Hasan Fevzi Batirel

Complications and management of long-term central venous access catheters and ports.

Purpose Although prolonged venous access devices (PVADs) are used in case prolonged intravenous therapy is required, implantation and use of these devices is associated with complications. The purpose of this study was to evaluate perioperative and long-term complications associated with PVADs and the management of these complications. Methods A retrospective review was undertaken of 225 PVADs implanted in 217 patients from February 1993 to June 2004. This included 144 single-lumen port infusion systems, 49 single-lumen Hickman® catheters and 32 double-lumen Groshong® catheters. The PVADs were inserted using either the percutaneous Seldinger method (n=183) or cutdown access to the subclavian vein (n=42). Indications for placement were as follows: chemotherapy in 66.2% of patients, drug-infusion treatment in 31.6% of patients and total parenteral nutrition in 2.2% of patients. Results Perioperative complications occurred in 13 patients (5.7%): catheter malposition in seven patients (3.1%), pneumothorax in three patients (1.3%), hemorrhage in two patients (0.9%) and catheter embolization in one patient (0.4%). Long-term complications appeared in 15 patients (6.6%): infection in five patients (2.2%), thrombosis in three patients (1.3%), extravasation in three patients (1.3%), and catheter fracture in four patients (1.8%). The fractured fragments were removed by the Amplatz® snare device. In 10 patients (4.4%) only were PVADs removed prior to completion of the intended therapy. Indications for removal were catheter infection in five patients (2.2%) and catheter fracture in five patients (2.2%). Conclusions PVAD implantation is associated with some risk of serious perioperative and long-term complications. Care of the catheter and the patient should be maintained with the proper and immediate evaluation of the perioperative and long-term complications.

Trimodality Treatment of Malignant Pleural Mesothelioma

Introduction: Multimodality treatment has achieved significant success in local control and treatment of early-stage malignant pleural mesothelioma patients. However, its favorable effect on survival is questionable. Methods: We have instituted a trimodality treatment protocol consisting of extrapleural pneumonectomy, adjuvant high-dose (54 Gy) hemithoracic irradiation, and platin-based chemotherapy in a multi-institutional setting. Preoperative pulmonary function tests, echocardiogram, chest computed tomography, and magnetic resonance imaging scans were performed in all patients. Twenty patients have been treated with this protocol during 2003–2007. Seventeen had a history of environmental asbestos/erionite exposure. Clinical stages were T1-3N0-2. Results: Median age was 56 (41–70, 8 female). There was one postoperative mortality (% 5) due to ARDS. Morbidity occurred in 11 patients (% 55). Histology was epithelial in 17, mixed in 2, and sarcomatoid in 1. Sixteen patients underwent extrapleural pneumonectomy. Microscopic margin positivity was present in 14 patients with macroscopic complete resection. Twelve patients completed all three treatments. Median follow-up was 16 months (1–43). Overall median survival was 17 months (24% at 2 years). Eight patients had extrapleural lymph node involvement (internal mammary [n = 3], subcarinal [n = 2], pulmonary ligament [n = 1], diaphragmatic [n = 1], subaortic [n = 1]). There was better survival in patients without lymph node metastasis (24 versus 13 months median survival, p = 0.052). Currently, 7 patients are alive, 6 without recurrence, and 2 patients at 40 and 45 months. Conclusions: Trimodality treatment in malignant pleural mesothelioma seems to prolong survival in patients without lymph node metastasis. Novel techniques are needed for preoperative assessment of extrapleural lymph nodes.

Isolated primary chylopericardium.

Isolated primary chylopericardum is known to be a rare clinical entity. A 17-year-old girl was diagnosed as isolated primary chylopericardium. She was unresponsive to conservative treatment with pericardial tube drainage and medium chain triglyceride diet. At 2 weeks after the conservative treatment, ligation and resection of the thoracic duct with establishment of a pericardial window through a left thoracotomy was performed. At 6 months, follow-up showed no accumulation of the pericardial fluid. This case also supports that ligation and resection of the thoracic duct with establishment of a pericardial window is the treatment of choice in isolated primary chylopericardium.

Correlation between sizes and intracystic pressures of hydatid cysts.

BACKGROUND A bicentral prospective study was performed to assess the relationship between sizes and intracystic pressures (ICP) of pulmonary hydatid cysts as well as to compare these measurements in different age groups. METHODS A total of 20 patients with 22 unperforated pulmonary hydatid cysts underwent surgery between April 1994 and September 1995. There were 12 males and 8 females with a mean age of 25.7 (7-62). Intraoperatively, ICPs were measured in cmH2O by direct cannulation. RESULTS Out of a total of 22 cysts, 12 were located in the lower lobes. Mean diameter, volume and ICP of cysts were 9.6 cm (S.D. 4.2), 728.8 cm3 (S.D. 1014.9) and 36.6 cmH2O (S.D. 9.3), respectively. There was no significant correlation between various measurements of hydatid cysts, namely their short and long diameters, volumes and intracystic pressures (P > 0.05). There was no difference regarding the volume, ICP and age of patients, either among pulmonary lobes or between sexes. Patients who were 20 years old and less, presented a mean cystic diameter of 7.2 cm and mean ICP of 35.1 cmH2O, whereas the over 20 age group showed results of 11.9 cm and 38.1 cmH2O, respectively (P values were < 0.0083 for diameter and > 0.05 for ICP). CONCLUSIONS Due to the small sample size and a few extreme measurements, the correlation between the sizes and the pressures of hydatid cysts turned out to be insignificant, but it is believed that a positive correlation is most probable with larger sample sizes. On the other hand, while the difference between the mean cystic diameters in age groups of below and over 20 was significant, the pressure difference between them was insignificant. This is why young patients carry the same risk of perforation as adults, although they present with relatively smaller cysts. Therefore, due to the well-known anaphylactic, obstructive and infectious risks of hydatid cyst perforation, urgent surgical removal is always necessary.

Local recurrence of tumor at sites of intervention in malignant pleural mesothelioma

In malignant pleural mesothelioma (MPM) patients, local dissemination (LD) of the tumor is frequently observed at the sites of intervention where diagnosis/treatment are performed. We evaluate the factors affecting LD frequency and discuss the use of PR in MPM patients. Histopathologically diagnosed 212 MPM patients who had not received PR were evaluated in terms of development of LD. Of the 212 patients, 29 received supportive therapy, 157 received chemotherapy and 26 received multi-modal therapy. The LD frequency was 13.2% for all patients. The median survival rate was 9 or 10 months in patients with or without LD, respectively. A higher LD frequency was observed in patients receiving thoracotomy. The LD appearance time in supportive care is short. The LD frequency in patients treated with chemotherapy that revealed progressive disease was higher than the patients who revealed stable disease or objective response. LD developed in 2 months in patients with sarcomatous and mixed cell type, and the survival rate was low. LD was not associated with the stage of the disease. The most suitable candidate groups for PR are patients receiving supportive therapy, thoracotomy without multi-modal therapy or patients with sarcomatous and mixed cell type tumors.

Adoption of pleurectomy and decortication for malignant mesothelioma leads to similar survival as extrapleural pneumonectomy

OBJECTIVE We changed our surgical approach to malignant pleural mesothelioma (MPM) in August 2011 and adopted pleurectomy and decortication (PD) instead of extrapleural pneumonectomy (EPP). In this study, we analyzed our perioperative and survival results during the 2 periods. METHODS All patients who underwent surgical intervention for MPM during 2003-2014 were included. Data were retrospectively analyzed from a prospective database. Before August 2011, patients underwent evaluation for EPP and adjuvant chemoradiation (group 1). After August 2011, patients were evaluated for PD and adjuvant chemotherapy and/or radiation (group 2). Demographic characteristics, surgical technique, histology, side, completeness of resection, and types of treatments were recorded. Statistics was performed using Student t test, χ(2) tests, uni- and multivariate regression, and Kaplan-Meier survival analysis. RESULTS The same surgical team operated on 130 patients. Median age was 55.7 years (range, 26-80 years) and 76 were men. EPP and extended PD was performed in 72 patients. Ninety-day mortality was 10%. Median survival was 17.8 months with a 5-year survival rate of 14%. Uni- and multivariate analyses showed that epithelioid histology, stage N0, and trimodality treatment were associated with better survival (P = .039, P = .012, and P < .001, respectively). Demographic variables and overall survival (15.6 vs 19.6 months, respectively) were similar between the groups, whereas nonepithelioid histology, use of preoperative chemotherapy, and incomplete resections were more frequent in group 2 (P < .001, P < .001, and P = .006, respectively). Follow-up was shorter in group 2 (22.5 ± 20.6 vs 16.4 ± 10.9 months; P < .001). CONCLUSIONS Adoption of PD as the main surgical approach is not associated with survival disadvantage in the surgical treatment of MPM.

The effect of aqueous garlic extract on the levels of arachidonic acid metabolites (leukotriene C4 and prostaglandin E2) in rat forebrain after ischemia-reperfusion injury

Leukotriene C4 (LTC4) and prostaglandin E2 (PGE2) are known to be highly potent cerebral vasoconstrictors which are formed from arachidonic acid (AA). They enhance vascular permeability, inducing vasogenic edema that may damage the ischemic penumbra after ischemia and reperfusion. The inhibitory effect of aqueous garlic extract (AGE) on AA metabolism in human platelets is known. In this study, following the global ischemic model application to the rats, all underwent 10 min ischemia and were reperfused for different periods. The levels of LTC4 and PGE2 in rat forebrain were then measured. One rat group consisted of 8 rats. In the combined reperfused groups both metabolites increased significantly when compared with the 10 min ischemia alone, no reperfusion group (p < 0.05). In the 8 min reperfused group, PGE2 and LTC4 levels increased significantly at 60 min of reperfusion compared with each corresponding control group (P < 0.005). PGE2 and LTC4 levels were reduced significantly at 60 min of reperfusion compared with the 8 min reperfused group (P < 0.005). AGE (1 ml/kg) reduced both LTC4 and PGE2 levels significantly in the 8 min and 60 min reperfused group (P < 0.001, P < 0.001, P < 0.05, P < 0.01). In conclusion, AGE reduced LTC4 and PGE2 levels at a dosage of 1 ml/kg following 8 and 60 min reperfusion. It may be helpful in reducing AA metabolite levels and preventing injury after ischemic phenomena.

Original ArticleIASLC Staging Committee ArticleThe IASLC Mesothelioma Staging Project: Proposals for Revisions of the T Descriptors in the Forthcoming Eighth Edition of the TNM Classification for Pleural Mesothelioma

Introduction: The current T component for malignant pleural mesothelioma (MPM) has been predominantly informed by surgical data sets and consensus. The International Association for the Study of Lung Cancer undertook revision of the seventh edition of the staging system for MPM with the goal of developing recommendations for the eighth edition. Methods: Data elements including detailed T descriptors were developed by consensus. Tumor thickness at three pleural levels was also recorded. An electronic data capture system was established to facilitate data submission. Results: A total of 3519 cases were submitted to the database. Of those eligible for T‐component analysis, 509 cases had only clinical staging, 836 cases had only surgical staging, and 642 cases had both available. Survival was examined for T categories according to the current seventh edition staging system. There was clear separation between all clinically staged categories except T1a versus T1b (hazard ratio = 0.99, p = 0.95) and T3 versus T4 (hazard ratio = 1.22, p = 0.09), although the numbers of T4 cases were small. Pathological staging failed to demonstrate a survival difference between adjacent categories with the exception of T3 versus T4. Performance improved with collapse of T1a and T1b into a single T1 category; no current descriptors were shifted or eliminated. Tumor thickness and nodular or rindlike morphology were significantly associated with survival. Conclusions: A recommendation to collapse both clinical and pathological T1a and T1b into a T1 classification will be made for the eighth edition staging system. Simple measurement of pleural thickness has prognostic significance and should be examined further with a view to incorporation into future staging.

The principles of surgical management in dumbbell tumors

OBJECTIVE Tumors located in posterior mediastinum that extends into spinal canal via intervertebral foramen are called as Dumb-bell or Sand-glass tumors. Most of these tumors are neurogenic in origin but sometimes other rare tumors can also form in this shape. Herein three neurogenic tumors of the mediastinum that extended into the spinal canal are presented METHODS In all patients that have been operated in our clinic during 1992-1993, we preferred one-stage removal described by Akwari that consists of posterior laminectomy by neurosurgical team to free the tumor within the spinal cord followed by a posterolateral thoracotomy and excision of the tumor by thoracic surgeons in the same setting. RESULTS All three patients are alive and free of symptoms after 23, 16 and 13 months respectively. According to the pathological examinations of the specimens in the three patients, the exact diagnosis were reported as neurofibroma, paraganglioma and pheochromocytoma respectively. CONCLUSIONS In recent reports, a combined surgical approach is recommended for dumb-bell neurogenic tumors in posterior mediastinum. We also recommend a combined and one stage removal of dumb-bell neurogenic tumors if possible. A team-work of thoracic and neurosurgeons will minimize the morbidity and mortality after the surgical procedure, as well as giving the opportunity to remove the tumor totally in one session.

Approach to Fragmented Central Venous Catheters

Prolonged venous access devices are needed in cancer patients for central venous access. Catheter fragmentation leading to catheter malfunction represents a rare problem. Herein we present our experience in the management of fragmented catheters. Between 2001 and 2003, 183 catheters were placed via the subclavian vein, and five cases of fragmented catheters were observed. Fragments were removed by an Amplatz gooseneck snare (Microvena, St. Paul, MN) with angiographic intervention. The diagnosis of the breakage was made by chest radiography. The incidence of catheter rupture was 2.7%. All fragments were removed by the snare, without any complications. Catheter narrowing and breakage owing to its medial positioning in the subclavian vein were the main causes of catheter malfunction. In any case of catheter malfunction, radiologic evaluation of the catheter must be done to rule out its rupture. Removal of the fragments using the Amplatz snare is a safe and easily applied procedure.