Gokhan Arslan

Thoracic endoscopic surgery for hyperhidrosis: comparison of different techniques.

BACKGROUND Hyperhidrosis is pathological perspiration in palmar, plantar or axillary surfaces. Video-assisted thoracic surgery (VATS) is currently the most commonly used therapy for hyperhidrosis. Blockage of sympathetic ganglia is achieved by segmental resection, transection and/or cauterization, and clipping of the chain. We aimed to compare the efficacy of these methods with respect to patient satisfaction, recurrence of symptoms and complications. METHODS Eighty male patients with a mean age of 22.02 +/- 2.61 years undergoing bilateral thoracoscopic sympathectomy or sympathetic blockage to treat primary hyperhidrosis were included in this randomized study. The patients were divided into four groups depending on the technique used for sympathetic blockage; techniques included resection (n = 20), transection (n = 20), ablation (n = 20), and clipping (n = 20). RESULTS The primary success rate for isolated palmar hyperhidrosis was 96.3 %; for palmar and axillary hydrosis it was 95.7 % and for palmar and face/scalp hyperhidrosis it was 66.7 %. No recurrence was observed. The overall success rate of the operation was 95 % and the differences between the four groups were not statistically significant. In the clipping group, the duration of the surgical procedure was significantly shorter than in the other groups. Complication rates were similar among the groups. The postoperative chest roentgenogram revealed pneumothorax in nine patients, but none of them required intervention. CONCLUSION Thoracic endoscopic sympathetic blockage yields similar results irrespective of the surgical technique adopted.

Mitral Valve Replacement with Bileaflet Preservation for Complex Annular Calcification

Extensive calcification of mitral apparatus may preclude optimal valve repair, thus requiring debridement. We performed mitral valve replacement in a 55-year-old woman with a modified bileaflet preservation technique to avoid complications related to extensive debridement. Posterior transposition of the anterior leaflet as a buttress over the posterior ventricular wall provided extra support for the weakened tissues and covered the decalcified areas, which protected against debris embolism. This technique is safe and reproducible, especially for elderly patients who have complex calcification that requires extensive debridement, enables better preservation of ventricular function, and avoids disruption of the mechanical left ventricular wall.

Four different strategies for repair of aortic coarctation accompanied by cardiac lesions

OBJECTIVES Coarctation accompanied by cardiac lesions is a complex clinical situation due to the presence of two different pathologies that necessitate surgical treatment. An individual strategy, according to the severity of the disease, is important to reduce perioperative mortality and morbidity. METHODS We report here on 25 patients with coarctation accompanied by cardiac lesions who were treated by various surgical approaches. Coarctation and associated disease were treated in 14 patients in a single stage by an ascending-to-descending bypass (n = 11) or by a hybrid procedure (n = 3). The remaining 11 patients underwent a two-stage operation for their treatment. Six of these 11 patients who had coronary artery disease or signs of congestive heart failure were first operated for their cardiac disease, whereas in the remaining five patients, who did not have any congestive signs, coarctation repair was performed first. RESULTS All the patients were male, between the ages of 20 and 24 years, except for one 45-year-old woman. The mean cross-clamp times, cardiopulmonary bypass times and operation times were 52 ± 14.5, 102.3 ± 28.5 and 174 ± 24.8 min in the extra-anatomical bypass group; 29.8 ± 11.7, 55.5 ± 17.6 and 116 ± 22 min in the two-stage groups and 49 ± 19.8, 63 ± 18.7 and 159 ± 21.3 min in the hybrid patients, respectively. One patient who underwent extra-anatomical bypass died on the 14th postoperative day. There were no events during the follow-up period for the other patients. Also, there were no gradients between the extremities and no graft-related complications. CONCLUSIONS As a consequence of the progress in the development of endovascular techniques, hybrid treatment is becoming a more popular option for the treatment of coarctation accompanied by cardiac diseases. Two-stage procedures and extra-anatomical bypass might be alternative techniques if endovascular procedures are contraindicated or failing.

Pre-treatment before coronary artery bypass surgery improves post-operative outcomes in moderate chronic obstructive pulmonary disease patients.

Introduction Chronic obstructive pulmonary disease (COPD) has traditionally been recognised as a predictor of poorer early outcomes in patients undergoing coronary artery bypass grafting (CABG). The aim of this study was to analyse the impact of different COPD stages, as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) spirometric criteria, on the early surgical outcomes in patients undergoing primary isolated non-emergency CABG Methods Between January 2008 and April 2012, 1 737 consecutive patients underwent isolated CABG in the Department of Cardiovascular Surgery of Gulhane Military Academy of Medicine; 127 patients with the diagnosis of moderate-risk COPD were operated on. Only 104 patients with available pulmonary function tests and no missing data were included in the study. Two different treatment protocols had been used before and after 2010. Before 2010, no treatment was applied to patients with moderate COPD before the CABG procedure. After 2010, a pre-treatment protocol was initiated. Patients who had undergone surgery between 2008 and 2010 were placed in group 1 (no pre-treatment, n = 51) and patients who had undergone surgery between 2010 and 2012 comprised group 2 (pre-treatment group, n = 53). These two groups were compared according to the postoperative morbidity and mortality rates retrospectively, from medical reports. Results The mean ages of the patients in both groups were 62.1 ± 7.6 and 64.5 ± 6.4 years, respectively. Thirty-nine of the patients in group 1 and 38 in group 2 were male. There were similar numbers of risk factors such as diabetes, hypertension, renal disease (two patients in each group), previous stroke and myocardial infarction in both groups. The mean ejection fractions of the patients were 53.3 ± 11.5% and 50.2 ± 10.8%, respectively. Mean EuroSCOREs of the patients were 5.5 ± 2.3 and 5.9 ± 2.5, respectively in the groups. The average numbers of the grafts were 3.1 ± 1.0 and 2.9 ± 0.9. Mean extubation times were 8.52 ± 1.3 hours in group 1 and 6.34 ± 1.0 hours in group 2. The numbers of patients who needed pharmacological inotropic support were 12 in group 1 and five in group 2. Duration of hospital stay of the patients was shorter in group 2. While there were 14 patients with post-operative atrial fibrillation (PAF) in group 1, the number of patients with PAF in group 2 was five. Whereas there were seven patients who had pleural effusions requiring drainage in group 1, there were only two in group 2. There were three mortalities in group 1, and one in group 2. There were no sternal infections and sternal dehiscences in either group. Conclusion Pre-treatment in moderate-risk COPD patients improved post-operative outcomes while decreasing adverse events and complications. Therefore for patients undergoing elective CABG, we recommend the use of medical treatment.

Adding Doppler ultrasonography to the follow-up of patients with vasospastic disorder improves objectivity.

Background Assessing therapeutic efficacy and patient satisfaction objectively and quantitatively has always been a problem in patients with vasospastic disorders. We aimed to present the additive value of ultrasonographic assessment of peripheral arteries secondary to cold stimulation, as a test for treatment efficacy during follow-up. Material/Methods Arterial blood flow rates were measured from radial artery with Doppler USG in patients who presented to our department with vasospastic disorders. Ultrasonography was performed at the following intervals; before cold stimulation and at 5th, 10th, 15th, 20th minutes of cold stimulation. Patients were controlled by repeat cold stimulation test and Doppler US at the 2nd month of the treatment. Results were analyzed with SPSS for Mac 20.0 package program. Results We enrolled 46 patients in the study. All patients were male and mean age was 22.3±2.17 years. Most common symptoms were cyanosis and coldness. There were statistically significant differences between pre-treatment and post-treatment arterial blood flow rates at each measurement time point (p<0.001) except initial measurement (p>0.05). On post-treatment values, there were 10.04±0.78 cm/s increase in 5th minute, 6.25±1.39 cm/s in 10th minute, 6.43±2.13 cm/s in 15th minute, and 6.38±1.86 cm/s in 20th minute measurements. All increases at the 5 time points were statistically meaningful when compared to their pre-treatment corresponding time points (p<0.001). Conclusions Doppler flowmetry added to standard cold stimulation test for evaluating the patients with vasospastic disorders provides better and more objective results when compared to the patient-oriented subjective scoring systems.

Is chronic obstructive pulmonary disease a risk factor for epistaxis after coronary artery bypass graft surgery? : cardiovascular topic

Summary Background Chronic obstructive pulmonary disease (COPD) has customarily been associated with increased surgical morbidity and mortality rates after coronary artery bypass graft surgery (CABG). The aim of this study was to determine whether there is a relationship between epistaxis and COPD after CABG surgery. Methods There were 3 443 patients who consecutively underwent isolated CABG from January 2002 to March 2012. We retrospectively analysed the data of 27 patients (0.8%) with newly developed and serious spontaneous epistaxis, which required consultation with the Ear Nose and Throat (ENT) Department. The patients were divided into three groups according to severity of nasal bleeding. Twenty-one (77.7%) patients in the three groups had COPD. Results There were 19 males (70%) and eight females (30%). Their ages ranged between 52 and 72 years (mean 61 ± 5). Fifty-five per cent of the patients had hypertension and 78% had COPD. The overall duration of hospital stay was six to 11 days (mean 7.9 ± 1.1). Epistaxis was seen particularly on the fourth and seventh days postoperatively and 17 patients (63%) were treated with anterior, posterior, or anterior and posterior nasal packing (group 1). Nasal bleeding was controlled with electrocautery in six patients (22%) (group 2), and four (15%) were treated with surgical excision and blood transfusions (group 3). All patients (100%) had a good recovery with no mortality. Conclusion The high coincidence between epistaxis and COPD made us wonder whether COPD may be a risk factor for epistaxis after CABG surgery. However, we could not find any direct causative link between COPD and epistaxis in patients who had undergone CABG. Epistaxis was more common in patients with COPD and it was more serious clinically in patients who had both COPD and hypertension.

Is the right vertical axillary incision an alternative technique to the submammarian incision for the repair of simple congenital heart defects in female patients

We read with interest the surgical approach of Yan et al. [1] to simple congenital heart defects. The right vertical axillary incision (RVAI) procedure decreased neither cardiopulmonary bypass time nor aortic cross-clamp and hospital stay. The authors claim that they had excellent results, achieving cosmetically satisfactory outcomes in young female patients. Although an objective multiple-choice questionnaire that focused attention on the autoevaluation of the aesthetic result and its psychological influences has been reported previously [2], we could not understand how Yan et al. evaluated patient satisfaction. Meanwhile, it is not stated whether the subgroup analysis was made in terms of age and gender. This approach is recommended for its cosmetic advantages in young female patients, but adult patients in particular, might be dissatisfied regarding the incision of lateral breast tissue. Minithoracotomy with a submammarian incision can be specifically considered a more favourable approach. Contrary to the authors’ comment, breast deformity or asymmetry or any cage deformity will not develop when a careful tissue approximation is performed by the elevation of the breast tissue in young or adult female patients [3, 4]. As stated by the authors, due to poor exposure of the operating field with the RVAI approach, the learning period of this technique will take longer than the other minimally invasive techniques. The conversion of the process into another approach such as an additional surgical incision, can be very difficult, may cause the sacrifice of the internal mammarian artery and may pulmonary complications and increase the magnitude of pain in the postoperative period as well. We fully agree with the authors’ concern about femoral artery stenosis in the future, however, vascular complications such as dissection or stenosis after femoral cannulation is still a debateable topic. Femoral access [5] has been shown to be a safe and preferable option in selected patients and allows limited surgical chest incisions thereby reducing the patient’s surgical trauma. In the preoperative period, Doppler examination of the femoral artery (diameter and quality) can minimize the possible vascular problems and assist in determining the surgical strategy in the young or adult patient. In conclusion, this is a valuable study, and we are grateful to the authors for sharing their experiences. This surgical technique, specialized according to gender, might be performed in male adolescent patients in particular. It might be an alternative to the submammarian incision in female and adult patients.

How Can Follow-Up of Patients with Raynaud Phenomenon be Optimized?

Background Raynaud phenomenon (RP) is common worldwide and presents diagnostic and therapeutic difficulties. We aimed to share our experience with optimizing of patient follow-up by using the cold-stimulation test (CST). Material/Methods Data of 81 patients admitted with RP symptomatology were collected. Demographic data and symptoms were recorded. A scale was used for determining the severity of disease at pre-treatment and post-treatment. CST was performed to all patients at pre-treatment and post-treatment for assessment of treatment efficiency in follow-up. Results were analyzed with the SPSS for Mac 20.0 program. Results All the patients were male. Mean age was 22.3±2.14 (19–29). Mean duration of symptoms from onset to present was 4.59±2.85 years. There were statistically significant differences between pre-treatment and post-treatment hand temperatures measured by CST (p<0.001). However, there were no statistically significant differences between pre-treatment and post-treatment severity scores of patients (p=0.135). Conclusions To quantitatively determine the treatment efficacy, CST may be used instead of asking simple questions of patients.

Oxaliplatin Induced Digital Ischemia and Necrosis.

Introduction. Digital ischemia is a rare complication of several chemotherapeutic medications. We aimed to present a patient with digital ischemia, secondary to a new generation chemotherapeutic drug, oxaliplatin. Case Report. 62-year-old woman presented to our department with severe pain, paresthesia, and distal acrocyanosis on her right hand fingertips. Her complaints started five days after the third cycle of a chemotherapy protocol consisting of 5-fluorourasil (5-FU), folinic acid, and oxaliplatin due to advanced colon carcinoma. On physical examination, hemorrhagic and partly ulcerative lesions were detected at her right hand fingertips. Radial and ulnar pulses were absent at affected side. Digital subtraction angiography revealed severe vascular resistance in the affected extremity. Iloprost trometamol treatment was started with the dosage of 1 ng/kg/min. In addition, low-molecule-weight heparin was used for preventing possible microemboli. Symptomatic relief was provided after five days, and patient was discharged on 7th day of treatment. Discussion. The pathogenesis of oxaliplatin induced vascular toxicity remains unclear. Endothelial damage, increased adherence of platelets, deposition of immune complexes as an immunologic effect of oxaliplatin, and hypercoagulable state may be the reason for arterial thrombosis, digital microemboli, possible digital ischemia, and their several consequences.

Very bad clinical aspect towards diagnosis of deep femoral artery injury: Hypovolemic shock

DOI: 10.4103/0974-2700.120396 hematoma. On physical examination, the pulses on injured lower limb were observed. On follow-up, deterioration of the general condition and development of patient confusion, he was urgently taken to the operating room and then lateral thigh incision was enlarged and searched source of hemorrhage. Profunda femoral vein and artery were clamped. By removing the wide injured sections on the vessels, saphenous vein graft was interposed in these segments. After an uneventful recovery, he was discharged on the 8th postoperative day.