İlker Ökten

Management of Esophageal Perforation

Abstract Despite recent advances in thoracic surgery, the management of esophageal perforation remains problematical and controversial. Thirty-one patients were treated for an esophageal perforation between 1986 and 1998. The esophageal perforation was iatrogenic in 25 cases, spontaneous in 2, traumatic in 2, and caused by a tumor and tuberculous lymphadenitis in 2 patients. There were 10 cervical, 19 thoracic, and 2 abdominal perforations. The interval from perforation to operation was less than 24 h in 12 patients and more than 24 h in 19 patients. The surgical procedures included a primary repair in 12 patients, a resection in 8, and conservative treatment with minor surgical approaches in 11. The mortality rate was 20% (4/20 patients) in the surgical treatment group and 45.5% (5/11 patients) in the conservative treatment with minor surgery group. The overall mortality was 29% (9/31 patients). The prognosis is thus concluded to depend on the cause and location of the perforation, the presence of underlying esophageal diseases, and the surgical procedure chosen.

Transthoracic approach in surgical management of Morgagni hernia

OBJECTIVE Morgagni hernia is an uncommon type of diaphragmatic hernias. Numerous approaches have been described and, particularly the significance of laparatomy has been emphasized as an operative technique. We present our experience on patients with Morgagni hernia operated on via transthoracic approach in our department. MATERIALS AND METHODS Between January 1986 and March 2000, 16 patients with Morgagni hernia were operated in our department. Their ages ranged from 16 to 68 years (mean 51.5). Five (31.25%) patients were male, and 11 (68.75%) patients were female. Chest roentgenograms, thorax CT, barium enema roentgenographic studies were used as diagnostic utilities. Right posterolateral thoracotomy was performed in all patients. RESULTS Hernia sac was present in all cases. Exploration revealed omentum in hernia sac in eight patients (50%), colon and omentum in seven patients (44%), only colon in one patient (%6). Postoperative course was uneventful. The mean follow-up was 5.7 years. There was no recurrence or symptoms related to the operation. CONCLUSIONS We advocate transthoracic approach for surgical exposure as it provides wide exposure and easy repair of the hernia sac in Morgagni hernia.

Parenchyma-Preserving Surgery in the Management of Pulmonary Hydatid Cysts

Pulmonary hydatid cysts remain a significant health problem in endemic regions like Turkey. Here, we present our surgical experience in patients with pulmonary hydatid cysts. Between January 1985 and January 2001, 1118 operations were performed in 1032 patients (528 males, 504 females; mean age 32.7 years; range 1–87 years) with pulmonary hydatid cysts in our department. Posterolateral thoracotomy was performed in 1015 (98.3%), two-stage thoracotomy in 34 (3.3%), and median sternotomy in 17 (1.7%) patients. We preferred conservative surgical procedures. As a surgical procedure, cystotomy and capitonnage was performed in 626 (56%), cystotomy alone in 368 (33%), wedge resection in 81 (7%), enucleation in 29 (3%), and decortication in 11 (1%) patients. None of our patients were treated with anatomic resection. During surgery, 949 patients (92%) had unruptured and 83 patients (8%) had ruptured hydatid cyst. The morbidity ratio was 6.7%. Major complications were wound infection (2.3%), prolonged air leak (1.9%), atelectasis (1.2%), pleural effusion (0.8%), postoperative hemothorax (0.6%), and empyema (0.3%). Two patients (0.2%) died within the first month postoperatively. Mean follow-up was 31.2 months. Recurrence was detected in only 35 patients (3.3%). Treatment of pulmonary hydatid cyst is primarily surgical. Medical treatment is indicated for recurrent and multiple hydatid cysts postoperatively. Cystotomy alone, or cystotomy and capitonnage, as parenchyma-preserving surgery, is preferred. Radical surgery including pneumonectomy, lobectomy, and segmentectomy should be avoided.

Surgical treatment of peripheral lung cancer adherent to the parietal pleura

OBJECTIVES The objective of this paper is to assess the results of surgical treatment retrospectively in a consecutive series of 85 patients with peripheral non-small cell lung cancer (NSCLC) invading parietal pleura and chest wall. METHODS From 1994 to 1998, of the 572 patients having pulmonary resection for NSCLC, 29 patients with neoplasm involving the parietal pleura (group I) and 56 with that invading the chest wall (group II) underwent resection. RESULTS The operative mortality rate was 3.4% in group I and 1.8% in group II. In groups I and II, pathologic N status was N0 in 20 (69%) cases, N1 in five (17%), N2 in four (13.8%) and 44 (78.6%), seven (12.5%), five (8.9%), respectively. An incomplete resection (R1) was performed in two (6.9%) patients in group I and seven (12.5%) in group II. Postoperative radiotherapy was carried out in 18 patients in group I and 46 in group II. Systemic chemotherapy was also administered in seven patients in group I and eight in group II. There was a significant difference in adjuvant therapy between the groups (P<0.05). Two patients (R1) in group I (7.4%) and 12 patients (seven patients R1+5 R0) in group II (24%) had local recurrence. There was no significant difference in local recurrence between the groups (P=12). Follow-up was completed in 79 cases (28 in group I and 51 in group II). Median survival for groups I and II were 27+/-6 and 16+/-4.6 months, respectively. Five-year survival was longer in group I than in group II (33 vs. 14%), but there was no significant difference (P=13). CONCLUSIONS We found similar survival rates for extrapleural resection in limited parietal pleura invasion and chest wall resection in exceeded-beyond-parietal pleura invasion. The completeness of resection is important in both groups.

Comparison of Mersilene Mesh–Methyl Metacrylate Sandwich and Polytetrafluoroethylene Grafts for Chest Wall Reconstruction

We report the outcomes of patients who underwent reconstruction with Mersilene mesh–methyl methacrylate (MM–MM) sandwich and polytetrafluoroethylene (PTFE) grafts after a large chest wall resection. Between June 1990 and September 2001, 59 consecutive patients (37 men, 22 women; mean age, 48.1 ± 11.8 years; range 22–74 years) underwent large chest wall resection (greater than 5 cm diameter) and reconstruction with prosthetic material in our department. Twenty-one patients (33%) underwent reconstruction with a PTFE graft (group 2) between 1990 and 1994, and 38 patients (67%) underwent reconstruction with an MM–MM sandwich graft (group 1) between 1994 and 2001. Operative morbidity ratios were 5.2% (2/38) in group 1 and 24% (5/21) in group 2 (p =. 036). The paradoxical respiration ratio was significantly higher (p =. 018) in group 2 (5/21: 24%) than it was in group 1 (1/38: 2.6%). The operative mortality ratio was 4.5% (1/21) in group 2 and 0% in group 1. Mean hospital stay was 10.6 days (range 5–21 days) in group 1 and 13.3 days (range 7–36 days) in group 2 (p =. 015). The MM–MM graft is inexpensive and easy to apply, provides better cosmetic options, and offers minimal morbidity. We therefore recommend that the MM–MM sandwich graft be used rather than the PTFE graft for large defects of the anterolateral chest wall and sternum where successful prevention of paradoxical respiration is required.

An unusual foreign body in the esophagus: report of a case.

Foreign body ingestion occurs commonly in children and in specific high-risk groups of adults. Foreign bodies in the gastrointestinal tract can result in serious complications depending on the size and shape of the ingested object. This report presents a patient with an unusual foreign body in the esophagus.

Benign Localized Fibrous Tumor of the Pleura: Report of 25 New Cases

OBJECTIVE Benign localized fibrous tumors (BLFT) of the pleura are very rare slow-growing neoplasms that generally have a favorable prognosis. The aim of this manuscript is to evaluate the predictors of outcome with the review of the literature in a series of 25 patients with BLFT. METHODS Between January 1985 and November 2009, 25 patients underwent an operation due to BLFT. Of these patients, 14 (56%) were male; mean age was 41.1 (25 to 64) years. All patients underwent thoracotomy. Left thoracotomy approach was used in 16 patients. The mass lesions were totally excised. The histopathological examinations were performed with hematoxylin-eosin and immunohistochemical staining methods. RESULTS Of the patients, 18 (72%) were symptomatic. Symptoms were cough in 36%, shortness of breath in 32%, and chest pain in 20% of the patients. One patient (4%) appeared to have some symptoms (pain and swelling of the joints) associated with pulmonary osteoarthropathy. Seven patients (28%) underwent an operation due to mass lesion detected at routine control visits. None of the patients had a history of exposure to asbestos. Radiological investigations revealed 16 (64%) mass lesions in the left. Of the lesions found on exploration, 5 (20%) were intrapulmonary localized lesion without pedicle and 20 were pedicled. Of the pedicled masses, 5 were connected to parietal pleura and 15 to visceral pleura and all were intrathoracic extrapulmonary localized lesions. Eight (32%) lesions connected to left lower lobe. Additionally, three pedicled lesions were located in the lung fissure. Pedicled lesions were totally excised together with their pedicles. Intraparenchymal mass lesions were resected using wedge resection. The diameter of the resected masses was ranging between 3 and 22 cm (mean: 8.7). Macroscopically, all were encapsulated with a homogeneous cut surface. Intraoperative mortality and morbidity was not observed. The average hospitalization duration for all patients was 8.6 days (5 to 12). The mean follow-up was 33.6 (9 to 142) months with no recurrence. CONCLUSIONS Benign localized fibrous tumors are uncommon and treated by surgical means. According to our data obtained from literature review, clinicians should be aware of recurrence possibility even after complete resection of benign localized fibrous tumor and the risk of malign transformation.

THE COEXISTENCE OF THYMIC CARCINOMA AND MULTIPLE GRANULOMAS IN A TURKISH CHILD

Thymic carcinoma, which is a thymic epithelial neoplasm with obvious cytologic atypia, is a rare neoplasm. The authors report on a 10-year-old boy who presented with respiratory distress due to bulky anterior mediastinal mass. Histological and immunohistochemical studies confirmed a lymphoepithelioma-like pattern thymic carcinoma. In addition, evaluation of the specimen showed foci of caseation and multiple granulomas with extensive central necrosis within the thymic tissue. The child received chemotherapy, followed by surgery and radiotherapy. To rule out difficulties of tuberculosis he also received antituberculosis therapy. Two years after cessation of treatment, he is still in remission for thymic carcinoma.

Female and male differences in the survival of patients undergoing resection for lung cancer.

Abstract Objective: In recent years much attention has been focused on the rapidly increasing incidence of primary lung cancer in women. The aim of this study was to determine gender differences in patients treated surgically for lung cancer. Methods: We performed a retrospective review of patients who had lung resection for primary lung cancer from January 1994 to December 1998. Results: There were 530 men and 42 women. Women were younger than men (55.6 ± 10 versus 57 ± 9.9). The difference was not statistically significant (p = 0.9). The mean cigarette consumption was greater in men than in women (p < 0.001). We observed a higher operative morbidity and mortality rate in men compared to women (p < 0.05). Men had more squamous cell carcinoma (61.7%). In female patients, squamous cell cancer and adenocarcinoma were found with almost the same incidence (35.7% versus 33.3%). There was a significant difference in the distribution of cell types (p < 0.001). Pathologic stages for women were; I = 38.2%, II = 21.4%, IIIa = 21.4%, IIIb = 9.5%, IV = 9.5% and for men; I = 40.4%, II = 26.6%, IIIa = 24%, IIIb = 6%, IV = 3%. There was no significant difference in the stage distribution between genders (p = 0.2). Median survival for female and male patients were 38 ± 9.2 and 35 ± 3.2 months. Female patients’ survival was longer than male patients but the difference was not statistically significant (p > 0.05). Conclusions: This study emphasizes sex differences in cigarette consumption, operative mortality and the distribution of cell types of patients with primary lung cancer. These initial results should strongly encourage additional studies in different countries on the interaction between sex and lung cancer characteristics to improve clarity.

Özofagus Kanserinde Helicobacter Pylori ve Barret Özofagus’un Rolü = The Role Of Helicobacter Pylori And Barretts Esophagus In Esophageal Cancer

Ozofagus kanserlerinin gelisiminde; sigara ve alkol kullanimi, beslenme ile ilgili etkenler, genetik ve cevresel faktorler ve bazi predispozan hastaliklar rol almaktadir. Peptik veya kostik ozofajit, Barret ozofagus, Plummer Winson Sendromu, akalazya, tylosis, gluten enteropatisi gibi hastaliklar predispozan hastaliklardir. Ozofagus kanseri olusumunda Barret ozofagusun onemli bir predispozan faktor oldugu tum otorler tarafindan kabul edilmektedir. Helicobacter pylori’nin ise predispozan rol aldigini belirten yayinlar olmakla birlikte bunun tersini iddia eden gorusler de ortaya atilmistir