M. Nesimi Eren

Open Fixation in Flail Chest: Review of 64 Patients

The strategy for treatment of flail chest remains controversial. Various alternatives were assessed by reviewing the records of 64 patients treated from 1991 through 2000. Patients were classified according to therapeutic approach: group 1 was 27 patients who underwent open fixation of the fractured ribs, group 2 was 19 patients managed by intermittent positive-pressure ventilation, and group 3 was 18 patients managed mainly by synchronized intermittent mandatory ventilation. Two patients initially treated by ventilation underwent successful open fixation. In group 1, ventilatory support was required in 21 (77.8%) patients postoperatively, the mean duration of ventilation was 3.1 days, mean hospital stay was 18.3 days, morbidity was 11.1% (3/27), and mortality was 11.1%. In groups 2 and 3, the mean time for stabilization of paradoxical chest wall movement was 6.6 days, and mean duration of ventilation was 7.2 days. Mortality was 27.0% (10/37) in patients treated nonsurgically; 21.0% (4/19) in group 2, and 33.3% (6/18) in group 3. In groups 2 and 3, pain control required epidural analgesia in 13 (35.1%) cases, intercostal nerve blockade in 16 (43.2%), and narcotic or nonnarcotic parenteral analgesia in 8 (21.6%). Open fixation is a successful treatment modality for traumatic flail chest.

The effect of aprotinin on ischemia-reperfusion injury in an in situ normothermic ischemic lung model

OBJECTIVES In the context of the physiopathology of damage due to ischemic preservation and reperfusion injury following preservation, we aimed to demonstrate the positive effects of the addition of aprotinin, a serine protease inhibitor, to low potassium dextran (LPD), used as a single-flush solution in normothermic ischemic animal models, on lung protection and the prevention of reperfusion injury. METHODS In the study, 21 New Zealand white rabbits were used as experimental subjects. The subjects were ventilated with the assistance of a manual mechanical ventilator at 30 breaths/min and 10 ml/kg tidal volume. Lung protection solution was supplied to the pulmonary artery via a catheter. After applying the solution, ischemia was carried out for 120 min. At the end of this period, reperfusion was carried out for 90 min. The subjects were divided into three groups of seven subjects each. In the control group, pulmonary perfusion solution was not employed, whereas in the second group LPD was employed, and in the third group LPD and aprotinin (LPD+A) were perfused. Blood gas analysis, bronchoalveolar lavage (BAL) fluid examination, tissue malondialdehyde (MDA) level analysis and morphological examinations were performed. RESULTS The LPD+A group showed the significantly highest levels of oxygenation at the 15th and 60th minutes of reperfusion (297+/-76.7 and 327+/-97.4 mmHg) in comparison to the LPD (157+/-20.6 and 170+/-53.6 mmHg) and control (64+/-8.4 and 59+/-7.2 mmHg) groups (P<0.001). The LPD+A group showed the significantly lowest levels of alveolar-arterial oxygen difference at the 60th minute of reperfusion (389+/-15 mmHg) in comparison to the LPD (478+/-19 mmHg) and control (542+/-23) groups (P<0.001). The BAL fluid neutrophil percentage was significantly lower in the LPD+A group (22+/-2.4%) compared to the LPD (31+/-6.1%) and control (38+/-2.4%) groups. MDA levels were significantly lower in the LPD+A group (119.8+/-5.3 nmol MDA/g) when compared to the LPD (145.06+/-9.5 nmol MDA/g) and control (147.3+/-3.9 nmol MDA/g) groups (P<0.05). Morphological examinations revealed pathological lesions and alveolar hemorrhaging in all samples, with the LPD+A group having statistically more significant levels than the LPD and control groups (P<0.005). The LPD+A group had a significantly lower percentage of pathological lesions and alveolar hemorrhage grade values than the LPD and control groups (P<0.005). CONCLUSIONS It was observed that the addition of aprotinin to LPD solution as a pulmonary flush solution in an in situ normothermic ischemic lung model prevents reperfusion injury by means of various mechanisms and also protects the morphological, functional and biochemical integrity of the lung. In our view, therefore, the addition of aprotinin to lung protection solution will provide positive results in lung transplantation protocols.

Non-capitonnage method for surgical treatment of lung hydatid cysts.

Capitonnage is usually advocated for obliteration of the residual cavity after removal of a hydatid cyst. To assess a non-capitonnage method, results in 33 patients were compared with those of 80 patients who had capitonnage. The non-capitonnage patients had a shorter mean hospital stay and earlier radiologic improvement but higher morbidity than the capitonnage patients. Extended air leak caused significant morbidity in each group. Bronchoscopic intervention was needed for atelectasis in 1 patient. There was no mortality in either group. In the follow-up period, no late complication or recurrence was observed in non-capitonnage patients. Among the capitonnage patients, 2 had bronchiectasis, and suture material expectoration occurred in one. The non-capitonnage method may be a good alternative to the capitonnage procedure for lung hydatid cyst. Better management of bronchial openings should improve the results of the non-capitonnage method.

N‐acetylcysteine Reduces Lung Reperfusion Injury After Deep Hypothermia and Total Circulatory Arrest

Abstract  Objective: We hypothesized that the use of N‐acetylcysteine would ameliorate the lung reperfusion injury observed after deep hypothermia and total circulatory arrest (DHTSA). Methods: Experiments were carried out on 12 adult mongrel dogs of either sex weighing 25 to 30 kg. The animals were randomly divided into two groups of six animals each. All animals were cooled to an esophageal temperature of 15 °C during 30 minutes and underwent 60 minutes of DHTSA, followed by the reinstitution of cardiopulmonary bypass (CPB) and rewarming. Before rewarming, while 100 mL physiologic saline solution was added into the pump in group I, 50 mg/kg N‐acetylcysteine(NAC) was given in group II. Heart rate, mean arterial pressure, pulmonar arterial pressure, left atrial pressure, central venous pressure, and cardiac output were recorded. To measure lung tissue malondialdehyde (MDA), water content and polymorphonuclear leukocytes (PMNs) count, lung tissue samples were taken before CPB and after weaning CPB. In addition, alveolar‐arterial oxygen difference (AaDO2)for tissue oxygenation was calculated by obtaining arterial blood gas samples. Dynamic lung compliance (DLC) was measured before CPB and after CPB. Results: MDA levels before CPB of 44.2 ± 3.9 nmol/g tissue rose to 76.6 ± 5.6 nmol/g tissue after weaning CPB in group I (p = 0.004). In group II also, the MDA levels increased from 43.5 ± 4.2 to 57.4 ± 5.6 nmol MDA/g tissue after weaning CPB (p = 0.006). The MDA increase in group II after CPB was found to be significantly lower than in group I (p = 0.006). The wet‐to‐dry lung weight ratio in the NAC group was 5.1 ± 0.2, significantly less than in the control group (5.9 ± 0.3), (p = 0.004). AaDO2 significantly increased in the group I and II (p = 0.002 and p = 0.002, respectively); this elevation in group I was significant than in group II (p = 0.044). In histopathological examination, it was observed that neutrophil counts in the lung parenchyma rose significantly after CPB in both groups (p < 0.001). The increase in group I was significantly larger than group II (p < 0.001). Conclusions: Results represented in our study indicate that addition of NAC into the pump after DHTSA can reduce lung reperfusion injury. (J Card Surg 2004;19:221‐225)

Thoracic firearm injuries in children: management and analysis of prognostic factors

OBJECTIVE Thoracic firearm injuries (TFI) have become increasingly prevalent in children. Our purpose is to assess the injury pattern, Injury Severity Score (ISS), length of hospital stay (LOS), management and outcome of children with TFI with respect to the type of injury and to evaluate the value of ISS for predicting injury severity and the eventual need for thoracotomy, as well as the rate of morbidity and mortality. METHODS Between January 1987 and June 2002, 110 children (88 boys and 22 girls) </=16 years of age with firearm injuries to the chest were evaluated. The children were divided in four groups according to cause of injury. An ISS was calculated for each child. Those children who died before admission were excluded from the study. The relationship between ISS and prognostic factors was analyzed in all four groups. RESULTS The mean age was 11.1+/-3.0 (range 3-16) years. Eighty-eight (80%) were male and 22 (20%) were female. The causes of firearm injuries were high-velocity gunshot wounds (HVGSW) in 52 (47.2%), low-velocity gunshot wounds (LVGSW) in 23 (20.9%), shotgun wounds (SGW) in 18 (16.3%), and explosives wounds (EW) in 17 (15.4%). Lung injury occurred in 72 (65.5%) patients. Tube thoracostomy was sufficient in 76.3% (84 of 110) for thoracic injury. The morbidity rate was 16.3% (18/110) and the mortality rate was 4.5% (5/110). Mean ISS was 16.62+/-8.2 (range 4-48). Fifty-eight patients (52.7%) had an ISS </=16, while 31 (28.2%) had a score between 17 and 25, and 21 (19.1%) had a score greater than 25. The need for thoracotomy, as well as the rate of morbidity and mortality were significantly higher in children for those with an ISS >25. SGW and EW groups had a significantly higher ISS. The mean LOS was 10.84+/-4.7 days (range 4-42). The value of LOS was significantly higher in children with SGW and EW. CONCLUSION The majority of TFI in children can be treated successfully by tube thoracostomy if there are no gross pulmonary lacerations and airway injuries. SGW and EW were commonly associated with higher ISS and LOS. The ISS was found to be an independent predictor of the need for thoracotomy, as well as for rates of morbidity and mortality.

Huge Popliteal Arterial Aneurysms in Behçet's Syndrome: Is Ligation an Alternative Treatment?

Behçets syndrome is a multisystemic disease characterized by relapsing uveitis, oral and genital ulcerations, and vascular system involvement. The vascular involvement is seen as venous occlusion, arterial occlusion, and aneurysm formation in this disease, and the surgical treatment of a Behçets aneurysm has technical difficulties. In this report, we suggest that the huge popliteal artery aneurysm in Behçets syndrome can be treated by ligation of the popliteal artery. A 58-year-old male patient was admitted to our clinic because of an infrapopliteal great mass at the left leg. Color Doppler ultrasonography and arteriography revealed a 71 × 54 mm aneurysmal dilatation at the distal popliteal artery. Surgery did not reveal any suitable arterial formation for bypass to the distal area of the popliteal artery and tibial arteries. For this reason, we applied ligation of aneurysmal dilatation at the distal popliteal artery. The patient tolerated the operation well and had no signs of ischemia during the postoperative period. In conclusion, especially in aneurysm of arteries such as the popliteal artery, which has critical importance for maintaining distal perfusion, ligation may be a treatment method if there are no other alternatives.

Spontaneous pneumothorax in children in the South-east of Turkey.

Abstract Background : The purpose of the present study was to investigate the etiological factors, symptomatology, management and outcome of spontaneous pneumothorax in children aged <15 years.