Bülent Tunçözgür

The role of tissue reperfusion in the reexpansion injury of the lungs

OBJECTIVE The aim was to discuss the balance between free radical damage and body defense mechanisms that occurred in reexpansed pulmonary tissue and to evaluate the relationship between the changes in the pulmonary circulation and the mentioned balance. METHODS Twenty male Wistar Albino rats were used for these study results. Pneumothorax was created in the left hemithorax by percutaneous route in all the rats. After 7 days, the first group (n = 10) had a sternotomy under ketamine anesthesia. Following invasive measurement of pulmonary artery pressure, tissue samples were obtained from the lower lobes of the right and left lungs before reexpansion occurred. Tracheotomies were opened in the second group (n = 10) with a 16 gauge cannula. Following sternotomy, invasive mean pulmonary artery pressure measurements were obtained by the support of non-invasive cardiac monitorization. The lungs were aerated with 4 cmH(2)O oxygen and fixed volume support and 1 h of reexpansion was obtained. Invasive mean pulmonary artery pressure measurements were repeated after reexpansion and tissue samples were obtained from the lower lobes of left and right lungs. Nitric oxide (NO), malondialdehyde (MDA) and superoxide dismutase (SOD) levels were measured in tissue samples, surfactant staining and light microscopic evaluations were performed. RESULTS At the end of the reexpansion, there was a decrease in mean pulmonary artery pressure (P < 0.01), MDA (P < 0.01) and SOD (P < 0.05) levels and an increase in NO (P < 0.05) levels. Under the light microscopic examination, in the samples that were provided with reexpansion, the alveolo-capillary membrane was thickened due to increasing edema, increase in the number of lymphocytes and return of the neutrophil leukocytes to the area. There was no significant difference between the groups in terms of surfactant staining. CONCLUSION The tissue reperfusion that is achieved with the restoration of blood flow during the reexpansion of collapsed lungs, can be the initial pathology in the chain of events that result in reexpansion injury.

Reliability of positron emission tomography-computed tomography in identification of mediastinal lymph node status in patients with non-small cell lung cancer

OBJECTIVE The involvement of mediastinal lymph nodes is a very important prognostic factor in patients with potentially resectable non-small cell lung cancer. Our aim in this study was to investigate the value of positron emission tomographic-computed tomographic scanning in staging lung cancer, especially for mediastinal lymph node evaluation, and to determine whether this could decrease the need for mediastinoscopy. METHODS Seventy-eight patients with non-small cell lung cancer who were potential candidates for surgical resection and admitted to the thoracic surgery unit of our hospital from March 2006 to June 2008 joined this prospective study. Positron emission tomographic-computed tomographic scanning was performed as part of the prospective studies used to diagnose or stage the tumors. All 78 patients underwent tissue sampling of mediastinal lymph nodes to compare these with imaging results. The diagnostic efficacy of the computed tomographic and positron emission tomographic-computed tomographic scans compared with histopathologic findings were calculated with sensitivity, specificity, positive and negative predictive values, and accuracy. RESULTS Final histology was available on 397 lymph node stations (N1, N2, and N3) sampled from 78 patients during mediastinoscopy or surgical intervention. Sensitivity, specificity, and positive and negative predictive values of mediastinal lymph node involvement in patients undergoing thoracic computed tomographic scanning were 45.4%, 80.5%, 27.7%, and 90%, respectively. The accuracy of computed tomographic scanning was 75.6%. The sensitivity, specificity, and positive and negative predictive values of mediastinal lymph node involvement in patients undergoing positron emission tomographic-computed tomographic scanning were 81.8%, 89.5%, 56.2%, and 96.7%, respectively. CONCLUSION There is a need for mediastinoscopy in positron emission tomographic-computed tomographic scanning-positive mediastinal lymph nodes, but it might not be necessary for positron emission tomographic-computed tomographic scanning-negative lymph nodes.

Intrapleural hyperthermic perfusion chemotherapy in subjects with metastatic pleural malignancies

OBJECTIVES Malignant pleural effusion (MPE) means poor prognosis in the majority of cases. Intrapleural Hyperthermic perfusion chemotherapy (HIPEC) looks promising approach for these patients. We aimed to investigate whether cytoreductive surgery followed by HIPEC provides any survival benefit in cases with metastatic MPEs. METHODS Between January 2009 and December 2011, 19 patients with metastatic MPEs were treated with HIPEC following surgical interventions such as pleurectomy/decortication and/or lung resection (group 1). Comparison was done with historical control groups consisted of patients who received either talc pleurodesis or pleurectomy/decortication followed by systemic treatment for the management of metastatic MPEs between June 2007 and June 2008 (group 2 and 3). Statistical analyses including overall survival, disease free interval were done for the group comparisons. RESULTS Median survival in group 1, 2 and 3 were 15.4, 6, 8 months, respectively. One year survival was 54.7% in group 1 where it was 0.6% and 0.8% in group 2 and 3, respectively. There was no operative mortality. Morbidity was occurred in 1 patient in group 1 (5.3%). CONCLUSIONS HIPEC combined with cytoreductive surgery seems to be a promising treatment option for subjects with metastatic MPEs. Further studies are needed for the optimization of HIPEC method, drug of choice, and the best combination therapy for the multimodal treatment.

The reliability of mediastinoscopic frozen sections in deciding on oncological surgery in bronchogenic carcinoma

IntroductionThis study was carried out to determine the accuracy of mediastinoscopic frozen section examination, performed prior to major surgery-especially where mediastinal lymph node metastasis (N2 disease) was suspected. We aimed to find out whether or not mediastinoscopic frozen section analysis was (i) a reliable tool when deciding to continue resection in lung cancer patients and (ii) reliable in diagnosing mediastinal masses.MethodsOne-hundred and thirty-six patients undergoing mediastinoscopy were enrolled in this study. Resection was planned for each case, and biopsies were taken from at least two sites, including the subcarinal lymph node. Thoracotomy and resection were performed when the results of frozen section examination were negative for malignancy in patients with lung cancer. Results of frozen section examination during mediastinoscopy were compared to the results of definitive histological examination of the same specimens stained using haematoxylin-eosin. Additionally, the results of frozen section examination were compared to the results of definitive histological examination of the lymph nodes excised during resection.ResultsWe determined total sensitivity, specificity, positive predictive and negative predictive values of 94.51%, 100%, 100% and 90%, respectively. In the 105 patients with malignant diseases, these values were 93.33%, 100%, 100% and 91.84%, respectively. In the 31 patients with benign diseases, values were 96.77%, 100%, 100% and 100%, respectively.ConclusionsIt was confirmed that mediastinoscopy supported by frozen section examination plays an important role in establishing diagnosis and planning treatment both in benign and malignant diseases.

Peripheral Intrapulmonary Lipoma : a Case Report

Abstract Lipomas are common benign neoplasms but they rarely occur in visceral organs. Pulmonary lipomas are rare, and most of them are seen in endobronchial localization. Peripherally located pulmonary lipomas are extremely uncommon. There are only eight cases reported in the literature and only one of the patients was female. Our case is the second peripheral pulmonary lipoma in a female patient. The patient is a 38-year old female, who has an incidentally found solitary pulmonary nodule, revealed by X-ray, during routine check-up procedure. A 1.5 cm diameter soft tissue mass was seen in the superior segment of the lower lobe of right lung in computerized thorax tomography. Wedge resection was performed with frozen section evaluation. Histopathologically the well-circumscribed lesion consisted of mature adipose tissue, containing areas of myxoid degeneration, organized as lobules surrounded by respiratory epithelium. The lesion was diagnosed as lipoma. Radiological imaging techniques have high sensitivity detecting the solitary pulmonary lesions but their ability to give information about their nature is limited. Although they are rare, intrapulmonary lipomas should be considered in the differential diagnosis of solitary pulmonary nodules. Wedge resection with frozen section evaluation seems to be the best choice for both diagnosis and treatment.

Dilemma on the Treatment of Haemoptysis: An Analysis of 249 Patients

Abstract Background: Mild haemoptysis can change into massive haemoptysis and unfortunately one cannot predict whether it will change or not. For this reason, we investigated the records of patients who had been admitted due to haemoptysis retrospectively in order to find the trigger mechanisms of haemoptysis and the effects of conservative and aggressive treatment methods. Methods: Hospital records of 249 patients with haemoptysis between 1997 and June 2005 were analysed retrospectively. Patients were classified into three groups according to the amount of blood expectorated in 24 hours. Group 1 included cases that had haemoptysis of less than 200 ml/24 h; group 2 consisted of massive haemoptysis which was defined as expectoration of blood of 200–400 ml/24 h, and group 3 comprised patients who had 400ml/24h or more of haemoptysis defined as life-threatening haemoptysis. Results: There were 169 male and 80 female patients. Mean age was 43.9 (4–78) in male patients and 33.8 (7–82) in female patients. The most frequent cause of haemoptysis was lung cancer in groups 1 and 2, and hydatid disease in group 3. Furthermore, we found that at least one trigger mechanism beyond primary disease caused haemoptysis in all groups. Conclusions: Haemoptysis is a life-threatening symptom that can alert patients to see a physician. Mild to moderate haemoptysis may change into massive and life-threatening forms. Unfortunately it is not predictable whether it will change or not. We deduced that a treatment strategy has to be planned according to trigger mechanism in patients with haemoptysis and that surgery is a definitive solution in these patients.

[Treatment for esophageal perforations: analysis of 11 cases].

BACKGROUND We present 11 cases with esophageal perforations who were treated in our department, with the intent of underlining the importance of surgical intervention. METHODS We retrospectively analyzed 11 cases of esophageal perforation who were treated from 2005 to 2010. The cases diagnosed within the first 24 hours were regarded as early diagnoses; those diagnosed later than this period were regarded as late diagnoses. RESULTS The mean age of the patients was 45.8 years. Following the perforation, 3 of the patients had early diagnoses and the others had late diagnoses. Of the 3 cases with early diagnosis, all had primary repair; of the late diagnosis cases, 4 had primary repair, 2 had colonic interposition, 1 had stent implantation, and 1 received medical treatment. All the cases with late diagnoses underwent drainage. The 3 cases who received early treatment recovered without complications. Of the other 8 cases, 1 had leakage from the anastomosis and 1 developed a fistula. Two (18.1%) of our patients died. CONCLUSION Treatments performed before the development of mediastinitis are lifesaving in esophageal perforation patients. We think that surgical treatment performed within the first 72 hours that includes primary repair would yield favorable results.

Two-piece cryopreserved tracheal allotransplantation: an experimental study.

OBJECTIVES For successful reconstruction with tracheal allotransplants following long tracheal resections, problems related to the preservation and vascularisation of the tracheal graft have to be solved. In this study, instead of using a long-segment single-piece graft, we used a graft that has been split into two. The aim was to use this graft after cryopreservation in order to ease neo-vascularisation and to maintain tracheal integrity by transplanting it to two separate regions of the dog cervical trachea. METHODS This experimental study was conducted in animal laboratories of the medical school on 11 half-blood dogs. The trachea obtained from the first dog was 8 cm in length; it was split into two pieces of 4 cm each and stored in the preservation solution at -80 degrees C for 4 weeks. Following this, the dog was sacrificed. Two 2 cm portions of cervical trachea were excised from the second dog. These parts were then reconstructed with two tracheal grafts of the same length as the cryopreserved ones. Ten dogs that were grouped into five groups of two dogs each underwent the same procedure. The subjects had a bronchoscopic evaluation on the third postoperative week. Anastomosis regions of the test tracheas were resected to be examined histopathologically. RESULTS Seven subjects were found to have third-degree obstructions during bronchoscopy; two had close to fourth-degree obstructions. In the histopathological examination, contrary to the findings of the bronchoscopies, 75% of the anastomoses had intact epithelium. The cartilage was seen to have well-preserved structural characteristics in all the anastomoses. Twelve anastomoses had moderate, seven mild and one had severe inflammation. All anastomoses had either good or very good level of vascularisation. CONCLUSIONS The integrity of the tracheal epithelium can be maintained with cryopreservation and split anastomosis technique. The cartilage preserves its structural characteristics despite losing its viability, thereby offering an advantage to maintain airway patency.

Outcomes after lobectomy and pneumonectomy in lungcancer patients aged 70 years or older

BACKGROUND/AIM For the early stage of nonsmall-cell lung cancer, surgical resection provides the best survival, but the surgical risk generally increases with age because of the increased prevalence of comorbidities, especially cardiovascular disorders. The aim of this study was to compare survival and mortality rates of two groups with different ages, younger and older than 70 years, who went curative resection for nonsmall-cell lung cancer. MATERIALS AND METHODS We analyzed the patients who underwent curative lung cancer surgery in the Department of Thoracic Surgery of Gaziantep University Research Hospital between January 1997 and November 2014. Patients were divided into 2 groups according to their ages. RESULTS A total of 497 patients were included in data analysis (381 were under 70 years old and 116 of them were ≥70 years old). The older group showed a 1.4-fold increased risk of mortality hazard ratio when the probability of survival was analyzed by histological type, lymph node involvement, disease stage, and age. CONCLUSION There was no distinct increase in 30-day mortality rates of patients with nonsmall-cell lung cancer who were ≥70 years old, but the hazard rate for long-term survival was higher in the older group. Curative pulmonary resections due to lung cancer should be carefully performed in septuagenarians.

Successful repair in a child with traumatic complex bronchial rupture

Tracheobronchial ruptures (TBR) are dramatic injuries, rarely observed in children, that can have fatal consequences, even threatening life. Etiologically, especially high-impact blunt trauma, penetrating trauma with perforating/penetrating instruments or firearms and iatrogenic injuries may result in TBR. These can be difficult to diagnose in emergency room conditions and the diagnosis may be delayed. Delay in the diagnosis causes acute or delayed complications. Treatment methods change depending on the type of the injury, its localization and comorbid pathologies. By presenting this case from our clinic with fragmented bronchial rupture due to a blunt trauma, we aimed to point out the maneuvers during the operation together with treatment methods and their results.