients with metastatic or concurrent involvement. Here we document the presentation, treatment, and outcome of two cases with concurrent involvement of the lung and liver.