Salih Topcu

A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management

OBJECTIVE A rib fracture secondary to blunt thoracic trauma is an important indicator of the severity of the trauma. In the present study we explored the morbidity and mortality rates and the management following rib fractures. METHODS Between May 1999 and May 2001, 1417 cases who presented to our clinic for thoracic trauma were reviewed retrospectively. Five hundred and forty-eight (38.7%) of the cases had rib fracture. There were 331 males and 217 females, with an overall mean age of 43 years (range: 5-78 years). These patients were allocated into groups according to their ages, the number of fractured ribs and status, i.e. whether they were stable or unstable (flail chest). RESULTS The etiology of the trauma included road traffic accidents in 330 cases, falls in 122, assault in 54, and industrial accidents in 42 cases. Pulmonary complications such as pneumothorax (37.2%), hemothorax (26.8%), hemo-pneumothorax (15.3%), pulmonary contusion (17.2%), flail chest (5.8%) and isolated subcutaneous emphysema (2.2%) were noted. 40.1% of the cases with rib fracture were treated in intensive care units. The mean duration of their stay in the intensive care unit was 11.8+/-6.2 days. 42.8% of the cases were treated in the wards whereby their mean duration of hospital stay was 4.5+/-3.4 days, while 17.1% of the cases were followed up in the outpatient clinic. Twenty-seven patients required surgery. Mortality rate was calculated as 5.7% (n=31). CONCLUSIONS Rib fractures can be interpreted as signs of significant trauma. The greater the number of fractured ribs, the higher the mortality and morbidity rates. Patients with isolated rib fractures should be hospitalized if the number of fractured ribs is three or more. We also advocate that elderly patients with six or more fractured ribs should be treated in intensive care units due to high morbidity and mortality.

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.

Localized fibrous tumors of the pleura: clinical and surgical evaluation

BACKGROUND Localized fibrous tumors of the pleura, which are considered to originate from submesothelial connective tissue, are rare. The purpose of this study was to investigate the clinical features of these tumors and to determine the optimal treatment and follow-up. METHODS The records of 10 consecutive patients with localized fibrous tumors of the pleura operated on at the Ataturk Center for Chest Diseases and Thoracic Surgery between 1995 and 2001 were retrospectively reviewed. Diagnostic procedures, clinical courses, and outcomes of these patients were studied. Total excision through a thoracotomy was performed in all of the patients. Pneumonectomy was required in 1 patient because of a giant intraparenchymal localized fibrous tumor of the pleura. Additional partial chest wall resections were done in 2 patients. RESULTS The size of excised tumors ranged from 10 x 8 x 4 cm to 30 x 25 x 20 cm. Malignant transformation was seen in 1 patient 22 months after resection of a benign tumor. Four cases were pathologically considered to be malignant. All patients except 1 are alive (follow-up 16 to 57 months after resection). CONCLUSIONS Although localized fibrous tumors of the pleura are considered histologically benign tumors, because of the risk of recurrence and malignant transformation, complete surgical resection is indicated and long-term follow-up is recommended in all patients.

Surgery in bronchial carcinoids: experience with 83 patients

OBJECTIVE With the changing clinical presentation and histopathological pattern, carcinoids are now considered as a distinct and well-defined group in the neuroendocrine tumour scale. Surgery, especially parenchyma-sparing operations, are the treatment of choice for carcinoids. METHODS Over a 25-year period, 83 patients with typical carcinoid tumour underwent thoracotomy on in our institution. The records of the patients were reviewed and the results were evaluated. RESULTS The diagnosis was made with radiological methods and bronchoscopy. Cough and recurrent pneumonia were the most common symptoms. A variety of surgical procedures were performed. Thirty of the 83 patients underwent tissue-saving operations. Twenty patients underwent bronchotomy excision, eight were managed with sleeve or partial sleeve resective procedures, and two underwent segmentectomy. CONCLUSIONS Conservative surgery is the treatment of choice of carcinoids, which were histologically typical and anatomically endobronchial. Especially for polypoid type carcinoids and for selected cases with sessile type, bronchotomy with simple excision and sleeve resections is a simple and effective method. As these types of operations produce a better functional result, they should be encouraged in these patients.

Local complications of hydatid disease involving thoracic cavity: Imaging findings

Hydatid disease, a worldwide zoonosis, is caused by the larval stage of the Echinococcus tapeworm. Although it can involve almost every organ of the body, lung involvement follows in frequency the hepatic infestation in adults and is the predominating site in children. Radiologically, hydatidosis usually demonstrates typical findings, but many patients are at risk of developing various complications of hydatid disease with atypical imaging findings and these are rarely described in the literature. In this pictorial review, the imaging features of local complications of hydatid disease involving the thorax including intrapulmonary or pleural rupture, infection of the ruptured cysts, reactions of the adjacent tissues, thoracic wall invasion and iatrogenic involvement of pleura are described. Additionally, imaging characteristics of transdiaphragmatic thoracic involvement of hepatic hydatid disease are presented. To prevent the development of subsequent catastrophic results, all radiologists need to be aware of the atypical imaging appearances of complications of pulmonary hydatid disease.

Malignant pleomorphic adenoma (malignant mixed tumor) of the trachea: a case report and review of the literature

Abstract. A case of malignant mixed tumor of the trachea in a 56-year-old man is described. His tumor was removed by segmental tracheal resection, and end-to-end anastomosis was performed. Histologically, the tumor was characterized by a biphasic composition showing admixtures of epithelial elements in varying proportions; these were cytologically atypical with prominent mitotic figures. However, stromal elements were osteoid and mixoid with a benign appearance. The patient had no evidence of disease in the head and neck region and had no history of previous surgery for a salivary gland tumor. These findings were interpreted as indicative of malignant pleomorphic adenoma of the trachea.

Giant hydatid cysts of lung and liver

A 13-year-old girl was admitted to our clinic with the complaints of dyspnea, abdominal distention, cough, and right-sided chest pain.The diagnosis of disease was made with physical examination and radiologic evaluation. She underwent right thoracotomy and phrenotomy for the management of the hydatid cysts of the lung and the liver. The postoperative course was uneventful and she was discharged on the 10th postoperative day. We believe that the simultaneous management of concomitant pulmonary and hepatic hydatid cysts through a thoracicroute is a convenient option.

RESPONSE TO RITUXIMAB AND PREDNISOLONE FOR OPSOCLONUS-MYOCLONUS-ATAXIA SYNDROME IN A CHILD WITH GANGLIONEUROBLASTOMA

Opsoclonus-myoclonus-ataxia (OMA) syndrome is a rare neurobehavioral paraneoplastic disorder in children with neuroblastic tumors. The neurologic symptoms are generally treated with a number of immunosupressive and immunomodulating agents. A 4-year-old previously healthy male patient was admitted to the authors’ center with progressive ataxia, gait disturbance, diffuculty of speech, and opsoclonus. He had a diagnosis of ganglionueroblastoma at the thoracal paraspinal region. Following surgey, the patient received IVIG and prednisolone but his cerebellar symptoms progressed. Rituximab therapy was started and continued for total 8 weeks without any side effect. The authors observed excellent neurologic response in the patient at the 4th week of treatment. Rituximab is a new, promising, and safe therapy for OMA syndrome in children with neuroblastoma.

Neurogenic Tumors of the Mediastinum: A Report of 60 Cases

OBJECTIVES To analyze retrospectively 60 patients (13 infants and children, 47 adults--21 men and 39 women) with mediastinal neurogenic tumours admitted to Atatürk Centre for Chest Disease and Chest Surgery, Ankara, Turkey between 1988 and 1999. This comprised 21.2% of 283 patients who had surgical operations for all mediastinal masses during the same period. PATIENTS AND METHODS The patients ranged from four to 67 years of age. Thirteen patients were younger than 15 years and 47 were 15 years of age or older. Medical records were reviewed for demographic data, clinical presentation, diagnostic investigations, operative procedures, and tumour location and invasion. Postoperative morbidity and mortality were noted as well as long term follow-up. The clinical investigations included chest x-ray and computed tomography of the thorax in all patients, and spinal magnetic resonance imaging and bronchoscopical examination in some. Clinical variables were compared. RESULTS The tumours had the following characteristics: 42 (70%) were nerve sheath tumours; 15 (25%) were autonomic ganglion tumours; two (3.6%) were paragangliomas; and one (1.4%) was a malignant peripheral neuroectodermal tumour (Askins tumour). Nerve cell tumours comprised the majority of tumours in infants and children (nine of 13, 69%), whereas the nerve sheath tumours were most frequent in adults (39 of 47, 83%). There were 48 benign and 12 (20%) malignant tumours when all age groups were considered; the malignancy rate was 61.5% (eight of 13) in children and 8.5% (four of 47, P<0.05) in adults. All patients were operated via a posterolateral thoracotomy. Surgical resection of the tumour was complete in 56 of 60 patients (93.3%). Resection of malignant tumours was grossly incomplete in four cases (four of 12, 33.3%). All benign tumours were totally excised. There were two major complications (respiratory failure and pulmonary emboli) and 14 minor complications in the perioperative period. The mean follow-up period was five years and seven months. Tumours recurred in 5.3% (three of 56) of patients who had a complete resection initially. There were no late deaths related to benign tumours. CONCLUSIONS Complete resection of tumours can be performed safely by a thoracotomy approach and is important for achieving satisfactory long term survival in most mediastinal neurogenic tumours.

Management of intrathoracic goitre

A retrospective review is presented of 20 cases with resection of intrathoracic goitre between 1975 and 1993. The mean age of the 11 men and nine women was 53 years. The intrathoracic goitre was primary in seven cases and secondary in 13. The presenting clinical features and the pathology, surgical risks and optimal approaches are discussed. Primary intrathoracic goitre should be approached via a thoracotomy, because of the independent vascular supply. As secondary intrathoracic goitres are supplied by vascular pedicles arising from the inferior thyroid artery, a cervical collar incision is preferable. In the event of significant mediastinal bleeding, which is difficult to control from a cervical incision, a T-shaped incision for partial or full sternotomy can be performed, or even thoracotomy.