Gürhan Öz

Completion pneumonectomy for bronchiectasis: morbidity, mortality and management.

BACKGROUND Completion pneumonectomy performed for benign causes is associated with a high morbidity and mortality. We analyzed the patients who underwent completion pneumonectomy procedure for bronchiectasis, which constitutes a specific benign condition, together with the indications for surgery, the difficulties encountered during operations and the postoperative results. METHODS Records of all patients who underwent completion pneumonectomy for the diagnosis of brochiectasis between January 1991 and April 2006 at the thoracic surgery clinic of a training and research hospital specializing in chest diseases and chest surgery were retrospectively evaluated. The age and the gender of the patients, etiologic factors, symptoms, characteristics of the first operation, the time between the first operation and completion pneumonectomy, and postoperative follow-up are examined. RESULTS During the evaluation period of more than 15 years, 23 patients underwent completion pneumonectomy. The median age of these 23 patients was 28 (range: 9 - 53); 17 of the patients were male and 6 were female. The most common indication for surgery was recurrent lung infections (n = 15). The most common symptoms were cough (n = 21), expectoration (n = 19), and hemoptysis (n = 15). The mean time between the first operation and the completion pneumonectomy was 4.9 years (range: 5 months - 11 years). Left completion pneumonectomy was performed in 14 and right completion pneumonectomy was performed in 9 cases. The mean duration of hospital stay was 16.7 days (range: 12 - 42 days). The course after surgery was uneventful in all patients. The mortality rate was 0 % and morbidity was 43.5 %. CONCLUSION Although completion pneumonectomy for benign causes is a high risk procedure, it can be performed in selected patients with an acceptable morbidity and mortality after an effective preoperative medical therapy for inflammation of the lungs and with careful dissection at the operation.

The effectiveness of transdermal opioid in the management multiple rib fractures: randomized clinical trial.

BACKGROUND The most commonly observed pathology in chest traumas is rib fracture, and the most important clinical symptom is severe pain. AIMS To investigate the effectiveness of intramuscular opioid (IMO), intravenous patient-controlled analgesia (IVPCA) and the Fentanyl transdermal therapeutic system (TTS) in the management of rib fracture pain. STUDY DESIGN Prospective randomized clinical trial. METHODS In our prospective and randomised study, we included 45 patients with a diagnosis of multiple rib fractures. There were three groups and intercostal nerve blockage (ICB) in the first day and oral paracetamol for five days was administered to each group as standard. In Group IMO (n=15), 4×40 mg pethidine HCl was administered to the patients, while in Group IVPCA (n=15) this was 5 μg/mL continuous intravenous fentanyl and was 50 μg fentanyl TTS in Group TTS (n=15). The demographics, injury data and vital signs of the patients were recorded. Pain was scored using Visual Analogue Scale (VAS). The pain during lying down (VASl) and mobilisation (VASm) was detected. RESULTS There were no differences between the three groups regarding age, sex, the trauma pattern, the number and distribution of costal fracture localisations, the presence of additional pathology, complications, thoracal catheter and the duration of thoracal catheter. No significant difference between the groups regarding systolic and diastolic arterial tension, number of breaths and beats in a minute was observed (p>0.05). We observed an improvement in the mean VAS score after treatment in all three groups. The mean VASl score significantly decreased after treatment in each group (p<0.05). The mean VASl and VASm scores measured on the 1(st), 2(nd), 3(rd), 4(th) and 5(th) days were found to be higher in Group IMO than in Groups IVPCA and TTS; however, these differences were not statistically significant (p>0.05). CONCLUSION In the analgesia of patients with multiple rib fractures, TTS administration with ICB showed similar effectiveness with IVPCA administration with ICB. In the management of pain due to multiple rib fractures, TTS administration is a safe, non-invasive and effective procedure.

Effect of intrapleural povidone-iodine lavage on thyroid hormones in thoracic surgery.

OBJECTIVE Povidone-iodine (PI) is an effective disinfectant used in many surgical operations. It is known that PI is absorbed by the skin after application. Absorption is even greater in infants, as their skin is thinner and more permeable. Iodine absorption in the orbita, neck and during abdominal surgery has been previously investigated, but such a study has not been performed for the pleura, which has a greater area and capacity for absorption. In this study, we investigated the effect of intraoperative povidone-iodine lavage on thyroid hormones during thoracic surgery. MATERIAL AND METHOD Fifty patients without any thyroid pathology scheduled for thoracotomy were divided into 2 groups. Group A (n = 25) was given intraoperative saline lavage, while group B (n = 25) had povidone-iodine lavage. Levels of free T3 (FT3), free T4 (FT4) and thyroid-stimulating hormone (TSH) measured 1 day preoperatively and 1 day postoperatively were analyzed. RESULTS There was a statistically meaningful change in FT3 levels ( P = 0.033) between groups, but the measured changes in FT4 and TSH levels were not statistically significant ( P = 0.98 and P = 0.71, respectively). FT3 scores for group A were decreased postoperatively compared to the scores for group B, but all results were in normal ranges. In group A, the changes between preoperative and postoperative levels of FT3 and FT4 were statistically significant, while changes in TSH levels were not. In group B, changes in FT4 levels were statistically significant and changes in FT3 and TSH levels were not. CONCLUSIONS The scores show that the iodine absorbed by the pleura during intraoperative povidone-iodine lavage has an effect on thyroid function. Intrapleural PI lavage results in changes to some thyroid hormone levels due to pleural absorption. Thus, intrapleural PI lavage should be used with care.

Facial paralysis and mediastinitis due to odontogenic infection and poor prognosis.

Cervical necrotizing fasciitis (CNF) is a rare, rapidly advancing infection that involves the skin, the subcutaneous fibrofatty tissue, as well as the superficial and deep fascia and can cause life-threatening complications. The most frequent initiating factors in the head and neck region are a primary odontogenic infection, a peritonsillar infection, as well as posttraumatic or iatrogenic skin and mucosal injuries. Necrotizing fasciitis (NF) can expand within hours, and the reported mortality rate is up to 75% with delay interference. If the patients have any risk factors, poor prognosis can be seen. In this study, 1 patient with CNF with a history of peritonsillar infection and 2 patients with CNF who had a history of odontogenic infection with spreading to the temporal region and the mediastinum were described, with information of the literature and a clinical experience that was gained from 5 patients with NF who were seen at our clinic in the recent year, despite the fact that CNF was not seen up to last year. None of the patients had any risk factors. One of them had a worse clinical state with ascending infection to the temporal region, cranial nerve paralysis, and descending necrotizing mediastinitis, but he recovered from NF. After the oral intake began, dyspnea due to aspiration was seen and he died because of sepsis and multiorgan dysfunction. We aimed to attract attention to the importance of dental pathologies and increased mortality in a healthy patient.

Efficacy of budesonide and interleukin-10 in an experimental rat model with isolated bilateral pulmonary contusion created by blunt thoracic trauma

OBJECTIVES In our study, we aimed to investigate the anti-inflammatory mediator effects of budesonide (BS), an inhaled corticosteroid and interleukin-10 (IL-10) on a pulmonary contusion in an experimental rat model in which an isolated bilateral pulmonary contusion was created by blunt thoracic trauma. METHODS Fifty-five male Sprague-Dawley rats were used in the study. Sham, control, BS and IL-10 groups were created. A pulmonary contusion was created by performing isolated blunt thoracic trauma in all groups except for the sham group. The traumas severity was determined as 1.45 J. BS and IL-10 were administered orogastrically to the respective groups 30 min before trauma, and orogastrically and intraperitoneally, respectively, on the first and second days after the trauma. Only the blunt thoracic trauma was performed for the control group. SatO(2), PaO(2) and PaCO(2), blood glutathione, malondialdehyde (MDA) and tumour necrosis factor-α (TNFα) values were recorded on the zeroth, first, second and third days. The histopathological examination and the bronchoalveolar lavage cell count were performed on pulmonary tissues. RESULTS Blood gas analysis revealed that SatO(2) and PaO(2) values on the first and second days were significantly lower in the control, BS and IL-10 groups compared with the sham group (P < 0.05). The SatO(2) and PaO(2) values on the third day in the BS and IL-10 groups were higher than in the control group (P < 0.05). The mean MDA in the control group was higher than in the sham, BS and IL-10 groups (P < 0.05). The mean TNFα in the control group was higher than in the sham, BS and IL-10 groups (P < 0.05). Pulmonary pathology scoring in the control group was observed to be higher than in the sham, BS and IL-10 groups (P < 0.05). CONCLUSION In this rat experiment model in which an isolated pulmonary contusion was created by blunt trauma, BS and IL-10 were observed to reduce contusion severity in the lung and minimize the inflammatory reaction.

Comparison of Transcutaneous Electrical Nerve Stimulation and Paravertebral Block for Postthoracotomy Pain Relief

BACKGROUND Inadequate relief of postthoracotomy pain is a major reason of increased occurrence of postoperative complications. We aimed to investigate and compare the effects of transcutaneous electrical nerve stimulation (TENS) and paravertebral block (PVB) to relieve pain after thoracotomy procedures. MATERIALS AND METHODS We studied 40 patients who underwent thoracotomy. Patients were randomly allocated to receive either PVB (group P, n = 20) or TENS (group T, n = 20) for postoperative pain. The electrodes of TENS were placed 2 cm under and 2 cm over the thoracotomy cut on both posterior and anterior sides. The surgeon inserted paravertebral catheters using direct vision at the end of the surgery. A patient-controlled analgesia (PCA) device was connected to all patients. Visual analog scales, patient demand, and consumption of tramadol were evaluated postoperatively. RESULTS Mean visual analog scale (VAS) values were significantly lower in group P for all time points. The patients in group P needed lower amounts of opioid (tramadol) and the difference was statistically significant (258.4 ± 13.52 mg vs. 314.4 ± 8.65 mg, p = 0.005). In addition, the number of demand attempts recorded from the PCA device was significantly lower in group P (14.95 ± 13.64 vs. 26.7 ± 17.34, respectively and p < 0.001). CONCLUSION TENS has beneficial effects for pain relief after thoracotomy, without any side effects; however, it cannot provide sufficient pain relief when compared with PVB.

Paralysis of cranial nerve and striking prognosis of cervical necrotizing fasciitis.

Necrotizing soft-tissue infection (NSTI) is a bacterial infection with necrosis of the cutaneous, subcutaneous tissue and fascia with sparing of the underlying muscle. The most frequent initiating factor reported, for necrotizing fasciitis, in the head and neck region is a primary odontogenic infection or postextraction infection, abrasion, and laceration of the face or scalp. Necrotizing fasciitis can progress rapidly to systemic toxicity and even death if not promptly diagnosed and treated. If the patient has any risk factors, this can worsen the prognosis. In this study, 2 cases of NSTI with dental pathology history (one with the spreading to mediastinum and the other spreading to suprahyoid) were discussed with a review of the literature. One of the cases had diabetes mellitus, but interestingly, she had a better prognosis, and she was discharged asymptomatic. In addition, the other case had no any risk factors, but he had a worse clinical cranial nerve paralysis (a rare complication of NSTI) and died. As a conclusion, despite the intensive therapy, large debridement, and antibiotics with large spectrum, the delay in the patients diagnosis and treatment increased mortality. We aimed to attract attention to the importance of dental pathologies and early diagnosis.

Thoracic epidural anesthesia in a geriatric patient with cardiac risk: a case report

With increasing life quality, older population increase fastly. Cardiac and respiratory disorders and autonomic dysfunction seem to occur more frequently in older people.1 Unfortunately this circumstance limits choosing anesthetic methods for these patients. Epidural anesthesia or analgesia can decrease the potential complications due to general anesthesia such as prolonged ventilation, myocardial depression and prolonged ileus.2 Fifth cot resection was planned to a 83 years old man with 168 cm height and 68 kg weight due to the chest wall hydatic cysts. His past medical history revealed that he had high degree heart insufficiency, epilepsy, dyspnea and a pacemaker for five years. He had cholecystectomy and inguinal hernia repair surgeries done 20 years and 10 years ago respectively. He was oriented, cooperative and hemodynamically stable. Physical examination revealed basal rales and rhonchi. The ejection fraction was assessed as 33% by echocardiography. He was evaluated as ASA III. Cardiac treatment was given him according to cardiologist suggestion preoperatively and epidural anesthesia was planned for surgery. No premedication was given before arrival to the operating room. After routine monitoring, peripheral intravenous access was provided and preloading of isotonic solution was given. Epidural catheter was inserted between T4 and T5 intervertebral spaces with a loss of resistance method at sitting position. The catheter tip was set forward to 3 cm cephale and the test dosage of 3 mL 2% Lidocain was applied. Then, 7 mL 5% levobupivacaine and 50 mcg fentanyl were added. Ten minutes later from the application of epidural anesthesia adequate sensorial blockage level was provided between T3 and T8 spaces. Surgical procedure was performed with standard technique at lateral decubitus position. 4 lt/min oxygen was given with a face mask. During surgery, his blood pressures were between 154/94 and 97/54 mmHg, heart rates were 65--108 min−1 and saturations were 89--96%. Approximately 15 min after epidural anesthesia, his blood pressure was recorded as 76/45 mmHg; therefore 5 mg Efedrin was applied intravenously. Simultaneously evaluated sensorial blockage level was T4. Patient has no additional sedation and analgesia requirements during the surgery which lasted 45 min. He had no respiratory distress intraand post-operatively. For epidural analgesia 3 mL 5% bupivacaine + 50 mcg fentanyl mixture was applied through the epidural catheter three hours after surgery. Epidural catheter was drawn 24 h later. The patient was discharged with stable vital signs four day after surgery. High thoracic anesthesia (T1--T5) decreases sempatic tone; however dysrhythmia risk is reduced by blockading cardiac accelerator fibers during cardiac surgery.3 Niimi et al. reported that high thoracic epidural anesthesia decreased cardiac output but did not affect left ventricular ejection fraction and diastolic filling function.4 Rodgers et al. reported that perioperative cardiac complications were less in patients undergoing surgical operations with regional anesthesia.5 We applied successful high thoracic epidural anesthesia to our high-risk patient with arrhythmia and low ejection fraction undergoing cot resection.

Swyer-James syndrome or destroyed lung?/Coronary artery bypass in a patient with Swyer-James syndrome due to pulmonary tuberculosis

1. Selbst SM, Ruddy RM, Clark BJ, Henretig FM, Santulli T Jr. Pediatric chest pain: a prospective study. Pediatrics 1988; 82:319-23. 2. Biteker M, Ekşi Duran N, Sungur Biteker F, Ertürk E, Aykan AC, Civan HA, et al. Kounis Syndrome secondary to amoxicillin/clavulanic acid use in a child. Int J Cardiol 2009;136:e3-5. 3. Paç FA, Çağdaş DN, Ulaş M, Özatik MA, Paç M. Left main coronary artery and aortic root compression associated with atrial septal defect and pulmonary hypertension. Int J Cardiol 2007; 118:e 41-3.

Sleeve resections for squamous cell carcinoma of the lung.

BACKGROUND Sleeve resection is an advanced technique that was developed as an alternative to pneumonectomy. This study evaluated our cases of sleeve resection for squamous cell carcinoma of the lung and compared the outcomes with the literature reports. METHODS In total, 26 bronchial, 5 bronchovascular, and 3 vascular sleeve lobectomies were performed between January 2000 and July 2005 in our clinic. Age, gender, operations, postoperative diagnosis and staging, and postoperative morbidity and mortality were evaluated. RESULTS Sleeve resections were performed in 34 patients. All patients were male, with a mean age of 59.4 years. The operations consisted of 16 right upper, 14 left upper, and 1 left lower sleeve lobectomies and 3 superior sleeve bilobectomies. The most common postoperative pathological staging group was stage IIb (32.3%). Operative mortality was 5.9% (n=2). Postoperative morbidity was 20.5% (n=7), including 4 prolonged air leaks plus empyema, 1 prolonged air leak, 1 postoperative bleeding needing revision, and 1 severe bronchostenosis; of these, 6 had persistent atelectasis. The local tumour recurrence rate was 11.7% (n=4). The median survival time and 5-year survival were 36 months and 42%, respectively. CONCLUSIONS Sleeve resection proved to be good therapy for lung cancer and has a lower morbidity and mortality than standard pneumonectomies and results in better lung function and quality of life. The anastomosis-related complications are experience-related technical complications and training thoracic surgeons to perform SRs at experienced centres will reduce the morbidity associated with SRs.