Koray Dural

A comparison of epidural and paravertebral catheterisation techniques in post-thoracotomy pain management

BACKGROUND Thoracotomy is a surgical procedure associated with severe pain. Operative morbidity rates reduce by effective postoperative pain control. The aim of this study is to compare the effectiveness of the thoracic epidural blockade (TEB) and the paravertebral blockade (PVB) methods in relieving the pain caused by a thoracotomy incision. MATERIALS AND METHODS We studied 44 consecutive patients who underwent elective posterolateral thoracotomy. The patients were classed into two groups: TEB (n=19) and PVB (n=25). Patients in both the groups could self-control the infusion of bupivacaine infusion and diclofenac sodium. The groups were compared according to the parameters such as analgesic efficacy (VAS), respiratory function tests (forced expiratory volume in 1s (FEV(1)), peak expiratory flow rate (PEFR) and arterial blood gases), stress response (serum cortisol and glucose levels), adverse effects, necessity for additional analgesia, duration of catheter application procedure, mean hospital stay and postoperative follow-up. Results are analysed statistically by Mann-Whitney U, Wilcoxon, chi-square and Fishers exact tests, and a p-value of <0.05 was accepted to be statistically significant. RESULTS There was no significant difference between the two groups with regard to age, gender, VAS, FEV(1), PEFR, serum cortisol and glucose levels, necessity for additional analgesia and hospital staying days. In contrast, adverse effects and duration of catheterisation were statistically significantly lower in group PVB (p=0.001 and p<0.001, respectively). CONCLUSION PVB catheterisation can be easily performed and placed in a short span perioperatively. Therefore, it might be the preferred method over TEB which has a high incidence of adverse effects and complication rates.

Cystic lymphangioma: report of two atypical cases

Cystic lymphangioma is an uncommon congenital benign neoplasm, which frequently occurs to children and young adults and acquired form may be detected in middle-aged adults. Cystic lymphangioma usually appears in the neck, the axillary region, and the mediastinum. In the first case, cystic lymphangioma located in the posterior mediastinum extending over the vertebral column to the both hemi thoraces. In the second one, it was palpated on the posterior chest wall at the level of T6-8 vertebrae. In the view of literature, these cystic lymphangioma are accepted to be atypical because of their locations.

Pseudoaneurysms of the popliteal and tibioperoneal arteries after gunshot injuries

BACKGROUND Pseudoaneurysms (PsAns) of the popliteal and tibioperoneal arteries are very rare and occur as a late complication after arterial injury. This study was undertaken to describe the management of PsAns of the popliteal and tibioperoneal arteries after gunshot injuries in a civilian vascular surgical unit with a large trauma workload. METHODS A retrospective review of the records of nine patients treated between January 1998 and November 2001 at the Thoracic and Cardiovascular Surgery Department of Numune Education and Research Hospital was undertaken. RESULTS Nine PsAns of the popliteal and tibioperoneal arteries after gunshot injuries were treated. The delay in diagnosis from the time of injury ranged from 15 days to 14 months, with a median delay of 75 days. One case with graft occlusion was noticed in a patient with a popliteal artery PsAn. In these cases, the early and late patency rate and limb salvage were 100%. CONCLUSION Early diagnosis of popliteal and tibioperoneal PsAns is an important factor in successful surgical reconstruction. The operative procedures will be simple if the interval between injury and operation is short, and surgical treatment for PsAns includes reconstruction of both arterial and venous arteries.

Transaxillary approach in thoracic outlet syndrome: the importance of resection of the first-rib

OBJECTIVE The aim of this study was to analyze the transaxillary surgical approach and results of thoracic outlet cases in our clinic in the light of the recent literature data. METHODS Between 1996 and 2002 a series of 35 cases diagnosed as thoracic outlet syndrome (TOS) hospitalized and surgically treated in our clinic have been studied retrospectively. RESULTS Twenty-six of our cases were females (75%) and the mean age was 25+/-1 (17-40 years). The most important symptom was localized pain in the arm. In 90% of the cases the Adson, hyperabduction and abduction external rotation (AER) tests were positive. There was paresthesia in 30 cases (85%), atrophy in 3 cases (10%), and cyanosis in 6 cases (20%). Preoperative electromyogram (EMG) was demonstrated as 56.7 m/s (50-65) and postoperative EMG was demonstrated as 65.1 m/s (60-71). Postoperative EMG values were significantly higher than the preoperative EMG values (p<0.001). All patients were operated using the transaxillary approach. A total number of 40 operations were performed. Upon radiological investigation (n=17) 50% of the patients were found to have cervical ribs. In 30 cases (85%) the results were very good and in four cases (12%) good, and in one case (3%) the results were bad. There was no recurrence and reoperation in the long term follow-up. CONCLUSION Careful patient history and physical examination should be done by a team, which consists of thoracic surgeon, physical therapy specialist, and a neurologist. Total resection of the first-rib with periosteally should be preferred in all of these cases with accompanying pathologies such as cervical rib, fibrous ligaments, and scalenius muscles. The transaxillary approach has provided a good exposure for the resection of cervical ribs, the first-rib and excision of fibrous ligaments and scalenius muscle by a perfect cosmetic result. All the patients should be encouraged for 2 months of physical exercises starting from early postoperative period.

A novel and safe technique in closed tube thoracostomy

BackgroundTube thoracostomy (TT) is the most commonly performed surgical procedure in thoracic surgery clinics. The procedure might have to be repeated due to ineffective drainage in patients with tube malposition (TM), in whom the drain is not directed to the apex or located in the fissure. Trocar technique, which is used to prevent TM, is not recommended because of its potential for severe complications.MethodsThe study involved 180 patients who required TT application for any etiology within one year. The patients were divided into two groups as Group A, who had undergone classical surgical technique (n = 90) and Group B, who had undergone a combination of surgery and trocar techniques (n = 90). The groups were compared for TM, the effect of TM on the drain removal, and other insertion related complications.ResultsIn Group A, 23 patients had TM, 4 of whom developed associated ineffective drainage, while the patients in Group B had no insertion related complications (p = 0.001). The mean drain removal time of the patients with TM was 5 ± 2.25 days. In the patients who did not develop TM, it was 3.39 ± 1.18 days (p = 0.001).ConclusionsThe modified combination technique is a reliable method in preventing TM and its potential complications.

Elastofibroma dorsi management and outcomes: review of 16 cases

OBJECTIVES Elastofibroma dorsi (ED) is a rare, benign lesion arising from connective tissue, usually found at the inferior pole of the scapula. To date, only a few small series have been reported in the English literature and there are few data about the long-term outcomes after surgery. Our goal is to contribute a better understanding of this tumour and to determine the long-term outcomes after surgery. METHODS Sixteen patients with a diagnosis of ED were identified from the units database. The clinical presentation, diagnosis, pathological evidences and long-term outcomes were evaluated. RESULTS There were 11 females and 5 males with a mean age of 61.1 years (range 38-78 years). The tumour was located on the right in 5 (31.2%) patients, on the left in 6 (37.5%) patients and bilaterally in 5 (31.2%). Six patients had painful scapular swelling resulting in restriction of movement of the shoulder whereas 10 reported only painful scapular mass. All 16 patients underwent complete resections. The tumour size ranged from 3 to 15 cm. The mean hospital stay was 3.1 ± 1.4 days with a morbidity of 18.75% (seroma observed in 3 patients). The mean follow-up was 58.4 ± 29.5 months (range 11-92 months). In 2 patients (12.5%) a new occurrence on the contralateral side was observed at the follow-up. CONCLUSIONS Elastofibroma dorsi is a rare, ill-defined, pseudotumoural lesion of the soft tissues. Surgical treatment can be proposed if the lesion is symptomatic. Furthermore, at the follow-up, the possibility of new occurrences on the contralateral side should be kept in mind.

Traumatic pulmonary pseuodocysts: two case reports

Traumatic pulmonary pseudocyst (TPP) is a rare complication, sometimes encountered after blunt thoracic trauma and even more rarely following penetrating injuries. It is more common among pediatric and young adult patients. Although TPP is usually benign in nature, complications associated with hemoptysis and secondary infection may develop. The treatment is conservative. In this report, we present two rare cases of TPP occuring after a high-speed accident and a stab wound injury, where conservative treatment provided good outcomes.

A case of radiation-induced sternal malignant fibrous histiocytoma treated with neoadjuvant chemotherapy and surgical resection

BackgroundPrimary sternal malignant fibrous histiyocytoma (MFH) is highly rare. Effective treatment modality is surgical resection with wide margins. However, to date, the effects of radiotherapy or chemotherapy has not been clearly defined.Case presentationHerein, we aimed to present a 50-year old female patient with MFH occurred in the radiotherapy field who had had surgical procedure for breast cancer 19 years ago and had followed by radiotherapy. Neoadjuvant chemotherapy was applied for MFH due to cardiac and mediastinal vascular invasion. Wide resection was carried out for the mass after having been decreased in size following neoadjuvant chemotherapy.ConclusionNeoadjuvant chemotherapy was an effective method. In planning the surgical resection, the size of the tumor before chemotherapy should be considered as the initial size and surgical margins should be determined accordingly.

Analysis of Pulmonary Hydatidosis According to Their Segmentary Locations

The objective of this analysis is to compare the pulmonary locations of lung hydatid cysts and their size with respect to their locations with available literature. The records of 82 patients who were operated for pulmonary hydatid cysts between January 2001 and December 2005 were retrospectively evaluated. One hundred eleven cysts detected in 82 patients were placed into 2 groups as those located in the right lung (group A, 55 cysts) and those located in the left lung (group B, 56 cysts), and the segments involved were investigated. The gender distribution of the patients was 40 male and 42 female, with a mean age of 35.2 ± 17.64 years (range: 7–82 years). No difference was detected with respect to involvement between the 2 lungs (P = 0.285). The most commonly involved segment was the posterior basal segment of the lower lobe with 15 cysts (27.3%) from group A and 20 cysts (35.7%) from group B. No involvement of the lower lobe medial basal and anteromedial basal segments was observed. The most common surgical procedures applied were cystotomy and capitonnage. The findings of the study showed that pulmonary hydatidosis were located in some segments of the lungs more frequently, primarily in the posterior segment of the lower lobe and the apicoposterior segment of the upper lobe. In addition, the higher prevalence of giant cysts in the lower lobe and their ability to produce symptoms only after being enlarged suggest a role of mechanisms other than elasticity of the lungs.

An analysis of clinical features of pulmonary giant hydatid cyst in adult population

BACKGROUND We performed an analysis of giant hydatid cysts (GCHs) detected in the adult population by comparison with the features of other simple hydatid cysts (CHs) in the light of the relevant literature. METHODS The records of 74 adult patients who were operated on in our clinic for pulmonary CHs between 2001 and 2005 were retrospectively evaluated. Cysts that were 10 cm or larger in diameter on any plane were considered GCHs. The cysts were classified into 2 groups as GCHs (group A) and other (group B). The groups were then compared for age, sex, symptom, cyst location, preoperative complications, surgical procedure performed, operative morbidity, and mortality. RESULTS Of 74 patients, 10 (13.5%) were in group A and 64 were in group B. No differences were detected between the clinical presentation, gender distribution, surgical procedure performed, and postoperative morbidity and mortality rates of GCHs and other cysts in adults. In both groups, there were no significant differences between the rates of involvement of 2 lungs (P = .527). However, both groups had lower lobe involvement, more markedly in group A (81.8% and 45.5% respectively; P = .023). Two patients in group A (20%) and 18 patients in group B (28.1%) had complicated cysts. CONCLUSIONS The tendency of GCH to involve the lower lobe of the lung compared to smaller cysts suggests underlying mechanisms other than lung elasticity in the late onset of the symptoms parallel to cyst growth.