Burcu Kılıç

Validity of the updated European Society of Thoracic Surgeons staging guideline in lung cancer patients

OBJECTIVE The European Society of Thoracic Surgeons (ESTS) has proposed a revised preoperative lymph node staging guideline for patients with potentially resectable non-small cell lung cancer (NSCLC). We aimed to assess the validity of this revised ESTS guideline and survival results in our patient cohort. METHODS A total of 571 patients with potentially resectable NSCLC seen between January 2004 and November 2013 were included in the study. The preoperative mediastinal staging was performed by video-assisted cervical mediastinoscopy or video-assisted mediastinoscopic lymphadenectomy in all patients except those with peripheral cT1N0 nonadenocarcinoma tumors. Resection via thoracotomy or video-assisted thoracoscopic surgery was done in patients with no mediastinal lymph node metastasis. Surgical pathological results were compared with the ESTS staging guideline, and the validity of the guideline was tested. RESULTS In this series, mediastinal lymph node metastasis was revealed preoperatively in 266 patients (46.6%). A total of 305 patients underwent anatomic lung resection. The sensitivity, specificity, positive and negative predictive values, and accuracy of the guidelines were calculated as 95.0%, 100%, 100%, 94.6%, and 97.2%, respectively. CONCLUSIONS The ESTS revised preoperative lymph node staging guidelines for patients with NSCLC seem to be effective and valid, and may provide high survival following resectional surgery.

Minimally invasive repair of pectus excavatum (MIRPE) in adults: is it a proper choice?

Introduction The Nuss procedure is suitable for prepubertal and early pubertal patients but can also be used in adult patients. Aim To determine whether the minimally invasive technique (MIRPE) can also be performed successfully in adults. Material and methods Between July 2006 and January 2016, 836 patients (744 male, 92 female) underwent correction of pectus excavatum with the MIRPE technique at our institution. The mean age was 16.8 years (2–45 years). There were 236 adult patients (28.2%) (> 18 years) – 20 female, 216 male. The mean age among the adult patients was 23.2 years (18–45 years). The recorded data included length of hospital stay, postoperative complications, number of bars used, duration of the surgical procedure and signs of pneumothorax on the postoperative chest X-ray. Results The MIRPE was performed in 236 adult patients. The average operative time was 44.4 min (25–90 min). The median postoperative stay was 4.92 ±2.81 days (3–21 days) in adults and 4.64 ±1.58 (2–13) in younger patients. The difference was not statistically significant (p = 0.637). Two or more bars were used in 36 (15.8%) adult patients and in 44 (7.5%) younger patients. The difference was not statistically significant either (p = 0.068). Regarding the overall complications, complication rates among the adult patients and younger patients were 26.2% and 11.8% respectively. The difference was statistically significant (p = 0.007). Conclusions MIRPE is a feasible procedure that produces good long-term results in the treatment of pectus excavatum in adults.

A prospective randomized trial comparing homologous and autologous fibrin sealants for the control of alveolar air leak

Background Postoperative air leak is a common complication seen after pulmonary resection. It is a significant reason of morbidity and also leads to greater hospital cost owing to prolonged length of stay. The purpose of this study is to compare homologous sealant with autologous one to prevent air leak following pulmonary resection. Methods A total of 57 patients aged between 20 and 79 (mean age: 54.36) who underwent pulmonary resection other than pneumonectomy (lobar or sublobar resections) were analyzed. There were 47 males (83%) and 10 females (17%). Patients who intraoperatively had air leaks were randomized to receive homologous (Tisseel; n=28) or autologous (Vivostat; n=29) fibrin sealant. Differences among groups in terms of air leak, prolonged air leak, hospital stay, amount of air leak were analyzed. Results Indications for surgery were primary lung cancer in 42 patients (71.9%), secondary malignancy in 5 patients (8.8%), and benign disease in 10 patients (17.5%). Lobectomy was performed in 40 patients (70.2%), whereas 17 patients (29.8%) had wedge resection. Thirteen (46.4%) patients developed complications in patients receiving homologous sealant while 11 (38.0%) patients had complication in autologous sealant group (P=0.711). Median duration of air leak was 3 days in two groups. Time to intercostal drain removal was 3.39 and 3.38 days in homologous and autologous sealant group respectively (P=0.978). Mean hospital stay was 5.5 days in patients receiving homologous sealant whereas it was 5.0 days in patients who had autologous agent (P=0.140). There were no significant differences between groups in terms of measured maximum air leak (P=0.823) and mean air leak (P=0.186). There was no significant difference in the incidence of complications between two groups (P=0.711). Conclusions Autologous and heterologous fibrin sealants are safe and acts similarly in terms of air leak and hospital stay in patients who had resectional surgery.

Vascular thoracic outlet syndrome developed after minimally invasive repair of pectus excavatum.

The Nuss procedure is a minimally invasive surgical repair technique for pectus excavatum with fewer delayed complications compared to open procedures. We report the case of a 22-year-old man with deep pectus excavatum who developed vascular thoracic outlet syndrome after the Nuss procedure. Further evaluation demonstrated that the first rib was causing severe obstruction of the right subclavian artery. The patient showed clinical features of subclavian artery compression. A first rib resection, division of the anterior scalene muscle and fibrous bands provided complete relief of the complaints. The forced structural and spatial changes produced by the elevation of the depressed upper chest might have caused this complication. Vascular thoracic outlet syndrome should be kept in mind as a possible complication in patients who have undergone minimally invasive repair of pectus excavatum, and this complication can be treated by first rib resection.

Minimally invasive injection laryngoplasty in the management of unilateral vocal cord paralysis after video-assisted mediastinal lymph adenectomy

Introduction Video-assisted mediastinal lymphadenectomy (VAMLA) is a valuable tool for invasive staging of the mediastinum. Unilateral vocal cord paralysis (UVCP) may occur in patients following VAMLA and may result in secretion retention within the lungs, atelectasis and associated infectious situations such as pneumonia. Minimally invasive injection laryngoplasty (ILP) is the treatment of choice in UVCP. Aim To evaluate the efficacy and success of acute minimally invasive injection laryngoplasty for patients with UVCP following VAMLA. Material and methods Patients with the symptom of dysphonia following VAMLA were reviewed. All of the patients had UVCP according to the video laryngoscopy examination and had symptoms of aspiration and ineffective coughing. The Voice Handicap Index (VHI) questionnaire and maximum phonation time (MPT) were measured. Minimally invasive ILP was performed under general anesthesia with 1 cm of hyaluronic acid. Results There were 525 consecutive non-small cell lung cancer (NSCLC) patients who underwent VAMLA. Five (0.95%) of the patients had UVCP and were suffering from aspiration during oral intake and ineffective coughing reflex. Maximum phonation time (MFT) was measured before and after ILP, and the results were 7.1 ±1.6 and 11.1 ±2.3 s, respectively (p < 001). The Voice Handicap Index-10 (VHI-10) score was 30.4 ±4.7 and 13.4 ±3.5 (p < 0.01), respectively. Patients underwent surgical lung resection. There was no morbidity or mortality. Conclusions Unilateral vocal cord paralysis may occur as a complication of VAMLA. ILP may be an active tool for treating UVCP before anatomical lung resection to avoid potential morbidities. Successful management of this complication with multidisciplinary team work may encourage the use of VAMLA more frequently.

Comparative study of video-assisted thoracoscopic surgery versus open thymectomy for thymoma and myasthenia gravis

Introduction Thymectomy is the preferred standard treatment in younger non-thymoma patients with myasthenia gravis as well as in patients with early stage thymoma. Total thymectomy by median sternotomy has been the surgical approach since resection of the thymus with video-assisted thoracoscopic surgery (VATS). Aim To compare the clinical outcomes of VATS thymectomy with conventional open thymectomy for neoplastic and non-neoplastic thymic diseases. Material and methods Forty patients underwent thymectomy between October 2012 and January 2016. Fifteen patients were male and 25 patients were female. The mean age was 40.3 ±17.7 years. Seventeen (55%) patients underwent VATS thymectomy and 23 (45%) patients underwent an open procedure. We retrospectively reviewed the data of the patients and compared these two techniques. Results The mean tumor size was 5.17 ±3.2 cm in the thymoma group (VATS 2.5 ±2.4 cm vs. open access 4.7 ±3.7 cm). None of the patients experienced a myasthenic crisis. Conversion to thoracotomy was required in 1 patient in the VATS group due to bleeding from the right internal mammary artery; therefore, the conversion rate was 2.5% among all the patients. No mortality occurred in either group. No significant difference was found in the perioperative blood loss, operative time or pain visual analogue scale scores. On the other hand, regarding postoperative drainage, duration of chest tube drainage and length of hospital stay, VATS thymectomy yielded better results and the differences were significant. Conclusions Video-assisted thoracoscopic surgery thymectomy can be performed for both neoplastic and non-neoplastic thymic diseases with minimal morbidity and mortality.

Uniportal versus multiport video-assisted thoracoscopic surgery for anatomical lung resections: a glance at a dilemma

Introduction As the number of operations performed by videothoracoscopy is increasing, there is also a tendency to decrease the number of port incisions. Apart from the reduced number of surgical incisions, there are a few reports and systematic reviews that demonstrate some potential advantages of the uniportal video-assisted thoracoscopic surgery, but the impact of the reduced incisions in the clinical setting still remains uncertain. Aim To compare uniportal video-assisted thoracoscopic surgery to multiport video-assisted thoracoscopic surgery for anatomical lung resections in patients with malignant and benign lung diseases. Material and methods From August 2010 to April 2016, a total of 102 patients with malignant and benign lung diseases underwent videothoracoscopic lobar and sublobar lung resections in our department. Comorbidities, tumor stage, tumor localization, mortality, operative time, pain visual analogue scale, length of hospital stay, perioperative blood loss, duration and amount of postoperative drainage and air leak, number of harvested lymph nodes and complication rates were analyzed. Results No significant difference was found in the duration of chest tube drainage, pain visual analogue scale score, length of hospital stay, perioperative blood loss, amount of postoperative drainage, number of harvested lymph nodes or complication rate. There was no surgical mortality in either of the two groups. However, operative time was shorter (189 min vs. 256 min, p < 0.005) in the multiport group than in the uniportal group. Conclusions Compared with the uniportal approach, the multiport approach is associated with a significantly shorter operative time in our study.

Thoracoscopic removal of ectopic mediastinal parathyroid adenoma causing hyperparathyroidism: a rare entity

Ectopic mediastinal parathyroid adenomas are uncommon. Here, we report the successful thoracoscopic removal of a mediastinal parathyroid adenoma from a patient with hypercalcemia. A 58-year-old female patient was referred to our department with persistent hypercalcemia. Serum calcium and phosphorus levels were 13.2 mg/dl and 2.5 mg/dl respectively, while the intact parathormone level was 798.9 pg/ml. Parathyroid computed tomography revealed a solid and well-defined mass at the anterior mediastinum close to the distal aorta. Once the contrast was enhanced, our pre-diagnosis was ectopic parathyroid adenoma. The mass was detected at the anterior mediastinum, dissected free from the surrounding tissue and excised. The capsulated mass, which had a diameter of 3 × 1.5 × 0.7 cm, was confirmed as parathyroid adenoma histopathologically. Postoperative calcium and parathormone levels decreased dramatically to normal levels. Anterior mediastinal localization of an ectopic parathyroid adenoma is a rare entity. The transsternal approach is the most preferred method, but video-thoracoscopy can be used safely and effectively.

Eosinophilic granulomatosis with polyangiitis and bronchogenic cyst.

A 21-year-old woman with history of asthma and anaphylactic shock was admitted to internal disease department with stomachache, dysphagia, and dyspnea. Thorax computed tomography detected a bronchogenic cyst (Figure 1), ground-glass opacity, and focal acinar nodularly lesions. When the patient admitted to our clinic for resection of the bronchopulmonary cyst than we consulted with a rheumatologist because of stomachache and pelvic fluid that detected on abdominal ultrasonography. When we compared the computed tomography scan with previous scans, we noticed migratory pulmonary infiltrates (Figure 2). Current findings lead to a pulmonary involvement of a rheumatological disease. The patient underwent cyst excision and wedge resection from the superior segment of the right lower lobe. Hystopatological evaluation of the specimen demonstrated a necrotizing granulomatous-intense eosinophilic infiltrate in the wedge resection sample (Figure 3). The lining of the cyst was ciliated columnar epithelium (Figure 4). The patient Asian Cardiovascular & Thoracic Annals 2017, Vol. 25(9) 657–659 The Author(s) 2016 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492316678120 journals.sagepub.com/home/aan

Single stage bilateral uniportal videothoracoscopic sympathicotomy for hyperhidrosis: can it be managed as an outpatient procedure?

Introduction The videothoracoscopic approach is minimally invasive with benefits that include less postoperative pain and shorter hospital stay. It is also a safe procedure which can be performed on an outpatient basis. Aim To determine whether videothoracoscopic sympathicotomy can be performed safely in most patients as an outpatient procedure. Material and methods Between July 2005 and October 2015, a total of 92 patients underwent bilateral and single port thoracoscopic sympathicotomy in our department on an outpatient basis. The level of sympathicotomy was T2 in 2 (2.2%) patients, T2 to T3 in 31 (33%) patients, T2 to T4 in 46 (50%) patients and T3 to T4 in 12 (13%) patients. Demographic data, length of postoperative stay, substitution index (SI), admission rate (AR) and readmission rate (RR), complications and patient satisfaction were reviewed retrospectively. Results Two (2.2%) patients suffered from chest pain, while 4 (4.3%) patients complained about pain at the port site. Mean discharge time after surgery was 5.1 h (range: 4–6 h), mean duration of hospital stay was 0.15 days (0–3 days) postoperatively and the mean operation time was 43.6 min (15–130 min). In 8 (8.6%) patients, pneumothorax was detected on postoperative chest X-ray, while 5 (5.4%) patients required chest tube drainage. Mild or moderate compensatory sweating developed in 32 (34.7%) patients. No recurrence was observed, and the satisfaction rate was 96.7%. Substitution index and admission rate were 91.3% and 11% respectively, while RR was 0%. Conclusions Bilateral video-assisted thoracoscopic sympathicotomy can be performed safely in most patients as an outpatient procedure.