Sami Karapolat

The Perforation of the Superior Vena Cava Secondary to the Left Subclavian Dialysis Catheter

Introduction: The perforation of the superior vena cava during the placement of dialysis catheter and consequent hemothorax is a rare serious complication. Case Report: Dialysis catheter was placed in the left subclavian vein in a 69-year-old male patient with chronic renal insufficiency who was hospitalized for intracerebral hematoma. During hemodialysis a day after the procedure, the patient was noted having right-sided hemothorax, causing lethargy, dyspnea, hypotension, and bradycardia. Right tube thoracostomy was performed and 1500 cc of hemorrhagic fluid was drained. Under general anesthesia, the right posterolateral thoracotomy was performed and the tip of the dialysis catheter was found in the pleural space, penetrating the anteromedial side of the superior vena cava. The perforation area was repaired by suturing with 3-0 prolene, and the dialysis catheter was removed externally. Postoperative period was uneventful, and tube thoracostomy was terminated on day 4. Conclusion: Establishing the diagnosis early and accurately and performing appropriate surgery would be lifesaving in superior vena cava perforation due to dialysis catheter.

Comparison of T2 and T3 sympathectomy for compensatory sweating on palmar hyperhidrosis

Background: An otherwise successfully performed endoscopic thoracic sympathectomy (ETS) to treat palmar hyperhidrosis (PH) often has a serious side effect: compensatory sweating (CS). This side effect occurs in other parts of the body to a disturbing extent. The objective of this study is to determine whether there is a relationship between the level of ETS performed on patients with PH, and the occurrence and severity of postoperational CS. Methods: Between January 2014 and January 2015, ETS procedures were performed on 25 randomly selected consecutive subjects (group A) at T2 level, and on another 25 subjects (group B) at T3 level, who all felt severely handicapped due to PH. All subjects were assessed in terms of their demographic characteristics including gender and age, as well as postoperative complications, short-term results, side effects, recurrence of symptoms, and long-term results. Results: The symptoms disappeared in all subjects in short-term, and no recurrence was seen in their short or long-term follow-ups. At the end of year one, CS developed at a rate of 12% in group A and 8% in group B, particularly in their back and abdominal regions. The overall satisfaction with the procedure in year one was 96% in group A and 100% in group B. Conclusion: When an ETS performed at T2 or T3 level for PH involves only the interruption of the sympathetic chain, with a limitation on the range of dissection and avoidance of any damage to ganglia, sweating is stopped completely. No recurrence of PH is encountered, and CS develops only at low rates and severities.

Lung Image: Doege–Potter Syndrome

A 37-year-old male patient presented to an external clinic reporting dyspnea, fatigue, dizziness, and intermittent episodes of syncope. Upon blood testing, he was found to have hypoglycemia. His anamnesis revealed a surgical procedure and radiotherapy was performed 6 years prior due to a solitary fibrous tumor in his right hemithorax. He had no history of diabetes or medication at all. The patient was somnolent and his blood pressure was 125/80 mmHg, pulse was 95 bpm, and breathing rate was 19 breaths/min. Upon auscultation, no respiratory sounds were heard in the right hemithorax. His blood glucose level was approximately 50 mg/dL and his serum insulin level was 3.4 μU/mL. An intravenous infusion of 50% glucose was performed in an attempt to keep the patient’s blood glucose level within normal limits. Upon chest X-ray, opacity was observed in his right hemithorax. During thoracic tomography, a giant heterogeneous mass was seen in his right hemithorax (Fig. 1). No FDG uptake was observed in PET–CT scans (Fig. 2). The patient was reported to have a solitary fibrous tumor following a transthoracic fine-needle aspiration biopsy. A total excision of the mass and pleura with right redo posterolateral thoracotomy was performed next (Fig. 3). The patient’s blood glucose level remained within normal limits in the postoperative period. He was discharged on postoperative

How to treat right post‐pneumonectomy fistula with carinal sleeve resection

Despite the presence of some treatment methods for the closure of a right post-pneumonectomy bronchopleural fistula (BPF), unsuccessful outcomes still pose a major risk. Three male patients aged 32, 33 and 59 had undergone right pneumonectomy with posterolateral thoracotomy (two bronchial carcinoma and one destroyed lung caused by bronchiectasis). In all cases, bronchial closure was done with stapler and reinforcement of the bronchial stump was not performed. The patients presented to our department at postoperative day 11, 26 and 57 complaining about shortness of breath, cough, purulent phlegm, abundant serohaemorrhagic expectoration and fever. Chest X-rays showed decreased fluid levels in right hemithorax and thorax tomographies revealed fistula. The purulent fluid was aspirated with thoracentesis, the patients underwent tube thoracostomy and broad-spectrum antibiotic therapy was started. All patients underwent fiberoptic bronchoscopy to calculate the length of the main bronchus and determine the width of fistula. A pleural lavage was performed with isotonic solution through tube thoracostomy (average 2 weeks, once a day) until the direct microscopic examination and culture became negative. Then, patients were operated rethoracotomy. After removal of all debris, the lower end of the trachea and the left main bronchus were freed with dissection and extending up to 2 cm away from carina. The carinal region and the bronchial stump where the fistula was located were resected. At the same time, ventilation was continued by way of left main bronchus intubation from sterile area. Then, end-to-end anastomoses were performed at distal trachea and proximal left main bronchus with the continuous suture technique using 3.0 polyglactin (Vicryl; Ethicon, Somerville, NJ, USA) (Fig. 1). The patients were discharged within 6–9 days without complications and they were still asymptomatic at the end of their follow-up periods of 20 months on the average. Occurring mostly after lung surgery, BPF is a frightening complication and is among the most common causes of morbidity and mortality. A post-pneumonectomy BPF is seen more often after right pneumonectomy, and a clinically more severe form than that seen after a lobectomy with a mortality rate ranging from 25 to 71%. The widely used treatment methods include tube thoracostomy, open window thoracostomy, thoracomyoplasty, closure of the fistula with rethoracotomy and reinforcing the stump with live autologous flaps, and transpericardial closure of the fistula with sternotomy. The incidence of BPF in carinal sleeve resections is generally within the range of 3.8–21.6% in the literature. The carinal sleeve resection performed through rethoracotomy has lower probability of fistula recurrence as compared to other interventions. Since the bronchial system tends, by its nature, to remain open, the outward force along the suture line in the closed bronchi increases the probability of fistula formation. In fact, all sleeve resections have less BPF rates as they eliminate this tendency in the bronchi. We think here that since it has to be performed much closer to the carina region, a direct primary repair of the stump will increase the probability of fistula recurrence by causing greater tensile strength as compared to the initial operation. Conversely, the distal trachea and the left main bronchial lumens are brought facing each other and the cylindrical aspect of the bronchial structure is

Bilateral open pneumothorax resulting in a sucking chest wound

A 17-year-old male was brought to the emergency department after a sawmill injury. The patient’s general condition was poor, he was disoriented, his level of consciousness was somnolent, and he had difficulty cooperating with medical staff. His arterial blood pressure was 80–55mmHg, his pulse was 94/min, and his respiration was shallow (30/ min). A physical examination revealed an actively bleeding cut on the patient’s back extending transversely below both scapulae. The cut was up to 20 cm wide and so deep that it had severed the spinal erector muscles and the posterior thoracic wall muscles, resulting in a bilateral open pneumothorax (Figure 1). The patient was urgently intubated. The defect area was closed with occlusive dressing and a bilateral thoracostomy tube was immediately administered. Thoracic computed tomography revealed the bilateral pneumothorax as well as a laceration in the lower lobes of both lungs, segmental fractures in the posterior regions of right ribs 6–9 and left ribs 7–9, and fractures in the inferior right scapula and the right lamina of the sixth thoracic vertebra (Figure 2). The patient was operated on while in the prone position under general anesthesia. A thoracotomy was performed on the right side and then on the left to access the defect areas on the thoracic wall. The lacerated areas on the posterior basal segments of the lower lobes of both lungs were primarily sutured before the thoracotomies were closed. The vertebral defect area was then explored and bone fragments were removed. It was seen that, the dura mater was absent in the cut area, leaving the lacerated spinal cord uncovered. Finally, the muscle, fascia, and the subcutaneous and skin tissues of the posterior thoracic wall were primarily sutured. The patient was discharged on day seven with paraplegia due to the injury. At a six-month follow-up, he was still receiving physiotherapy for the paraplegia. In many countries, including Turkey, lumbering is a major economic activity and a significant source of labor employment. Due to the nature of the working conditions in this trade, cutting tools and sawmill machines are frequently used. Sawmill workers are at high-risk for work-related injuries and other health problems. A report by Alamgir et al. found the most common sawmill injuries to be open wounds, dislocations, sprains-strains, and fractures of the upper limbs, skull, intracranium, spine-trunk, and lower limbs [1]. Sawmill injuries generally involve the upper extremities, particularly the hands. A thorax-related injury is rarely encountered. Open pneumothorax is a rarely seen subgroup of traumatic pneumothorax that primarily occurs due to penetrating injuries. It typically involves a chest wall defect that directly communicates with the parietal pleura. In these sucking chest wounds, even after the atmospheric and intra-pleural pressures have equalized, air will continue to flow Figure 1. The defect area on the posterior chest wall after the sawmill injury.

Lung Image: Inflammatory Myofibroblastic Tumor

A 49-year-old male patient presented to our clinic with cough, fever, and chest pain complaints. With no peculiarities in his personal and family history, his physical examination revealed reduced breathing sounds in the basal regions of his right hemithorax during auscultation. Since opacity was seen at the right lower zone in his posteroanterior chest X-ray, a thoracic tomography was taken that showed a solid mass with irregular boundaries having a pleural base approximately 53 9 42 mm in size localized in the mediobasal segment of the right lower lobe, which had a feeding vessel from the thoracic aorta (Figure 1). In his PET/CT scan, an increased FDG uptake (SUVmax: 10.33) was seen in the mass (Figure 2). Fiberoptic bronchoscopy was normal, and transthoracic fine-needle aspiration biopsy did not allow making a diagnosis. The patient was operated under general anesthesia and right posterolateral thoracotomy incision was performed. The mass, which had a feeding artery from the aorta and could be distinguished from the lung parenchyma with smooth contours, was seen to congest the right lower lobe. After ligaturing the feeding artery, a right lower lobectomy and mediastinal lymph node dissection was performed. The pathological result was reported as inflammatory myofibroblastic tumor (Figure 3). The patient was discharged at postoperative day 4 with no complications, and he was still asymptomatic at the end of a 10-month follow-up period. Inflammatory myofibroblastic tumor (IMT) is a rare mesenchymal tumor with unknown etiology that is seen more in children and young adults and can be encountered in any region of the body (1, 2). IMTs are referred to with various names in the literature including plasma cell granuloma, inflammatory pseudotumor, solitary mast cell tumor, and pseudotumor pneumonia. Although IMT is mostly seen in the lungs, it comprises only 0.04–1% of all lung tumors (1, 3, 4). Being often asymptomatic and diagnosed incidentally, IMTs may involve respiratory complaints including cough, chest pain, shortness of breath and hemoptisis, and general complaints such as fatigue, joint pains, fever, loss of appetite, and weight loss. In radiological examinations, IMTs are seen as solitary masses with heterogeneous density, smooth and lobulated contours that are localized in the peripheral of the lower lobes of the lungs, showing calcifications particularly in children. Detection of an elevation in the acute phase reactants during the laboratory tests of the cases involving pulmonary masses and lack of any growth in the mediastinal or hilar lymph nodes in radiologic examinations should make clinicians suspect IMT (5). In the PET/CT scan, increased FDG uptake found in the mass seems more likely to have occurred secondary to the severe inflammation and increased metabolic activity rather than being a sign of malignancy for IMTs. The differential diagnoses of IMT include primary lung cancers, metastases, hamartoma, chondroma, and pulmonary granuloma. Since a definitive tissue diagnosis cannot be achieved through biopsies taken with the help of & Sami Karapolat samikarapolat@yahoo.com

A Comfortable Solution To Tracheal Anastomosis Protection: Tracheal Retention Sutures

Fixation of the chin to the anterior chest wall is the most commonly used method of reducing anastomotic tension following a segmental resection of the trachea and reconstruction with primary anastomosis. However, the sutures required for this method may lead to various organic and psychological problems. In five patients who underwent tracheal resection and primary anastomosis, retention sutures were placed on the proximal and distal-lateral edges of the anastomotic line rather than placing a Guardian chin stitch. All patients were mobilised in the early postoperative period and were able to perform their routine daily activities without restrictions. During their average 14.4 months of follow-up, no complications were found in their anastomotic lines during their clinical, radiological, and bronchoscopic assessments. The placement of tracheal retention sutures proved an inexpensive and reliable method to reduce anastomotic tension without additional surgical burden, and was effective in terms of patient comfort.

Do the nodules detected in chest X‐rays always indicate a disease of lung parenchyma?

A fracture in the radial/ulnar shaft of the left forearm, bilateral multiple rib fractures and a left haemopneumothorax were found in a 61-year-old male patient at an external clinic due to falling from height. After having been administered a left tube thoracostomy, he was referred to our clinic for further treatment. In the patient’s posteroanterior chest X-ray, which was sent to our clinic digitally before his transportation, bilateral multiple well-circumscribed nodules of various sizes were observed, suggesting the presence of different additional pathologies such as metastatic lung tumours, granulomatous diseases or infections (Fig. 1). During the physical examination after being admitted into the clinic, widespread skin nodules of various sizes were found all over his body (Fig. 2). The recollection heard from the patient and his family revealed that the patient and his brother were being treated for neurofibromatosis type 1. In thoracic tomography, no pathology was observed in the lungs and it was concluded that his skin nodules caused the pathological appearance in chest X-ray (Fig. 3). Affecting approximately 1 in 3500 live births, neurofibromatosis type 1 is an autosomal dominant, multisystem disorder with variable expressions. This disease is characterized by von Recklinghausen with multiple café-au-lait spots, axillary or inguinal freckling, cutaneous neurofibromas, plexiform neurofibromas, iris Lisch nodules, optic glioma and bony abnormalities. Neurofibromas are tumours of the nerve sheath comprised of Schwann cells, fibroblasts, perineural cells, mast cells, axons and blood vessels. They can occur in any part of the body in various shapes and sizes. In general, cutaneous neurofibromas are dome-shaped, soft, fleshy, skin coloured to slightly hyperpigmented lesions developing more commonly in teenagers and adults. As in this case, neurofibromas that can be in large numbers and great sizes covering the thoracic