Berker Ozkan

Rocuronium and sugammadex in patients with myasthenia gravis undergoing thymectomy

The use of neuromuscular blocking agents is still controversial in myasthenic patients but rocuronium could be useful after the introduction of sugammadex as a selective antagonist. The aim of the study was to evaluate the use of rocuronium‐sugammadex in myasthenic patients undergoing thoracoscopic thymectomy.

Robotic and video-assisted thoracic surgery lung segmentectomy for malignant and benign lesions

OBJECTIVES The experience with robotic techniques (RATS) and video-assisted thoracic surgery (VATS) in pulmonary segmentectomy is still limited. We evaluated our prospectively recorded database to compare two different minimally invasive techniques. METHODS Between May 2007 and July 2014, a total of 99 patients underwent RATS (n = 34) and VATS (n = 65) pulmonary segmentectomies at two institutions. The median age of patients was 59 ± 15 (16-84) years, and 61% were male. Seventy-six patients were operated on for malignancy and 23 for benign diseases. RESULTS The major morbidity and mortality rates were 24-23% and 0-1.5% for RATS and VATS (P = 0.57) and (P = 0.66), respectively. The mean console time for RATS was longer than the mean operation time for VATS [76 ± 23 (40-150) vs 65 ± 22 (30-120) min (P = 0.018)]. The mean duration of drainage was similar for RATS and VATS [3.53 ± 2.3 (1-10) days vs 3.98 ± 3.6 (1-21) (P = 0.90)], respectively. The duration of postoperative stay for RATS was 4.65 ± 1.94 (2-10) days and for VATS was 6.16 ± 4.7 (2-24) days (P = 0.39). CONCLUSIONS Both RATS and VATS pulmonary segmentectomy operations are performed with similar morbidity and mortality rates. Although the duration of operation is longer in RATS when compared with an established VATS programme, there is a tendency towards a shorter postoperative stay.

Early outcomes of video-assisted thoracoscopic resection of thymus in 181 patients with myasthenia gravis: who are the candidates for the next morning discharge?

The aims of this study are to present the results of videothoracoscopic thymectomy in patients with myasthenia gravis (MG) and to predict the factors affecting the next morning discharge (NMD). This is a retrospective analysis of the prospectively recorded data of 181 consecutive myasthenic patients who underwent videothoracoscopic thymectomy from June 2002 to September 2009. Sixty-one patients (33.7%) were discharged on the next morning. Univariate and multivariate analyses were evaluated to determine the predictors for NMD. Mean calculated variables were: age (29.8 years), duration of symptoms (22.5 months), duration of surgery (51.3 min), postoperative stay (2.1) days, and visual analogue scale (2.1). No mortality occurred. Four patients were required to stay in intensive care unit (ICU) with a mean of 18.6 h. With logistic regression analysis, duration of operation (DoO) was calculated to be the only predictive factor for NMD (P=0.006). Video-assisted thoracoscopic thymectomy (VAT thymectomy) is a safe surgery procedure with a smooth postoperative period for MG. Although a detailed analysis was performed, only DoO was found to be a predictive factor for NMD in MG patients.

Alternative paratracheal lymph node dissection in left-sided hilar lung cancer patients: comparing the number of lymph nodes dissected to the number of lymph nodes dissected in right-sided mediastinal dissections

OBJECTIVE Removing or sampling lymph nodes from the bilateral paratracheal area through a left thoracotomy is not a standard procedure in patients with lung cancer. The aim of this study was to evaluate the feasibility of a technique without ductus arteriosus division and mobilization of the aortic arch and to compare the number of lymph nodes resected in left-sided dissections to the number of lymph nodes removed in right-sided mediastinal dissections that are routinely performed in clinical practice. METHODS A total of 93 patients with hilar lung cancer were evaluated. A prospective study was conducted on 51 patients with primary left-sided hilar lung cancer, who underwent left thoracotomy and paratracheal lymphadenectomy between January 2008 and January 2010. The number of nodes dissected in these patients was compared with the number of nodes dissected in 42 patients with right-sided hilar lung cancer by right-sided mediastinal dissection within the same period. RESULTS The mean number of resected nodes in the bilateral paratracheal area via left thoracotomy was 8.4 (2-18 nodes). The distribution from 4R-4L-2L-2R was as follows: 3.3-2.5-0.5-2.1, respectively. Six patients (11.7%) were diagnosed with occult N2, and two (3.9%) of these patients also had N3 disease concomitantly. The number of dissected nodes from the ipsilateral station 2 via right-sided versus left-sided thoracotomy was 1.6 versus 0.5 (p=0.000), whereas the number of dissected nodes from ipsilateral station 4 via right-sided versus left-sided thoracotomy was 3.3 versus 2.5, respectively (p=0.1). The number of dissected nodes from the contralateral station 2 via right-sided versus left-sided thoracotomy was 0.2 versus 2.1 (p=0.000), whereas those numbers from the contralateral station 4 via right-sided versus left-sided thoracotomy were 1.0 versus 3.3, respectively (p=0.000). CONCLUSIONS Lymphadenectomy of the paratracheal area via left thoracotomy without ductus arteriosus division and mobilization of the aortic arch is technically feasible. From these data, regardless of approach, more lymph nodes are obtained from the right paratracheal space; this appears to be due to the fact that there are more right-sided paratracheal lymph nodes.

Concomitant etoposide and cisplatin provided improved survival compared with docetaxel and cisplatin in patients with locally advanced non-small cell lung cancer treated with chemoradiotherapy.

AbstractPresently, there is no consensus regarding which chemotherapy regimen is best to administer with radiotherapy in patients with locally advanced non-small-cell lung cancer (LA-NSCLC). Herein, our aim was to compare the outcome of patients treated with either etoposide–cisplatin (EP) or docetaxel–cisplatin (DP) in this curative setting.Patients treated with either EP or DP and concurrent radiotherapy from 2004 to2012 were identified and their detailed medical records and follow-up information were obtained for analysis in this retrospective study. Survival rates were compared using Cox proportional hazards regression models with adjustments for confounding parameters provided by propensity score methods.A total of 105 patients were treated with concurrent chemoradiotherapy for LA-NSCLC (stage IIB-IIIA-IIIB). The median ages were 54 years (range, 32–70 years) and 55 years (range, 37–73 years) in the EP (n = 50) and DP (n = 55) groups, respectively. The median follow-up time was 27 months (range, 1–132 months) in the EP group and 19 months (range, 1–96 months) in DP group. There was no significant difference in baseline clinicopathologic features including age, sex, performance status, histologic subtype, and clinical TNM stages between groups. In the univariate analysis, the median overall survival of patients treated with EP was higher than that of patients treated with DP (41 vs. 20 months, P = 0.003). Multivariate analysis further revealed a survival advantage with EP compared with DP (hazard ratio [HR], 0.46; 95% confidence interval: 0.25–0.83; P = 0.009). The toxicity profile of the 2treatment groups was similar except that pulmonary toxicity was higher in the DP group (grade 3–4: 0% vs. 6%, P = 0.024).Concurrent chemoradiotherapy with EP may provide more favorable outcomes than DP and with an acceptable safety profile.

Results of videothoracoscopic thymectomy in children: an analysis of 40 patients †

OBJECTIVES Experience in video-assisted thoracoscopic (VATS) thymectomy is limited in paediatric patients with non-thymomatous myasthenia gravis (MG). The aim of this study is to evaluate the medical status and surgical results of paediatric patients who underwent a VATS thymectomy. METHODS Of the 367 VATS thymectomies performed for MG patients in our Department of Thoracic Surgery between June 2002 and April 2013, 40 patients were in the paediatric age group. The data were evaluated retrospectively. Age, sex, duration of disease, body mass index, prescribed medication, duration of the operation, complications, chest tube duration, length of postoperative hospital stay and pain score using a visual analogue scale were analysed. RESULTS The average age was 14.8 ± 2.2 years (range, 8-18 years), and 27 (68%) patients were female. The electromyography and acetylcholine receptor antibody tests were positive in 30 (75%) and 27 (67%) patients, respectively. The mean quantitative MG score was 11.5 ± 5.3. The mean prescribed preoperative pyridostigmine bromide dosage was 209 ± 112 mg. Eleven (27.5%) patients were on corticosteroid treatment and 22 (55%) received intravenous immunoglobulin treatment preoperatively. There were no open conversions or mortalities. The average duration of the operation was 48.9 ± 31.3 min. All patients were extubated on the table and only one (2.5%) required mechanic ventilation for 18 h postoperatively. Three (7.5%) patients experienced complications. The average duration of chest drainage and postoperative stay were 20.5 ± 12.1 h and 1.8 ± 1.0 days, respectively. The average pain score using a visual analogue scale was 2.3 ± 1.2. CONCLUSIONS A right-sided VATS thymectomy is a safe procedure in paediatric patients with MG.

Accumulation of F-18 FDG in the infected pulmonary cyst in a patient with hydatid disease

Echinococcosis is endemic in certain parts of the world, including Turkey. When the pulmonary cyst has characteristic features, it can be easily diagnosed, but when the appearance changes as a result of complications, the cyst may resemble a malignant lesion. We presented a complicated pulmonary hydatid disease patient who was referred to our department for PET–CT, after the detection of 2 lung lesions.

Sleeve resection for bronchial carcinoid tumour in two children under six years old

BackgroundPaediatric tracheobronchial tumours are very rare, and pneumonectomy and lobectomy procedures are rarely indicated due to their surgical difficulties and high sequelae. Bronchoplastic techniques preserving lung parenchyma allow the resection and reconstruction of the main bronchi and carina.Case PresentationHere, we present a 6-year-old boy suffering from a carcinoid tumour of the right main bronchus which was successfully managed with a right upper sleeve lobectomy and a 4-year-old girl with an endobronchial carcinoid tumour narrowing the left main bronchus that received a sleeve resection of that bronchus.ConclusionBronchoplastic techniques are widely used in adults, can be very successful in paediatric patients where the preservation of the lung parenchyma is more important.

Catastrophes during video-assisted thoracoscopic thymus surgery for myasthenia gravis

OBJECTIVES Several series have demonstrated that video-assisted thoracoscopic (VAT) thymectomy is feasible and safe. However, VAT thymectomy is an operation that could invite catastrophes, such as major vascular injuries. We aimed to analyse the events and define the management and outcomes of these serious complications. METHODS All patients who underwent VAT thymectomy/thymothymectomy recorded in our clinical database were evaluated. A catastrophic complication was defined as any situation that resulted in an additional unplanned major surgical procedure other than the planned closed thymic surgery. Operations were performed by two surgeons: one experienced and one junior. The order of catastrophes in each surgeons experience was recorded. RESULTS A total of 441 VAT thymectomy/thymothymectomy operations were performed. Catastrophic complications were identified in 7 (1.5%) patients. These cases included 3 major innominate vein injuries, 1 superior vena cava injury, 1 aortic injury, 1 sudden cardiac arrest and 1 diaphragmatic injury. The first catastrophe for the experienced surgeon was his 96th case. The mean age was 37.1 ± 11.5 (minimum: 21, maximum: 53). There were 5 (71.4%) male and 2 (28.6%) female patients. Two (28.6%) of the patients had thymoma and the mean body mass index was 23.9 ± 2.8. A mean of 1.7 ± 1.4 (minimum: 0, maximum: 3) units of blood were transfused; a postoperative intensive care unit stay of 20.6 ± 25.7 h and a hospital stay of 8.4 ± 7.9 days were recorded. There were no deaths. CONCLUSIONS Catastrophic intraoperative complications of VAT thymectomy are very rare. They may not only occur in the learning curve period but also after a large experience. Experience in converting to open surgery within seconds is important to reduce morbidity and mortality.

Prognostic significance of carbonic anhydrase IX overexpression in stage III non-small cell lung cancer patients after neoadjuvant treatment

BACKGROUND To assess the prognostic importance of carbonic anhydrase IX (CA IX), a hypoxic biomarker, after neoadjuvant treatment in Stage III non-small cell lung cancer (NSCLC) patients. METHODS Tissue CA IX expression was examined after surgical resection in 77 patients who had undergone neoadjuvant treatment. The effects of CA IX overexpression and other clinical factors on disease-free survival and overall survival were investigated. RESULTS In multivariate analysis, number of neoadjuvant chemotherapy (CT) courses and gender emerged as significant independent predictors for disease-free survival, where administration of 2-3 courses of neoadjuvant chemotherapy (CT) (HR, 3.2 [95% CI 1.3-7.6], p = 0.009) and female gender were associated with poor survival (HR, 3.2 [95% CI 1.3-7.7], p = 0.009). The only significant independent predictor for overall survival was recurrence (HR, 5.6 [95% CI 2.4-12.8], p < 0.001). On the other hand, CA IX overexpression was not associated with disease free survival (p = 0.560) or overall survival (p = 0.799). DISCUSSION Our results do not suggest a prognostic role for CA IX overexpression in stage III NSCLC patients who received neoadjuvant treatment.