Metin Demircin

Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus

BACKGROUND The successful excision of a renal cell carcinoma (RCC) invading the inferior vena cava (IVC) remains a technical intraoperative challenge and requires a careful preoperative surgical management planning. Although a radical operation remains the mainstay of the therapy for RCC, the optimal management of the patients with RCC causing IVC tumor thrombus remains unresolved. In this study, we reviewed our experience in this group of patients and herein report the results. METHODS Between July 1990 and August 1998, 11 patients with RCC with IVC tumor thrombus underwent surgical treatment. The mean patient age was 54.2 years and the male to female ratio was 1.75. The cephalad extension of the tumor was suprarenal in all cases, being infrahepatic in 6 patients, intrahepatic in 2, and suprahepatic with right atrial extension in 3 patients. All tumors were resected via inferior vena cava isolation and, when necessary, extended hepatic mobilization and Pringle maneuver, with primary or patch closure of vena cavotomy. Cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) were used in 3 patients. RESULTS The mortality rate was 9.1% (1 patient was lost on the 11th postoperative day). Complications occurred in 3 patients. The remaining 10 patients (90.9%) could be successfully discharged from hospital. Two of them were lost during follow-up because of tumor progression at the 43rd and 54th postoperative months. The 10-year Kaplan-Meier survival estimate was 71.4%, with a mean follow-up of 4.6 years. The presence of lymph node metastases and perinephric spread seemed to possess an adverse effect on the survival. Although the groups included small numbers of patients, there was no significant difference in survival in regard to the different levels of tumor thrombus extension into the vena cava. CONCLUSIONS Surgical treatment is the preferred approach to patients with RCC and IVC tumor thrombi as it provides markedly better results when compared with the other therapeutical modalities. We believe that complete surgical excision of the tumor and the resulting thrombus with appropriate preoperative staging and a well-planned surgical approach, using CPB and DHCA when necessary, provide an acceptable long-term survival with a good quality of life expectation.

Preoperative Fibrinogen Levels as a Predictor of Postoperative Bleeding after Open Heart Surgery

BACKGROUND Open heart surgery still involving major bleeding continues to be a major challenge after cardiac surgery and is also a significant cause of morbidity and mortality. Most hemostatic factors are intercorrelated with postoperative bleeding, and fibrinogen seems the most fundamental hemostatic risk factor for open heart surgery. METHODS The study included 97 patients who underwent elective coronary artery surgery (78 men and 19 women; mean age, 60.9 +/- 10.3). Preoperative blood samples were obtained and preoprative quantitative determination of plasma fibrinogen levels were measured by the clotting method of Clauss using the fibrinogen kit. Patients were operated on by the same team and the same technique. The total amount of drainage blood from chest tubes was recorded after termination of operation. RESULTS There were statistical significance between the fibrinogen levels and the drainage (r = -0.897, P < .001). Chest drainage was a mean of 972 mL (range, 240-2445 mL) in the first 48 hours after sternotomy closure. Fibrinogen level and relation to age was statistically significant (P = .015). There was no statistical significance between fibrinogen levels and gender (male gender = 400.7 +/- 123.0 versus female gender = 395.6 +/- 148.1; P = .877) and between drainage and gender (male gender = 968.2 +/- 538.5 versus female gender = 990.0 +/- 554.7; P = .876). Two patients (2%) died early after the surgery. There were no significant differences between the postoperative bleeding and cardiopulmonary bypass time (P = .648) or cross-clamp time (P = .974). CONCLUSION The results of this study suggested that low preoperative fibrinogen level appears to be a useful diagnostic marker to assess the activity of the coagulation system, and that its preoperative level may serve as a potential risk factor for postoperative bleeding after coronary artery bypass surgery.

Double-chambered right ventricle: experience with 52 cases

The presence of anomalous muscle bundles may produce a pressure gradient between the inflow and outflow portions of the right ventricle, thus resulting in double-chambered right ventricle bearing troublesome clinically in its diagnosis. The aim of the present study was to review the diagnostic criteria. Fifty-two patients with a double-chambered right ventricle were seen during an 8-year period. They ranged in age at the catheterization from 4 months to 17 years (mean 7.5 +/- 4.4 years). Diagnosis was confirmed in 51 patients at cardiac catheterization and in other one on operation. The majority of the patients had associated cardiac anomalies: there were 33 ventricular septal defect (63%), 21 pulmonary valve stenosis (40%), nine atrial septal defect (17%), and four double-outlet right ventricle. The electrocardiograms revealed upright T waves alone in right precordial leads suggesting right ventricular hypertrophy in 33% of the patients. At cardiac catheterization, there was a pressure gradient of 20-160 mmHg between the right ventricular inflow and outflow portions. Forty patients have had surgery and four have undergone balloon pulmonary valvuloplasty. Surgical treatment was planned for two patients and other six had no indication for treatment.

Predictive significance of plasma levels of interleukin-6 and high-sensitivity C-reactive protein in atrial fibrillation after coronary artery bypass surgery.

BACKGROUND Postoperative atrial fibrillation (AF) plays a major role in the determination of hemodynamic deterioration and can be associated with cardiovascular events after coronary artery surgery. Elevated interleukin (IL)-6 and C-reactive protein (CRP) levels in patients with AF suggest a role of inflammation in the pathogenesis of AF. We conducted a study to investigate the correlation between postoperative AF and IL-6 and high-sensitivity CRP (hsCRP). MATERIALS AND METHODS Forty-nine patients with a mean age of 60.3 +/- 10.7 years were enrolled in this study. Preoperative and postoperative first day blood samples were collected to assess the IL-6 and hsCRP levels. IL-6 levels were measured by enzyme-linked immunosorbent assay, and hsCRP was measured by rate turbidimetry method. RESULTS Fourteen patients (28.5%) developed AF postoperatively. Patients who developed AF showed elevated serum concentrations of postoperative first day IL-6 (P < .001), preoperative hsCRP (P < .005), and postoperative first day hsCRP (P < 0.001). Preoperative hsCRP levels (P < .002) and postoperative first day IL-6 (P < .001) and hsCRP (P < 0.001) levels were associated with prolonged endotracheal intubation time. Prolonged intensive care unit stay showed significant correlations with elevated levels of preoperative hsCRP (P < 0.002) and postoperative first day IL-6 (P < 0.001) and hsCRP (P < 0.001). There was also statistical significance between the AF+ and AF- groups regarding intensive care unit stay and endotracheal intubation times (P < .001 and P < .001, respectively). Cut-off points for postoperative first day IL-6, preoperative hsCRP, and postoperative first day hsCRP were 46.4 pg/mL (sensitivity = 92.9% and specificity = 80%), 0.46 mg/L (sensitivity = 71% and specificity = 75%), and 17.9 mg/L (sensitivity = 92.9% and specificity = 78%), respectively. CONCLUSIONS Elevated IL-6 and hsCRP levels in patients with postoperative AF suggest inflammatory components have a role of in the pathogenesis of AF.

Short-term effects of inspiratory muscle training in coronary artery bypass graft surgery: A randomized controlled trial

Abstract Objective. To investigate the efficiency of inspiratory muscle training (IMT) on postoperative respiratory muscle strength, functional capacity, quality of life, and psychosocial status in patients with coronary artery bypass graft (CABG) surgery. Design. Forty-three patients undergoing CABG surgery were randomly assigned to the one of two groups. All subjects received usual care. In addition, subjects in the intervention group received IMT training pre- and postoperatively. Pulmonary function testing, six minute walk test (6MWT), quality of life and psychosocial parameters were assessed preoperatively and the fifth day after the surgery. Results. The mean inspiratory muscle strength increased from 82.64 cmH2O at baseline to 95.45 cmH2O five days postoperatively in the intervention group. The intervention group (319.55 ± 72.17 m before and 387.91 ± 65.69 m after surgery) covered further distance during the 6MWT than usual care (355.43 ± 56.08 m before and 357.69 ± 43.42 m after surgery). The improvement in quality of life was greater in the intervention group for the dimension of sleep. The anxiety scores were significantly lower in the intervention group than the usual care group. The length of intensive care unit stay was significantly shorter in the intervention group than the usual care group (p < 0.05). Conclusion. IMT results in faster recovery of inspiratory muscle strength, functional capacity, intensive care unit stay, quality of life and psychosocial status after CABG.

Gorham-Stout Syndrome with chylothorax: successful remission by interferon alpha-2b.

Gorham–Stout syndrome is a rare disease and most often recognized in children and young adults. Chylothorax is a serious complication of Gorham–Stout syndrome. The treatment of either Gorham–Stout syndrome or chylothorax is still a dilemma. We described a 9‐year‐old girl with Gorham–Stout syndrome and chylothorax who was admitted to our hospital because of dyspnea, orthopnea, and bone pain, and treated with interferon alpha‐2b. Pediatr Pulmonol. 2009; 44:613–615.

Postchemotherapeutic surgery for metastatic testicular germ cell tumors: Results of extended primary chemotherapy and limited surgery

OBJECTIVE Postchemotherapy surgery has become an increasingly important treatment for residual masses in germ cell tumors of the testis. However, it is still a challenge to find the optimal combination of chemotherapy and surgery for better survival and cure rates with lowest morbidity. This study evaluated the effectiveness of extended chemotherapy followed by surgery resecting only the residual masses. METHODS After an extended course (one or two additional courses after there is no decrease in tumor size and/or after the normalization of tumor markers) of combination chemotherapies with cisplatin-based regimens, 32 patients underwent surgery for metastatic germ cell tumors of the testis. Complete excision of radiologically determined residual masses and macroscopically suspicious neighboring nodes was performed rather than a conventional retroperitoneal lymph node dissection. RESULTS Histopathologic examination of the resected specimens revealed teratoma in 17 (55%), fibrosis and/or necrosis in 9 (26.5%), and active residual tumor in 8 (23.5%) of the patients. The patients with residual tumor have been treated with additional chemotherapy. In the follow-up (mean, 28.5 months) 4 patients have relapsed, and 1 died. None of the patients with residual teratomas have shown relapse. Only 1 of the 32 patients has had retrograde ejaculation. CONCLUSIONS A more conservative approach, such as excision of the residual masses after an extended course of chemotherapy, has given excellent results both in the outcome of the patients in the follow-up and in the rate of retrograde ejaculation. We therefore suggest that this approach would be a good alternative to nerve-sparing surgery following chemotherapy.

Intracardiac thrombosis diagnosed by echocardiography in childhood: predisposing and etiological factors

Eleven cases of intracardiac thrombi caused by different factors including protein-C deficiency are presented for discussion of the etiology and predisposing factors of intracardiac thrombi during infancy and childhood, and to stress the importance of protein-C deficiency as an etiological factor. Thrombi were localised in the left heart in five patients and right heart in five patients. One patient had both-sided thrombi. Four of our patients had dilated cardiomyopathy, one had mitral valve hypoplasia, and one had pulmonary valvar stenosis as the predisposing factors for thrombus formation. In three patients whose cardiac anatomies were completely normal, we determined protein-C deficiency as an etiological factor of thrombus formation. One of these had congenital protein-C deficiency and the other two had acquired temporary protein-C deficiency due to sepsis. In conclusion we recommend that protein-C deficiency should be investigated as an etiological factor in all cases of intracardiac thrombi irrespective of whether or not another predisposing factor is identified.

Blood cyst of the pulmonary valve causing pulmonic valve stenosis

B lood cysts of the heart valves are frequently seen as a postmortem finding on the atrioventricular valves of infants aged 16 months. They are usually small, rounded, pinpoint to pinhead nodules on the submarginal part of the atrial surface of the CUSPS,~,~ but are also seen less often on the ventricular surfaces of the semilunar valves2 Although these cysts seem to disappear after 6 months of age, rare cases have been described in children and adults.M We describe a child who underwent successful1 surgical excision of a blood cyst from the pulmonary valve. A lo-year-old girl was referred because of suspected pulmonary stenosis. At the age of 8 years, a precordial murmur was observed. There were no symptoms of cardiac dysfunction. She looked healthy. Physical examination was normal except for the heart. There was a palpable systolic thrill, and palpable pulmonary valve closure in the second left intercostal space. An opening click of the pulmonary valve and a grade 3 to 416 systolic ejection murmur was heard at the same area. A pulmonic second sound was accentuated ana’ relativelyhed splitting was established. The electrocardiogram showed a frontal QRS axis of loo”, and a mild right ventricular hypertrophy. Posteroanterior x-ray projection demonstrated moderate prominence of the pulmonary trunk. Two-dimensional echocardiography revealed an abrupt pressure gradient between the pulmonary artery and right ventricle of 68 mm Hg. Cardiac catheterization confirmed the diagnosis. Pulmonary balloon valvuloplasty reduced the gradient to 41 mm Hg. On the cineangiogram, there was a persistent, rounded, sharply demarcated filling defect in the pulmonary trunk, slightly below the valve (Figure 1). The cineangiocardiogram also showed mild pulmonary stenosis and poststenotic dilatation of the main pulmonary artery. On June 17, 1992, open heart surgery was peformed. At operation, the pulmonary artery was seen to be greatly dilated ana! a systolic thrill was palpated over the pulmonary trunk. A longitudinal incision was made and a dark red-colored, lobulated cystic mass measuring I .5 X 1 X 0.8 cm was seen (Figure 2). The valve cusps were normal. The cyst originated from the left posterior pulmonary valve leaflet. The cyst was removed by sharp dissection at its base. During the excision the cyst was opened and bloody fluid flowed out. The basilar layer of the cyst at its base was not removed from the ventricular suface of the cusp. The excised cyst was ovoid and lobulated, and measured I .5 X 1 X 0.9 cm. The wall of the cyst was 0.1 to 0.2 cm in thickness, and lined with a single layer of cuboidal cells overlying an eosinophilic, relatively hypocellular stroma. After operation, no murmur was heard, and on subsequent examination no gradient

Perigraft seroma diagnosed by echocardiography: a complication following Blalock-Taussig shunt.

Perigraft seroma is a specific clinicopathologic entity, which is a collection of clear, sterile fluid, confined within a nonsecretory fibrous pseudomembrane surrounding a vascular graft. Serous leaks and/or seroma formation from polytetrafluoroethylene grafts have been reported in peripheral arteriovenous anastomoses, arterial grafts and subclavian pulmonary anastomoses. We present a case of seroma formation which developed after a Blalock-Taussig shunt operation constructed with a polytetrafluoroethylene graft in a child with tricuspid atresia and which was diagnosed by echocardiography.