Nesimi Eren

Surgical treatment of post-traumatic tracheobronchial injuries: 14-year experience

OBJECTIVE Tracheobronchial injuries have different clinical pictures and high mortality unless aggressive treatment is used. We reviewed our surgical experience. METHODS The records of 32 patients from 1988 to 2002 were reviewed. Mean age was 22.3 years (range: 4-53). Three patients were female. Prominent symptoms were dyspnea, subcutaneous air and pneumothorax in chest X-rays. Associated injuries were seen in 22 patients (68.7%): most frequently in the lung parenchyma (11 patients) and esophagus (seven patients). Bronchoscopic detection of a rupture of the trachea or bronchus was the main indication for surgery. RESULTS Nineteen injuries (59%) were penetrating and 13 blunt (41%). The most common presenting sign of airway disruption was subcutaneous emphysema (25%) and stridor (22%). Of the 32 patients, 22 underwent bronchoscopic examination. Bronchography was used in three patients admitted during the late period. Surgical morbidity was 19.3%. Seven patients died (21.8%), of whom six had been operated on. In operations performed during the first 2 h of trauma, no mortality occurred. There were associated injuries in 100% of patients that died and in 60% of those that survived. The proportion (100 vs. 24%) and duration (2.8 vs. 11.6 days) of ventilatory support were lower in patients that survived than in those that died. Mean injury severity score of patients that died was 34.7+/-8.8 while it was 24.3+/-8.6 in those that survived. Tracheal stenosis developed in three patients (9.3%). CONCLUSION In civilian life, tracheobronchial injuries occur relatively rarely. Early diagnosis and operative intervention save lives. Associated injury is an important mortality factor.

Ruptured hydatid cysts of the lung in children: clinical review and results of surgery

BACKGROUND Rupture of a hydatid cyst may cause some unique problems, especially in children. METHODS Sixty-three children with a total of 68 ruptured lung hydatid cysts were operated on between 1980 and 2000. Mean age was 12.3 years (range, 1 to 15 years). Radiographic findings were hydropneumothorax (20.6%) and air-fluid level (19%). Mean follow-up was 19.3 months. RESULTS Transthoracic needle aspiration was responsible for the rupture in 3 children. The interval between cyst rupture and operation was less than 24 hours in 10 patients (15.9%), 1 to 4 days in 36 (57.1%), and more than 4 days in 17 (27%). Resection rate was 22.1%. The most frequent operative method was cystotomy and capitonnage (38%). Morbidity was 25.4% (extended air leak 5, empyema 3, bronchopleural fistula 3, atelectasis 3, pneumonia 2). Mortality was 4.7% (hemoptysis 1, pneumonia and sepsis 1, aspiration of hydatid material 1). Morbidity and mortality seem to be more frequent in late cases. CONCLUSIONS Early surgical intervention with single-lung ventilation and maximum parenchyma preservation are recommended.

Neuroprotective effect of N-acetylcysteine and hypothermia on the spinal cord ischemia–reperfusion injury

The purpose of this study was to investigate the effect of N-acetylcysteine (NAC) on spinal cord ischemia-reperfusion (I-R) in rabbits. Thirty rabbits were divided into five equal groups, group I (sham-operated, no I-R), group II (control, only I-R), group III (I-R+NAC), group IV (I-R+hypothermia), group V (I-R+NAC+hypothermia). Spinal cord ischemia was induced by clamping the aorta both below the left renal artery and above the aortic bifurcation. Forty-eight hours postoperatively, the motor function of the lower limbs was evaluated in each animal according to Tarlov Score. Spinal cord samples were taken to evaluate the histopathological changes. The sham-operated rabbits (group I) showed no neurologic deficit (Score=4). Paraplegia (Score=0) developed in all rabbits in the control group (group II). Administration of 50 mg/kg of NAC (group III) resulted in significant reduction of motor dysfunction (Score=3.1+/-1.3, p=0.002). Application of hypothermia alone (group IV) showed significant recovery of motor functions (Score=3.0+/-1.1, p=0.002), and combination of hypothermia and 50 mg/kg of NAC (group V) showed complete recovery of lower limb motor function (Score=4, p=0.001). Histologic examination of the spinal cord in rabbits with paraplegia revealed several injured neurons. The cords of animals with no motor function deficits showed only minimal cellular infiltrates in the gray matter, and there was good preservation of nerve cells. NAC showed protective effects of the spinal cord. Moderate hypothermia alone also showed protective effects. Combined use of NAC and hypothermia resulted in highly significant recovery of spinal cord function.

Surgical treatment of pulmonary hydatidosis in children: Experience in 92 patients

Ninety-two patients with a total of 112 pulmonary hydatid cysts underwent surgical treatment in our clinic between January 1980 and January 1992. Nine patients were found to have concomitant liver and pulmonary hydatid cysts. There were 65 boys and 27 girls; the age range was 5 to 14 years. The authors performed cystotomy and capitonnage in 78 patients, lobectomy in 9, segmentectomy in 3, and wedge resection in 2. Of 9 cases with concomitant liver and pulmonary hydatid cysts, 8 were approached by right thoracophrenotomy and 1 by median sternotomy and right phrenotomy. A one-stage operation via median sternotomy was performed in 3 patients who had bilateral pulmonary hydatid cysts. To prevent the development of secondary hydatid cysts because of spillage of hydatid fluid, the authors used 10% povidone-iodine poly (1-vinyl-2-pyrrolidone)-iodine complex intraoperatively as a scolicidal agent. There was no mortality or recurrence in the series.

Treatment of vascular injuries associated with limb fractures.

INTRODUCTION The goal of therapy in all patients with combined orthopaedic and vascular injuries of the extremities is salvage of a functional limb. In this study, we have evaluated our experience with a subset of patients who had a combination of vascular injury and limb fracture. PATIENTS AND METHODS The records of 192 patients with vascular injuries of the lower and upper limbs associated with bone fractures were reviewed. Of these, 168 were males and 24 were females; the mean age was 26 years. RESULTS The mechanism of injury was a penetrating wound in 97 (51%) patients and blunt trauma in 95 (49%) patients. Injured vessels included 6 subclavian/axillary, 39 brachial, 14 radial/ulnar, 11 radial, 8 ulnar, 36 femoral, 43 popliteal, 35 tibial arteries. Saphenous vein graft was the most common conduit of choice in arterial repair (55%). Amputations were needed for 20 patients. The limb salvage rate was 88%. Three patients died. CONCLUSIONS This study established that delay in surgery, blunt trauma and extensive soft tissue defect in combined orthopaedic and vascular injuries are associated with increased risk of amputation.

Penetrating chest injuries: unusually high incidence of high-velocity gunshot wounds in civilian practice.

AbstractPenetrating chest injuries are a challenge to the thoracic or trauma surgeon. Penetrating thoracic trauma, especially that due to high-velocity gunshot wounds, is increasing at an alarming rate in our region. We report our experience with penetrating chest injuries mainly due to high-velocity gunshot wounds. During a period of 6 years we retrospectively reviewed the hospital records of 755 patients admitted to the Department of Thoracic and Cardiovascular Surgery, Dicle University School of Medicine, with the diagnosis of penetrating thoracic trauma. The mean age was 27.48 years, and 89.8% were male. The causes of penetrating injury were stab wounds in 45.3% and gunshot wounds in 54.7%. About 30% of the wounds were due to high-velocity gunshots; and among the gunshot wounds 56.2% were due to high-velocity shots. The most common thoracic injury was hemothorax (n= 190) followed by hemopneumothorax (n= 184). Isolated thoracic injuries were found in 53% of the patients. Nonoperative management was sufficient in 92% of the patients. Thoracotomy was performed in 8.1%. The mean duration of hospitalization was 11.2 days. The mean injury severity score (ISS) was 20.17 ± 13.87. The morbidity was 23.3% and the mortality 5.6%. Fifty percent of all deaths were due to adult respiratory distress syndrome. Altogether 17% of patients with an ISS >25 died, whereas only 0.9% of those with a score <16 died. The mortality due to firearms was 8.95%. We concluded that in civilian practice chest tube thoracostomy remains by far the most common method of treating penetrating injury to the chest. The easy availability of high-velocity guns will continue to increase the number of civilians injured by these weapons.

Effects of N-acetylcysteine on pulmonary function in patients undergoing coronary artery bypass surgery with cardiopulmonary bypass

Cardiopulmonary bypass (CPB) has been implicated in causing poor pulmonary gas exchange postoperatively in patients undergoing coronary artery bypass grafting (CABG) procedures. In this prospective, randomized, double-blind, placebo-controlled study, we examined the pulmonary effects of N-acetylcysteine (NAC) in patients undergoing CABG. Twenty patients undergoing elective CABG and early tracheal extubation were randomized into two groups. Group I (ten patients) received a physiologic salt solution as a placebo in a continuous intravenous infusion for one hour before CPB and 24 hours after CPB; Group II (ten patients) received 100 mg/kg NAC intravenously for one hour before CPB and 40 mg/kg/day at 24 hours after CPB. Perioperative hemodynamic and pulmonary data were recorded. Postoperative tracheal extubation was accomplished at the earliest appropriate time. The postoperative clinical course was similar in the two groups. Both groups exhibited significant postoperative increases in A-a oxygen gradient (p<0.01), but patients in Group II exhibited significantly lower increases in postoperative A-a oxygen gradient (p<0.006). Other hemodynamic and pulmonary data (pulmonary capillary wedge pressure, pulmonary vascular resistance (PVR), cardiac index (CI), shunt flow, dynamic lung compliance and static lung compliance) exhibited no differences between the groups. There was no significant difference in terms of intubation time. The malondialdehyde (MDA) increase in Group II following CPB was found to be significantly lower than in Group I (p=0.043). This clinical study reveals that administration of NAC to patients undergoing elective CABG with CPB improves systemic oxygenation. There was no effect in other pulmonary parameters and in terms of intubation time.

Penetrating chest injuries in children: a review of 94 cases

Ninety-four children with penetrating chest injuries were treated at Dicle University School of Medicine during a 6-year period. The mean age was 11.51 +/- 3.31 years, and the male:female ratio was 5.25:1. Forty-five had stab wounds, 27 had high-velocity gunshot wounds, 13 had low-velocity gunshot wounds, seven had a bomb (shrapnel) injury, one had a shotgun wound, and one had a horse bite. Sixty patients had isolated thoracic injuries, and 34 had associated injuries. The most common thoracic injury was hemothorax (28), followed by hemopneumothorax (25). Tube thoracostomy alone was sufficient in 79.8% of the patients (75 of 94). Thoracotomy was performed in 4.25% (4 of 94). In two of the five observed patients, delayed hemothorax developed. The mean duration of hospitalization was 5.13 +/- 1.93 days. The mean Injury Severity Score was 14.71 +/- 8.62. Prophylactic antibiotics were used in all patients. The morbidity rate was 8.51% (8 of 94). Only one death occurred after cervical tracheal repair. The study suggests that the majority of penetrating chest injuries in children can be treated successfully by tube thoracostomy alone or in conjunction with expectant observation.

Peripheral vascular injuries in children

We report 94 arterial injuries in 91 children treated at the Department of Thoracic and Cardiovascular Surgery, Medical School of Dicle University, between 1978 and 1988. The average age was 10.3 (range, 3 to 14) years. Stab wounds were seen in 37 patients (40%). Gunshot wounds were seen in 21 patients (23%), and two cases were caused by iatrogenesis. Vein damage was present in 39 patients (44.4%), and nerve loss was observed in 20 patients (21.2%). Twenty-one cases (23.3%) were associated with fractures. Diagnosis of arterial injury was made by clinical findings. Arteriography was used in 15 patients (16.5%) as the diagnostic method. The surgical interventions performed for arterial repair in our series were end-to-end anastomosis in 61 (64.5%), interposition of autogenous reversed saphenous vein grafts in 22 (23.4%), lateral suture in 8 (8.3%), and ligation in 3 (3.9%) patients. Four patients (5.3%) underwent limb amputation.

Early Decortication for Postpneumonic Empyema in Children: Effect on Pulmonary Perfusion

Early pulmonary decortication was performed on 66 of 137 children with postpneumonic empyema, while 71 received conventional treatment. The mean age of the 66 patients with decortication was 5.5 years (range 6 months-14 years). The empyema was left-sided in 34 and right-sided in 32. Decortication was performed when lung expansion was not obtained after 10-12 days of intercostal tube drainage, antibiotic therapy (guided by sensitivity tests of pleural fluid) and pleural irrigation. Scintigraphy showed loss of pulmonary perfusion on the side of empyema to be 65% +/- SD 20 (25-98)% before decortication in the 23 tested patients. In ten of them the test was repeated after surgery and showed significant (p < 0.001) diminution of the perfusion defect, from 57 +/- 6.8 (25-84)% to 4 +/- 2.6 (0-8)%. The hospital stay was significantly (p < 0.001) shorter for the surgically treated than for the classically managed patients, viz. 19.5 +/- 4 (13-36) days vs 73.6 +/- 14 (34-110) days. Early decortication thus had beneficial effects on pulmonary perfusion and hospital stay.