Nurettin Karaoglanoglu

Current management of esophageal perforation: 20 years experience

Esophageal perforations are surgical emergencies associated with high morbidity and mortality rates. No single strategy has been sufficient to deal with the majority of situations. We aim to postulate a therapeutic algorithm for this complication based on 20 years of experience and also on data from published literature. We performed a retrospective clinical review of 44 patients treated for esophageal perforation at our hospital between January 1989 and May 2008. We reviewed the characteristics of these patients, including age, gender, accompanying diseases, etiology of perforation, diagnosis, location, time interval between perforation and diagnosis, treatment of the perforation, morbidity, hospital mortality, and duration of hospitalization. Perforation occurred in the cervical esophagus in 14 patients (31.8%), thoracic esophagus in 18 patients (40.9%), and abdominal esophagus in 12 patients (27.3%). Management of the esophageal perforation included primary closure in 23 patients (52.3%), resection in 7 patients (15.9%), and nonsurgical therapy in 14 patients (31.8%). In the surgically treated group, the mortality rate was 3 of 30 patients (10%), and 2 of 14 patients (14.3%) in the conservatively managed group. Four of the 14 nonsurgical patients were inserted with covered self-expandable stents. The specific treatment of an esophageal perforation should be selected according to each individual patient. To date, the most effective treatment would appear to be operative management. With improvements in endoscopic procedures, the morbidity and mortality rates of esophageal perforations are significantly decreased. We suggest that minimally invasive techniques for the repair of esophageal perforations will be very important in the future treatment of this condition.

Giant hydatid lung cysts

OBJECTIVE In this clinical retrospective study, we aimed to evaluate giant hydatid lung cyst cases as a different clinical entity that recorded in last 10 years in our clinic. METHODS Between February 1990 and May 2000, a total of 305 hydatid lung cyst cases from patients that had been operated were reviewed, and 67 (21.9%) cysts with more than 10 cm in diameters of them were regarded as a giant hydatid lung cyst. Further investigations were made with respect to different factors. RESULTS Thirty-six (54%) cases were male and 31 (46%) were female. The ages ranged between 5 and 54 (mean 21.6) years. The most common symptoms recorded were; cough (68%), thoracic pain (55%) and dyspnea (52%). Cyst sizes were ranged between 10 and 22 cm (mean 13.4) in diameters. Forty-two (62%) of them were in the right, 22 (33%) were in the left hemithorax, and three (5%) were located bilaterally. Cystotomy or cystectomy and capitonnage was the most frequent applied operation procedure (71%). Resection was performed in nine (13%) cases. Thirteen (19%) cases had air leakage more than 10 days in which five (7%) of them empyema occurred postoperatively. One case died due to respiratory failure in fourth postoperative day. The postoperative hospital stay ranged between 6 and 43 (mean 10.5) days. No recurrence was recorded in 1-5 years of a follow-up period. CONCLUSIONS Giant hydatid lung cysts must be regarded as a different clinical entity because of their early occurrence, having more serious symptoms, with frequent operative complications, and they need prolonged care with higher cost effects.

Primary hydatid cysts of the mediastinum

Hydatid disease remains a serious health problem for the Mediterranean countries, such as Turkey. Living in a rural area is an important risk factor for the disease. Hydatid cysts are usually located in the liver, lung, and brain. Mediastinal hydatid disease is very rare that have been only anecdotally in the literature. The objective of this study was to evaluate the clinical and radiographic findings and surgical treatment of this unusual lesion. Between 1985 and 2002, 11 cases with primary mediastinal hydatid cyst were treated surgically at our clinic. Median age was 28.4 and ranged from 19 to 46 years. Symptoms included chest pain in nine patients (82%), and cough in six patients (54%). The cyst was located in the anterior mediastinum in four patients (36%), in the posterior mediastinum in five patients (45%) and in the middle mediastinum in two patients (18%). All cysts were intact except one cyst that ruptured into right intrapleural space. Surgical approach was right thoracotomy in five patients (45%), left thoracotomy in three patients (27%), and median sternotomy in three patients (27%). Total pericystectomy was chosen as the surgical procedure in all patients except four (36%), who had cystectomy and local curettage for cyst located vital structures. There were no complications and mortality postoperatively. Primary hydatid cysts of the mediastinum are distinct clinical entity that must be considered when caring for a patient with a mediastinal mass in endemic regions. Because of surrounding vital structures the cyst should be treated without delay.

Pleurectomy:decortication for palliation in malignant pleural mesothelioma: results of surgery

OBJECTIVE Surgery can only offer palliation in an attempt to slow the progression of malignant pleural mesothelioma (MPM). We want to assess the effectiveness and safety of pleurectomy/decortication in establishing a tissue diagnosis, and controlling pleural fluid accumulation and symptoms in patients with MPM. METHODS We reviewed our pleurectomy results in 100 patients with MPM over a 19 year period. Major symptoms were chest pain, cough and dyspnea, and radiographic findings included pleural mass, pleural fluid and constriction of involved hemithorax. RESULTS Approximately two thirds of the patients underwent surgery prior to tissue diagnosis. Eighty-nine patients had stage I and stage II disease, 8 and 81%, respectively. The patients underwent subtotal (44%) or total pleurectomy (56%). The surgical mortality rate was 1% (1/100) and the morbidity rate was 22%. Morbidity included prolonged air leak (n = 12), empyema (n = 6), reaccumulation of pleural fluid (n = 2) and wound infection (n = 2). Palliative results included dyspnea and cough relief in all patients, chest relief in 60 (85%) and pleural fluid control in 52 (96%) patients. Median survival was 17 months in MPM patients. CONCLUSIONS We conclude that pleurectomy/decortication safely provides both tissue diagnosis and effective of pleural effusion and symptoms and therefore excellent palliation in patients with MPM.

Complications of albendazole treatment in hydatid disease of lung.

We present rupture of lung hydatid cyst in a patient with multiple organ involvement during albendazole treatment. The patient was first provided mechanical ventilation than residue cavity and the other intact cyst was treated surgically. We concluded that albendazole should be used in postoperative period in patients with hydatid disease of the lung to prevent recurrent disease.

Diagnosis and Surgical Treatment of Morgagni Hernia: Report of Three Cases

Morgagni hernia is a rare congenital disorder, which is usually asymptomatic, but may cause respiratory or gastrointestinal symptoms. We reviewed the clinical findings of three patients with a Morgagni hernia, diagnosed and treated in our department between 1997 and 2000. The Morgagni hernia caused various symptoms in all three patients and surgery was performed via posterolateral thoracotomy in two, and via laparatomy in one. The hernial defect was closed by primary suturing in two patients and by synthetic mesh in one. All three patients had an uneventful postoperative recovery. We believe that the transthoracic approach is an effective way of repairing Morgagni hernia.

Hydatid disease of rib

Osseous hydatidosis, especially when located in the rib, is a very rare disease. In 1978, only 39 costal echinococcosis cases were published. The course of the disease is generally slow and laboratory tests are frequently negative. Diagnosis is generally made through the combined assessment of clinical, radiologic, and laboratory data. Living in a rural area is an important risk factor for the disease. The gold standard for therapy is radical removal of the involved ribs or chest wall. We present the case of a 63-year-old herdsman with costal echinococcosis and a review of the literature.

The use of self-expandable metallic stents for palliative treatment of inoperable esophageal cancer

Most patients with esophageal carcinoma present in the advanced stage die from tumor invasion and widespread metastases. Because radical regimens are not appropriate for the majority of patients, and their expected survivals are as short as to be measured by months, the main aim of therapy is palliation with minimum morbidity and mortality. Among the palliative modalities are surgery, external radiotherapy or brachytherapy, dilatation, laser, photodynamic therapy, bipolar electrocoagulation tumor probe, and chemical ablation. The placement of self-expandable metallic stents is another method that improves dysphagia for these patients. In this study, the aim was to evaluate retrospectively the effectiveness of metallic stents deployed because of inoperable malignant esophageal stenosis and esophagotracheal fistulas. The results of 170 patients with 202 stents administered because of inoperable malignant esophageal stenosis and esophagorespiratory fistula between January 2000 and October 2008 at the Ataturk University, Department of Thoracic Surgery, were investigated. Despite epidemiological and clinical data, information regarding relief of dysphagia and quality of life were also examined. One hundred seventy patients with stents were between 28 and 91 years old (mean age 63.7 years+/-11.4 years). Ninety-seven were male and 73 were female. Stent indications were advanced tumors with distant metastasis (82 cases, 48.2%), unresectable tumors (51 cases, 30%), patients who cannot tolerate surgery or chemoradiotherapy (18 cases, 10.5%), local recurrence after primary therapy (1 case, 0.5%), esophagorespiratory fistulas from tumor or therapy (14 cases, 8.2%), and refusal of surgery (4 cases, 2.3%). Dysphagia scores evaluated by a modified Takitas grading system improved from 3.4 before the procedure to 2.6 afterward. The overall complication rate without chest pain was 31.7% (occurring in 64 cases). Mean survival was 177.7 days+/-59.3 days (2-993 days). Quality-of-life scores (The European Organization of Research and Treatment of Cancer QLQ C30) improved from 73+/-10.3 (57-85) to 112+/-12.6 (90-125). In therapy of malignant esophageal obstructions, metallic stents provide a significant improvement in dysphagia and require less frequent re-intervention according to other methods of dysphagia palliation such as dilatation, laser, and photodynamic therapy, nearly completely relieve esophagotracheal fistulas and improve quality of life to an important degree.

Right-sided Bochdalek hernia with intrathoracic kidney

Bochdalek hernias are usually congenital and are seen with much greater frequency on the left side. Intrathoracic kidney is a very rare congenital anomaly, with only about 50 cases reported in the world literature. The incidence of intrathoracic kidney with Bochdalek hernias was reported to be less than 0.25%. A 22-month-old boy was admitted to our clinic with recurrent pulmonary infections. A chest X-ray, intravenous urogram, computed tomography, and magnetic resonance angiography revealed a right-sided Bochdalek hernia with dilated colon loops and right kidney within right hemithorax. Under a thoracotomy, a direct closure of the hernia was performed after the colon and kidney were returned to the abdomen. We report the second case, which has a diagnosis of a right Bochdalek hernia with intrathoracic kidney. Clinical correlations among this unusual combination are discussed.

Complications of metallic stent placement in malignant esophageal stricture and their management.

Objective At the present time, covered self-expandable metallic stent placement is the palliative treatment method for inoperable esophageal cancer. However, life-threatening early and late complications are seen related to esophageal stent placement. In this study, we discuss complications of esophageal stent placement with their management and present our own experience. Methods Between January 2000 and February 2009, 215 covered esophageal stent placements were performed in 174 inoperable esophageal cancer and/or esophagorespiratory fistula patients in the Department of Thoracic Surgery at the Ataturk University Hospital. Results Major complications related to stent placement developed in 24 patients (11 bleeding, 6 aspiration pneumonia, 3 tracheal compressions, 2 perforations, and 2 esophagorespiratory fistulas). Two hundred and thirty minor complications were observed among 174 patients (165 chest pain, 29 tumoral overgrowth, 17 stent migration, 6 gastroesophageal reflux, 3 failure in stent placement, 3 hiccup, 2 foreign body sensation, 2 failure in stent expansion, 1 tumor ingrowth, 1 granulation tissue formation, and 1 food bolus obstruction). Reintervention was required in 56 (32.2%) patients who experienced complications. Stent-related mortality was seen in 4 (2.3%) patients (2 aspiration pneumonia, 1 tracheal compression, and 1 esophagorespiratory fistula). One hundred sixty-two of 174 patients died during follow up. The mean survival time was 177.3±59.3 days (range: 2 to 993 d). Conclusions The complication rate of self-expandable metallic stent placement is high in inoperable esophageal cancer patients. Although some of these complications are life threatening, many of them can be managed successfully with endoscopic reintervention.