Muzaffer Metin

Simultaneous bilateral spontaneous pneumothorax report of 12 cases and review of the literature.

Abstract Simultaneous bilateral spontaneous pneumothorax (SBSP) is a very rare condition, mainly seen in patients with underlying lung disease. Up to now, there are 65 patients who have been published. Twelve consecutive patients who presented with SBSP as definitive diagnosis were recruited for this study. They represented 1 % of all patients with spontaneous pneumothorax. All patients had immediate bilateral chest tubes on admission. Five of the 12 patients (42%) had no underlying lung disease. In 7 patients, SBSP was secondary to pulmonary metastases, histiocytosis X, undefined interstitial pulmonary disease, tuberculosis, pneumonia and chronic obstructive pulmonary disease. None of the patients died during hospitalization. Eleven patients were treated with chemical pleurodesis, whereas thoracotomy and pleurectomy were necessary in 7 patients. Reexpansion of the lungs was achieved in all patients. Immediate bilateral chest tube insertion and pleurodesis are of major importance in the treatment of SBSP although a subset of patients needed surgical pleurectomy. Combination of these treatments provides successful and uneventful treatment of the disease.

Extended cervical mediastinoscopy in the diagnosis of anterior mediastinal masses

BACKGROUND Although transthoracic needle biopsy (TNB) has been the preferred method for the diagnosis of anterior mediastinal masses, it has inherent limitations in accuracy. In particular, lymphoma and thymoma are diagnosed less reliably using needle biopsy. Videothoracoscopy has been advocated as an alternative method for diagnosis. Our goal was to assess the usefulness of extended cervical mediastinoscopy (ECM) in the diagnosis of anterior mediastinal masses. METHODS The ECM technique was performed in 9 patients in whom TNB and Tru-cut biopsies had been inefficient for histologic diagnosis. All lesions were in the anterior mediastinum. Extended cervical mediastinoscopy was carried out using the same incision as in a standard cervical mediastinoscopy and dissection was performed behind the sternum as previously published. Mean operative time was 50 minutes (range 40 to 70 minutes) and mean hospital stay was 8 hours (range 5 to 36 hours). RESULTS Diagnosis of lymphoma in 4 cases, thymoma in 3 cases, and thymic hyperplasia in 2 cases were obtained by ECM. In 1 of 2 patients with suspected thymoma who underwent resectional surgical procedures, final histologic diagnosis was non-small cell lung carcinoma. There was no surgical mortality or intraoperative complication. One patient had minimal pneumothorax requiring no intervention. CONCLUSIONS We conclude that ECM in the diagnosis of anterior mediastinal masses is technically feasible and provides an alternative to the conventional approaches in patients with paraaortic or aortopulmonary masses.

The effect of season of operation on the survival of patients with resected non-small cell lung cancer

Stage has been defined as the major prognostic factor in resected non-small cell lung cancer (NSCLC). However, there is some evidence that indicates season of operation could play a role in the survival of patients. Between January 1995 and June 2008, 698 (621 men and 77 women) patients who had undergone pulmonary resection for NSCLC were evaluated. Patients were analysed according to surgical-pathological stages and month of the year in which they were operated. Vitamin D receptor (VDR) polymorphism was also analysed in 62 patients. The median survival time in all patients was 60 ± 6 months (95% confidence interval (CI): 44-81 months). The survival of patients who underwent resection in winter was statistically significantly shorter than those operated in summer (P = 0.03). When patients were analysed according to T, N and season, resection time of the year was calculated to be an independent determinant of survival (P = 0.04). A VDR genotype was also associated with better prognosis (P = 0.04). Season of the operation, VDR polymorphism and N status seemed to have independent effects on survival of operated NSCLC patients.

Comparison of video-assisted mediastinoscopy and video-assisted mediastinoscopic lymphadenectomy for lung cancer

PurposeWe compared the efficacy and complications of video-assisted mediastinoscopy (VAM) and video-assisted mediastinal lymphadenectomy (VAMLA) for mediastinal staging of lung cancer.MethodsBetween March 2006 and July 2008, a total of 157 patients with non-small-cell lung cancer (NSCLC) underwent VAM (n = 113, 72%) or VAMLA (n = 44, 28%). We studied them retrospectively. Data for the operating time, node stations sampled/dissected, number of biopsies, and the patients who were pN0 by mediastinoscopy and underwent thoracotomy were collected. The false-negative rate was calculated. Demographics and operative complications were analyzed.ResultsThe overall complication rate was 5.7% (n = 9). The most common complication was hoarseness (n = 8). Complications were seen significantly more often after VAMLA than after VAM (11.3% vs. 2.6%, P = 0.04). There were no deaths. The mean number of removed lymph nodes (8.43 ± 1.08) and the station numbers (4.81 ± 0.44) per patient were higher with VAMLA than with VAM (7.65 ± 1.68, P = 0.008 and 4.38 ± 0.80, P = 0.001, respectively). The mean operating time was 44.8 ± 6.6 min for VAM and 82.0 ± 7.8 min for VAMLA. Patients diagnosed as pN2 numbered 9 in the VAMLA group and 27 in the VAM group. The patients diagnosed as pN0 with mediastinoscopy then underwent thoracotomy (VAM 77, VAMLA 32). When they were investigated for the presence of mediastinal lymph nodes, there were three (3.8%) false-negative results in the VAM group and five (15.6%) in the VAMLA group. Sensitivity, accuracy, and negative predictive values for VAM and VAMLA were 0.90/0.97/0.96 and 0.64/0.87/0.84, respectively.ConclusionVAMLA was found to be superior to VAM with regard to the number of stations and lymph nodes. Complications after VAMLA were common. The sensitivity and NPV of VAM for mediastinal staging are significantly higher than those of VAMLA.

Emergency surgery for massive haemoptysis.

Abstract Background : Massive haemoptysis (600 ml in 24 hours) results in considerable mortality and deserves appropriate management. Since it is life threatening, lung resection remains the surgical treatment of choice in unrelenting haemoptysis. Material and methods : We retrospectively reviewed all patients (n = 29) who were referred to our clinic between January 1994 to September 2001 with massive haemoptysis (> 600 ml/24 h). All patients had uncontrollable haemorrhage and/or failure of conservative treatment. After initial resuscitation, assuring adequate airway and providing adequate intravenous access, emergency thoracotomy was performed in all patients following rigid bronchoscopy (n = 27) in order to localize the bleeding. Results : The most common underlying cause of the massive haemoptysis was pulmonary tuberculosis (n = 10) followed by emphysema in 4, lung cancer in 3, collagenous vascular disease in 2 and aspergilloma in one patient. Seventeen lobectomies (58.6%), 5 pneumonectomies (17.2%), 3 segmentectomies and 3 bilobectomies were done whereas physiological lung exclusion was performed in one patient. Haemoptysis could be controlled in all patients. Rate of operative morbidity and hospital mortality were 27.5% and 11.5% respectively. We recorded one patient with recurrent haemoptysis who was treated by completion pneumonectomy. Conclusion : Despite the debate over definition of massive haemoptysis and indication for surgery in these patients, emergency pulmonary resection provides an effective treatment with acceptable morbidity and mortality in patients with massive haemoptysis.

The Coincidence of Mediastinal Tuberculosis Lymphadenitis in Lung Cancer Patients

Abstract Mediastinal lymph node enlargement in operable non-small cell lung cancer is of clinical importance since it indicates the high possibility of nodal metastasis. The coincidence of tuberculosis and lung cancer is detected by the mediastinal lymph node staging of lung cancer patients. In our study, we retrospectively re-evaluated the records of patients who had been hospitalized with the diagnosis of lung cancer for the past 10 years. The mean age was 58 ± 10 years (ranging from 39 to 72). A tuberculous lymphadenitis was detected in 16 of the 315 (5.1%) patients in one and/or multiple stations by either mediastinoscopy or thoracotomy. Inferior paratracheal lymph nodes (4R-4L) were the most frequently affected. None of the patients had a history of primary tuberculosis infection. The cell type was squamous cell carcinoma in ten patients (62.5%) and adenocarcinoma in six patients (37.5%). The tumour was located in the right lung in nine patients (56.2%). The most frequently involved site was the right upper lobe (n = 13, 81.2%). N2 disease was detected in six patients (37.5%). Our study showed that 5.1% of lung patients had tuberculous lymphadenitis coincidentally. The diagnosis and treatment of this latent disease could be considered as important, especially in lung cancer patients who would potentially receive radiotherapy or chemotherapy which alters the immune system. However, the real value of this finding needs further study.

Prompt surgery for massive hemoptysis: more acceptable than it was reported.

We read with interest the article by Jougon et al. [1] concerning the treatment of massive hemoptysis. The authors reported a mortality rate of 23% in patients who were operated on immediately close to bleeding crise. There were six pneumonectomies and six lobectomies in this group. In massive hemoptysis patients, prompt lateralization, localization and appropriate surgical intervention are of pivotal importance and may lead to acceptable mortality rates. We reviewed our experience in 29 patients with massive hemoptysis (.600 ml/24 h). We performed 17 lobectomies (58.6%), five pneumonectomies (17.2%), three segmentectomies and three bilobectomies and one physiologic lung exclusion. Two patients had been resuscitated and intubated in the emergency department. Following rigid bronchoscopy and aspiration of blood clotting and fresh blood, emergency intubation and lung isolation using onelung intubation or double-lumen intubation tube were accomplished. During the operation, the lung or part of the lung (lobe or segment) from which the intrabronchial hemorrhage originated could be localized in 27 patients (93.1%), by a localized radiologic appearance, emergency endoscopy or combination of these techniques and could be confirmed by bronchotomy to the bronchus of the suspected part of the lung (segment or lobe) or lung itself (i.e. bronchus first method). Probably due to having known the localization of the bleeding site in most patients, we only experienced 11.5% of mortality (i.e. three patients). We also believe that, delay in the surgical treatment (in tomographic examination, observation) of the patients with massive hemoptysis leads to exanguination and higher mortality and morbidity rates. Previously, when the initial treatment of massive hemoptysis has been believed to be medical, the mortality rate was reported to be as high as 50–85% [2]. Similarly, the authors found the mortality rate of non-surgically treated patients (i.e. Group 3) to be 26% which could be considered to be fairly high. In their series, a suboptimal effort to localize the bleeding site and delay in emergency surgery possibly due to the computerized tomography (CT) and pulmonary function test analyses might lead to the higher mortality rate (i.e. 23%) in the immediate surgery group (i.e. Group 1). Gourin and Garzon recommended prompt surgical resection for any individual who has bled more than 600 ml in 24 h or less [3]. This approach also decreases the number of pneumonectomies since rigid bronchoscopic evaluation during active bleeding provides better localization of hemorrhage in the lung. In patients in whom the site of bleeding was seen but the exact involved lobe was not identified using rigid bronchoscopy, bleeding lobe can be found via a small bronchotomy near to the suspected lobar carina. In our series we also found that, the advantage of immediate surgery outweighed the risk of not knowing the pulmonary function test and computed tomographic image of the lungs since the airway obstruction and exanguination of the patient are the major lethal elements in patients with massive hemoptysis. The authors recommended an immediate operation in case of pulmonary vessels hemorrhage and they also stated the difficulty in discrimination between pulmonary and bronchial vessel bleeding. In our series, all patients except six were followed-up for at least 1-year (range, 1–6 years) and we recorded only one patient with recurrence that required a completion pneumonectomy. We believe that, emergency surgical pulmonary resection following rigid bronchoscopy is a life-saving procedure with acceptable mortality and morbidity rate in all patients with massive hemoptysis.

A New Surgical Techique for Adenoid Cystic Carcinoma Involving Tracheal Carina

Reported is the successful treatment of a 24-year-old male with adenocystic carcinoma involving the tracheal carina, in which the tumor extended along the right main bronchus across the orifice of the right upper lobe. The patient underwent a carinal resection plus right upper lobectomy and reconstruction of the carina, resulting in neither anastomotic complication nor recurrence of disease during 28 months of follow-up.

Physiological exclusion for massive hemoptysis: when?

We read with interest the article by Dhaliwal and associates [1] describing the role of physiological lung exclusion in difficult lung resections for massive hemoptysis. Their conclusions “physiological lung exclusion is a safe and effective method for control of massive hemoptysis in cases where lung resection is technically hazardous or difficult” were assiduitied by us. We would like to share our experience about massive hemoptysis with the readers of the Journal. We have performed 27 lung resections in the past 8 years (one pneumonectomy, 26 lobectomies) in whom the blood loss was more than 600 ml/24 h. We excluded the percutaneous bronchial embolization patients. Diagnostic evaluation of these patients was done with a chest roentgenogram and computerized tomography of the thorax. Rigid bronchoscopy was performed in 24 of them before operation. Two patients (7.40%) died in the postoperative period, one patient required mechanical ventilation for 62 days and three patients (11.11%; including a mechanically ventilated patient) developed postlobectomy empyema and bronchopleural fistula. The pathological records demonstrated pulmonary tuberculosis in ten patients (three of them were multidrug resistant), pulmonary hemorrhagic syndrome in seven patients, bronchiectasis in three patients, pulmonary vasculitis in three patients, aspergillosis in three patients and lung cancer in one patient. We performed a physiological lung exclusion considering the experience of Dr Dhaliwal and associates. The patient was a 38-year-old man who had been treated for pulmonary tuberculosis. Acid resistant bacteria were present in the sputum. He had hemoptysis of 1400 ml/day. He was hemodynamically unstable (hematocrit, 20%; T/A, 80–40 mmHg; pulse was arrhythmic, 120/min) and desaturated (saturation, 84%). Rigid bronchoscopy revealed that the bleeding was from the origin of the right upper lobe bronchus. A posterolateral thoracotomy was performed, very tight calcific pleural adhesions were noticed. It would have taken a long time to mobilize the lung and hilus. Posteriorly, we identified the upper lobe bronchus and stapled. We prepared the fissure and ligated the major pulmonary arterial vessels to right upper bronchus. During these maneuvers, 4 units of blood were transfused and the Htc was still 18%. It would have been dangerous to mobilize the fixed upper lobe to the apex of the thorax. Two standard pleural drainages were employed and the thoracotomy was closed. He was mechanically ventilated for 6 h. The patient had an uneventful postoperative course and was discharged on postoperative day 10. Radiologically, a shrunk lobe was present in the apical region. We do not offer such an operation for a standard massive hemoptysis patient. However, we believe that physiological exclusion of the lung could be applicable in cases of: (1), really tight pleural adhesions which would increase the operating time and would cause more bleeding; (2), desaturated patients; (3), hemodynamically unstable patients. We strictly do not offer such an operation for lung cancer patients, stable patients and technically feasible resections. Non-surgical candidates could have bronchial embolization. Physiological lung exclusion for massive hemoptysis should be kept in mind as an alternative.

Ratio of neutrophil to lymphocyte counts in Crimean Congo Hemorrhagic Fever

1 Kenan Ahmet Turkdogan1, Sevki Hakan Eren2, Abuzer Coskun2, Aynur Engın3, Ertan Sonmez1, Cemil Cıvelek1 1Bezmialem Vakif University, Department of Emergency, Istanbul, 2Department of Emergency, Cumhuriyet University,Sivas, 3Infectious Diseases and Clinical Microbiology, Cumhuriyet University, Sivas, Turkey NLR in CCHF Patients Ratio of neutrophil to lymphocyte Counts in Crimean Congo Hemorrhagic Fever