Erdal Okur

Pleural tenting following upper lobectomies or bilobectomies of the lung to prevent residual air space and prolonged air leak.

OBJECTIVE Apical residual air space and prolonged air leak are not uncommon entities following resection of upper lobe of the lung. This study was carried out to observe the efficacy of pleural tenting in preventing these problems. METHODS This is a prospective randomised study. Pleural tenting after upper or upper and middle lobectomies was performed in 20 patients. In another 20 patients who underwent upper lobectomy or bilobectomy, pleural tenting was not performed. Both groups were compared in respect to durations of postoperative chest tube drainage and hospital stay, amount of total pleural drainage, and the presence of need for any additional intervention for prolonged air leak. RESULTS Age, sex, pathology and pulmonary function tests of two groups were similar. Duration of chest tube drainage was shorter in whom pleural tenting was performed when compared to whom pleural tenting was not performed (4.3+/-0.16 days versus 7.40+/-0.68 days, P<0.0001). Mean hospital stay was shorter in tented group (7.60+/-0.4 days versus 9.35+/-0.6 days, P=0.024). Although the mean amount of total pleural drainage was less in tented group (667.5+/-57.7 ml versus 802.5+/-83.3 ml, P=0.1911), the difference was not statistically significant. Three (15%) patients in non-tented group needed an apical chest tube insertion in postoperative period for prolonged air leak with an apical pleural space. Asymptomatic apical residual space was observed in 3 patients in tented group. There was no morbidity in patients in tented group. CONCLUSION Pleural tenting following upper lobectomy or bilobectomy of the lung shortens the duration of chest tube drainage and hospital stay, and it prevents apical residual air spaces and related complications. Pleural tenting is safe and relatively simple procedure, which has no associated morbidity.

Delays in the Diagnosis and Treatment of Primary Lung Cancer: Are Longer Delays Associated with Advanced Pathological Stage?

We aimed to investigate the delays from the first symptom to thoracotomy and to examine whether the delays cause the stage advancement in lung cancer. This prospective study included 138 patients with non-small cell lung carcinoma who underwent thoracotomy. Clinical files of the patients were analyzed and a questionnaire was created to obtain information from the patients. The mean duration values were 81.3 days for the application interval, 61.3 days for the referral interval, 20.3 days for the diagnostic interval, and 21.9 days for the treatment interval. The application interval was longer than 30 days (patient delay) in 50 patients (37.9 %). The mean interval from the first visit to doctor to thoracotomy was 97.2 days. There was a doctor delay in 102 (73.9 %) patients; a referral delay in 83 patients (60.1 %), a diagnostic delay in 47 patients (36.4 %), and a treatment delay in 96 patients (69.6 %). The mean total duration was 176.2 days. Ninety-four patients (71.2 %) had a total delay. Mean total delay was 184.5 days in pathologic stage I, 187.3 days in stage II, 167.7 days in stage IIIA, 142.6 days in stage IIIB, and 150.3 days in stage IV (p>0.05). Delays during the course between the first symptom and thoracotomy in lung cancer patients were a common problem among our patients. Prolonged durations in the application and referral of patients are the most significant cause of delays. Presence of delay or length of delay did not correlate with pathologic tumour stage in this study.

Streptokinase for malignant pleural effusions: a randomized controlled study.

Effective palliative treatment in malignant pleural effusion can only be carried out when the lung is fully expanded after drainage of effusion. We investigated the efficacy of intrapleural fibrinolytics for lysing fibrin deposits and improving lung reexpansion in patients with malignant pleural effusion. We randomly allocated 47 patients with malignant pleural effusion into 2 groups: a fibrinolytic group of 24 were given 3 cycles of 250,000 U intrapleural streptokinase; the control group of 23 received pleural drainage only. Pleurodesis with 5 mg of talc slurry was performed in all patients who had lung reexpansion after drainage. Patient characteristics, pleural drainage, lung expansion assessed by chest radiography, and pleurodesis outcomes were compared between the 2 groups. Patient characteristics were similar in both groups. Lung reexpansion was adequate for performing talc pleurodesis in 96% of patients in the fibrinolytic group and 74% in the control group. In the fibrinolytic group, the mean volume of daily pleural drainage before streptokinase administration was 425 mL, and it increased significantly to 737 mL after streptokinase infusion. Intrapleural administration of streptokinase is advisable for patients with malignant pleural effusion.

Unusual intrathoracic location of a primary germ cell tumour

The primary location of non-metastatic germ cell tumours of the chest is the anterior mediastinal compartment. Germ cell tumour arising from lung parenchyma is one of the rarest conditions in human and only a few cases of choriocarcinomas and yolk sac tumour have been reported to date. Here we report a case of intrapulmonary mixed type germ cell tumour, containing embryonal carcinoma, choriocarcinoma and yolk sac tumour elements. Diagnosis of the lesion was achieved by open thoracotomy and bulk of the tumour was resected by right upper lobectomy.

Lung decortication for chronic empyaema: effects on pulmonary function and thoracic asymmetry in the late period

OBJECTIVE Chronic empyaema deteriorates lung function and causes thoracic asymmetry due to intercostal narrowing in the diseased hemithorax. This study aims to investigate the rates of improvement in the pulmonary function tests (PFTs) and the thoracic deformity in late postoperative period of lung decortication, performed for chronic empyaema. METHODS A total of 50 patients who underwent standard open decortication for empyaema were included. The PFTs and computed tomographic (CT) scans of the chest were analysed in all patients after 6-58 months postoperatively. The measurements of antero-posterior and transverse diameters of both hemithoraxes were performed on both preoperative and postoperative chest CTs. The thoracic asymmetry was calculated as the ratio of the measurements of the diseased side to the normal side. The pre- and postoperative parameters were compared statistically. RESULTS The mean preoperative forced expiratory volume in first second (FEV(1)) and forced vital capacity (FVC) increased from 61.40% and 60.89% to 78.92% and 77.48%, respectively, in the late postoperative period (p<0.001). The mean preoperative transverse diameter of affected hemithorax increased from 11.22 cm to 11.98 cm (p<0.001) and, the transverse asymmetry improved from 11.52% to 5.94%, postoperatively (p<0.001). The mean preoperative antero-posterior chest diameter improved from 15.58 cm to 16.67 cm (p<0.001), and the antero-posterior asymmetry improved from 11.42% to 5.42% (p<0.001) in the late postoperative period. CONCLUSIONS The open decortication for chronic pleural empyaema significantly increases FEV(1) and FVC. Due to the re-expansion of the lung and enlargement of the intercostal spaces, the chest wall deformity also improves considerably after the operation.

Iatrogenic Tracheal Rupture during Intubation with a Double-Lumen Tube

Iatrogenic tracheal rupture after intubation with a double-lumen endotracheal tube is rare. An endobronchial tube positioning guide stylet, which is generally used during intubations with a double-lumen tube, may tear the trachea. A 76-year-old patient with right upper lobe carcinoma was scheduled for videothoracoscopic lobectomy. Mediastinal lymph node dissection was performed after a right upper lobectomy. When the mediastinal pleura in the right paratracheal region were opened, a tracheal cuff was noticed in the mediastinum. The tear in the membranous part of the trachea was repaired. Use of stylets during intubation may cause tracheal injury. To prevent such an injury, the stylet should be withdrawn after the tip of the tube has passed through the vocal cords.

An unusual presentation of Castleman's disease

Castlemans disease is one of the heterogeneous group of lymphoproliferative disorders of unknown aetiology. It commonly presents as a mediastinal mass. It can be unicentric involving only a single site, or multicentric involving multiple sites. We report a patient with unicentric Castlemans disease, in which the mass was located in the posterior mediastinum and accompanied by a massive pleural effusion, which is extremely rare in unicentric disease. This case report highlights the imaging techniques used in the differential diagnosis and surgical considerations due to the hypervascular nature of the tumour.

Prophylactic intraoperative pneumoperitoneum decreases pleural space problems after lower lobectomy or bilobectomy of the lung.

BACKGROUND Following lower lung lobe resection, prolonged air leaks and residual pleural space are common. We investigated whether an artificially induced prophylactic intraoperative pneumoperitoneum would prevent these complications. METHOD Sixty patients who underwent lower lobectomy or bilobectomy were prospectively randomized into 2 groups according to the use of intraoperative pneumoperitoneum. Air was delivered via a catheter placed under the diaphragm in the pneumoperitoneum group. Parameters related to pleural drainage, complications, and hospital stay were compared. RESULTS No difference between the preoperative characteristics of both groups was present. The mean duration of chest tube drainage was shorter (3.47 +/- 1.04 days vs. 4.87 +/- 1.43 days, P < 0.001) and the mean amount of chest drainage was lower (305.0 +/- 76.9 ml vs. 488.3 +/- 215.2 ml, P < 0.001) in the pneumoperitoneum group. Residual pleural space was observed in 1 pneumoperitoneum patient (3.3 %) and in 8 controls (26.7 %). Pneumoperitoneum patients were discharged 1.1 days earlier on average than the controls. CONCLUSION Artificial prophylactic intraoperative pneumoperitoneum is a simple and safe procedure that decreases the postoperative amount of fluid drainage, residual pleural space, duration of chest tube drainage, and hospital stay.

Thoracic surgery for haemoptysis in the context of tuberculosis: what is the best management approach?

Haemoptysis is not an unusual finding in patients with old or active pulmonary tuberculosis. Because of bronchial artery or a branch of pulmonary artery erosion due to cavitary infiltration, bronchiectasis, fungus ball, broncholithiasis or destroyed lung, the bleeding can sometimes be a life-threatening situation. Assessment of the patient and finding the exact site of bleeding can be difficult especially in a patient with disseminated lung disease. Chest computerized tomography and bronchoscopy remain the methods of choice for lateralization of the disease. Some patients can be treated successfully with endobronchial interventions. Bronchial artery embolization can be rewarding in some patients but the recurrence rate is higher in tuberculosis than other etiologies of haemoptysis. Surgical resection of the lung, mainly lobectomy, remains a life-saving procedure but it should be performed very selectively to avoid higher postoperative morbidity and mortality. Different management options of haemoptysis in patients with pulmonary tuberculosis are discussed in this manuscript.

Surgical Management for Hydatid Disease

Hydatid disease is caused by the parasite Echinococcus granulosus. The liver and the lungs are common sites. When a cystic lesion is seen on CT scan, diagnosis is made based on the patient having lived in an endemic area. Serologic tests are used for differential diagnosis. Medical treatment is centered on albendazole. Surgery is recommended either by open or endoscopic technique depending on the characteristics of the cysts and the patient. Complications of surgery are rare except for prolonged air leaks. Mortality occurs when the cyst is located in the central nervous system or occludes major vessels.