Okan Solak

Management of traumatic diaphragmatic rupture.

PurposeDiaphragmatic rupture following trauma is often an associated and missed injury. This report documents our experience of treating traumatic diaphragmatic rupture (TDR).MethodsWe retrospectively analyzed 18 patients who presented between 1993 and 2000 with TDR, caused by blunt injuries in 14 and by penetrating injuries in 4.ResultsThe average age of the patients was 32 years and the female to male ratio was 4 : 14. The TDR was right-sided in 5 patients and left-sided in 13. The diagnosis was made by chest X-ray, thorax and upper abdominal computed tomography, and upper gastrointestinal contrast studies. The most common herniated organs were the omentum (n = 11), stomach (n = 10), spleen and colon (n = 9), and liver (n = 2). Sixteen diaphragmatic injuries were repaired primarily, and two were repaired using a prolene mesh graft. The mortality rate was 5.5% (n = 1).ConclusionsA high index of suspicion and early surgical treatment determine the successful management of TDR, with or without the herniation of abdominal organs. The surgical approach to TDR is individualized. Acute left-sided injuries are best approached through the abdomen, although we prefer the chest approach, adding laparotomy when necessary. Acute right-sided injuries and chronic injuries should be approached through the chest.

Nonanatomic prognostic factors in resected nonsmall cell lung carcinoma: The importance of perineural invasion as a new prognostic marker

BACKGROUND A number of prognostic factors have been reported for resected nonsmall cell lung carcinoma. Although none of them reported to have greater prognostic impact than the TNM staging system, which is based on anatomical descriptions of tumors, the prognoses of a significant number of patients are not in agreement with real survival of the patients. Moreover, certain histopathologic properties of the tumor (such as lymphatic and vascular invasion) could help to predict the survival of the patients. METHODS A retrospective study was conducted on 82 surgically resected nonsmall cell lung carcinomas, and the following prognostic factors were evaluated in univariate analysis: age, gender, clinical and surgical-pathologic T and N status, histologic type of tumor, grade of differentiation, lymphatic invasion, vascular invasion, and perineural invasion. RESULTS Lymphatic invasion and perineural invasion of the tumor were found to be significant prognostic factors (p = 0.02 and p = 0004). Blood vessel invasion (venous or arterial involvement) had no prognostic impact (p > 0.05). According to multivariate analyses, three factors were selected as prognostic indicators: (1) clinical N status (p = 0.027), (2) lymphatic invasion (p = 0.027) and (3) perineural invasion (p = 0.0148). By combining these factors we identified a poor prognostic subgroup of patients with stage I disease. CONCLUSIONS Our study showed that lymphatic vessel and perineural invasion of the tumor could be prognostic factors, along with anatomical determinants such as cN and surgical-pathologic stage of the pulmonary carcinoma.

Very important histopathological factors in patients with resected non-small cell lung cancer: necrosis and perineural invasion.

BACKGROUND The current staging system provides an anatomical classification of lung tumors; its secondary purpose is to allow the prognostic stratification of patients into homogeneous groups after surgery. In this work, intratumoral perineural invasion, lymphatic and blood vessel invasion together with the necrosis content of the tumor exclusive of the non-small cell cancer staging system were studied. METHODS During a 4-year period, 152 patients operated for non-small cell lung cancer (NSCLC) at our hospital were analyzed. Mean age of patients was 55.7 +/- 10.1 years. RESULTS Overall 5-year survival was 42.2 %. Mediastinal lymph node involvement, tumor size, incomplete resection, pneumonectomy, presence of necrosis and perineural invasion were significant prognosticators ( P = 0.03, 0.04, 0.0001, 0.046, 0.0246, < 0.0001, respectively). Multivariate analysis revealed that N status, perineural invasion, and the presence of necrosis were independent prognostic factors ( P = 0.006, P = 0.001, P = 0.001, respectively). Patients who had stage I tumor with necrosis and perineural invasion had a lower survival rate than those with stage IIIA tumor without these histopathological features ( P = 0.04). The presence of these histopathological characteristics in stage IIIA patients was a sign of a poorer prognosis ( P = 0.0001). CONCLUSIONS Perineural invasion and the presence of necrosis independently indicated a dismal prognosis and their prognostic power is comparable to those of the TNM classification. These factors could be candidates for better survival stratification and the indicators of the need for adjuvant therapy in early stage lung cancer patients.

The effectiveness of transdermal opioid in the management multiple rib fractures: randomized clinical trial.

BACKGROUND The most commonly observed pathology in chest traumas is rib fracture, and the most important clinical symptom is severe pain. AIMS To investigate the effectiveness of intramuscular opioid (IMO), intravenous patient-controlled analgesia (IVPCA) and the Fentanyl transdermal therapeutic system (TTS) in the management of rib fracture pain. STUDY DESIGN Prospective randomized clinical trial. METHODS In our prospective and randomised study, we included 45 patients with a diagnosis of multiple rib fractures. There were three groups and intercostal nerve blockage (ICB) in the first day and oral paracetamol for five days was administered to each group as standard. In Group IMO (n=15), 4×40 mg pethidine HCl was administered to the patients, while in Group IVPCA (n=15) this was 5 μg/mL continuous intravenous fentanyl and was 50 μg fentanyl TTS in Group TTS (n=15). The demographics, injury data and vital signs of the patients were recorded. Pain was scored using Visual Analogue Scale (VAS). The pain during lying down (VASl) and mobilisation (VASm) was detected. RESULTS There were no differences between the three groups regarding age, sex, the trauma pattern, the number and distribution of costal fracture localisations, the presence of additional pathology, complications, thoracal catheter and the duration of thoracal catheter. No significant difference between the groups regarding systolic and diastolic arterial tension, number of breaths and beats in a minute was observed (p>0.05). We observed an improvement in the mean VAS score after treatment in all three groups. The mean VASl score significantly decreased after treatment in each group (p<0.05). The mean VASl and VASm scores measured on the 1(st), 2(nd), 3(rd), 4(th) and 5(th) days were found to be higher in Group IMO than in Groups IVPCA and TTS; however, these differences were not statistically significant (p>0.05). CONCLUSION In the analgesia of patients with multiple rib fractures, TTS administration with ICB showed similar effectiveness with IVPCA administration with ICB. In the management of pain due to multiple rib fractures, TTS administration is a safe, non-invasive and effective procedure.

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.

Efficacy of budesonide and interleukin-10 in an experimental rat model with isolated bilateral pulmonary contusion created by blunt thoracic trauma

OBJECTIVES In our study, we aimed to investigate the anti-inflammatory mediator effects of budesonide (BS), an inhaled corticosteroid and interleukin-10 (IL-10) on a pulmonary contusion in an experimental rat model in which an isolated bilateral pulmonary contusion was created by blunt thoracic trauma. METHODS Fifty-five male Sprague-Dawley rats were used in the study. Sham, control, BS and IL-10 groups were created. A pulmonary contusion was created by performing isolated blunt thoracic trauma in all groups except for the sham group. The traumas severity was determined as 1.45 J. BS and IL-10 were administered orogastrically to the respective groups 30 min before trauma, and orogastrically and intraperitoneally, respectively, on the first and second days after the trauma. Only the blunt thoracic trauma was performed for the control group. SatO(2), PaO(2) and PaCO(2), blood glutathione, malondialdehyde (MDA) and tumour necrosis factor-α (TNFα) values were recorded on the zeroth, first, second and third days. The histopathological examination and the bronchoalveolar lavage cell count were performed on pulmonary tissues. RESULTS Blood gas analysis revealed that SatO(2) and PaO(2) values on the first and second days were significantly lower in the control, BS and IL-10 groups compared with the sham group (P < 0.05). The SatO(2) and PaO(2) values on the third day in the BS and IL-10 groups were higher than in the control group (P < 0.05). The mean MDA in the control group was higher than in the sham, BS and IL-10 groups (P < 0.05). The mean TNFα in the control group was higher than in the sham, BS and IL-10 groups (P < 0.05). Pulmonary pathology scoring in the control group was observed to be higher than in the sham, BS and IL-10 groups (P < 0.05). CONCLUSION In this rat experiment model in which an isolated pulmonary contusion was created by blunt trauma, BS and IL-10 were observed to reduce contusion severity in the lung and minimize the inflammatory reaction.

Carinal resection and reconstruction for respiratory tumors using Miyamoto’s technique

PurposeSurgical processes that involve the carina pose a serious challenge to thoracic surgeons. Although techniques to allow resection and reconstruction have been developed, few institutions have accumulated sufficient experience to achieve meaningful results. There is still a debate about the indications and the morbidity and mortality rates for this type of surgery.MethodsWe have operated on six patients using a modified version of the tracheobronchial end-to-end and bronchial end-to-side anastomosis technique that was developed by Miyamoto and coworkers and reported in the English-language literature by Yamamoto and associates.ResultsFive patients underwent tracheal sleeve right upper lobectomy, and one underwent carinal resection only with two main bronchi and the trachea. None of the patients we operated on had any postoperative complications.ConclusionsWe concluded that when used with adequate surgical performance this seldom-used technique can be applied safely and provide great benefits in particular cases.

A rare cutaneous tumor of the axilla: Apocrine adenocarcinoma

Sweat gland neoplasms are rare with approximately 200 cases of eccrine sweat gland and less than 50 cases of apocrine gland carcinoma being reported in the worldwide literature. More than half of the reported cases with apocrine adenocarcinoma had lymph node metastases at the time of diagnosis. We report a case of a 56-year-old man, presented with a left axillary slow-growing seven year old painless nodule. Histopathological examination revealed an invasive apocrine adenocarcinoma with lymph node metastases. The patient successfully treated with total excision and radiotherapy. Apocrine adenocarcinoma is a rare malignancy with high metastatic potential that occurs mostly in the axilla. Physicians should be aware of this entity while differentiating cutaneous tumor located on the axillary region.

The Prognostic Significance of Metastasis to Lymph Nodes in Aortopulmonary Zone (Stations 5 and 6) in Completely Resected Left Upper Lobe Tumors.

INTRODUCTION We investigated the prognostic effect of lymph nodes metastasis in aortopulmonary (AP) zone in resected non-small cell lung cancer of the left upper lobe (LUL). METHODS Between 1998 and 2010, 181 patients with LUL carcinoma underwent complete resection and were retrospectively analyzed. The patients were divided into four groups according to N status: N0 (n = 68, 37.6%), N1 (n = 64, 35.3%), N2(5,6+) (only metastasized to stations 5 and/or 6, n = 36, 19.9%), and N2(7+) (only metastasized to stations 7, n = 13, 7.2%). N1 were divided according to single and multiple (N1(single) n = 49, N1(multiple) n = 15) or peripheral and hilar (N1(peripheral) n = 39, N1(hilar) n = 25). RESULTS Overall 5-year survival rate was 55.1%. Five-year survivals were 76.1% for N0, 54.3% for N1, and 20.7% for N2. N1(peripheral) had a better survival than N1(hilar) (60.3 vs. 29.4%, p = 0.09). Five-year survival of N1(single) was 60.1%, whereas it was 36.6% for N1(multiple) (p = 0.02). Five-year survival rate was 24.6% for N2(5,6+). Skip metastasis for lymph nodes in AP zone (n = 13) was a factor of better prognosis as compared to nonskip metastasis (n = 23) (29.9 vs. 19.2%). There was no statistically significant difference between the N2(5,6+) and N1(hilar) (p = 0.772), although N1(peripheral) had a significantly better survival than N2(5,6+) (p = 0.02). AP zone metastases alone had a significantly worse survival than N1(single) (p = 0.008), whereas there was no statistically significant difference between the N1(multiple) and N2(5,6+) (p = 0.248). N2(7+) was not expected to survive 3 years after operation. They had a significantly worse prognosis than N2(5,6+) (p = 0.02). CONCLUSION LUL tumors with metastasis in the AP zone lymph nodes, especially skip metastasis, were associated with a more favorable prognosis than other mediastinal lymph nodes. However, the therapy of choice for lung cancer with N2(5,6+) has not been clarified yet.

Tracheobronchial Rupture due to Compression Under a Cannon Barrel

Tracheobronchial ruptures following blunt thoracic trauma are rare in children. To our knowledge, there is no reported case of tracheobronchial rupture due to compression under the barrel of a cannon. The involvement of both the trachea and right main bronchus is highly unusual. The case of a 16-year-old boy with both distal tracheal and right main bronchial ruptures following blunt chest trauma is herein reported, in which we emphasize the need for a prompt diagnosis and appropriate management. (Tur Toraks Der 2012; 13: 28-9)