Serdar Evman

Trimodality Treatment of Malignant Pleural Mesothelioma

Introduction: Multimodality treatment has achieved significant success in local control and treatment of early-stage malignant pleural mesothelioma patients. However, its favorable effect on survival is questionable. Methods: We have instituted a trimodality treatment protocol consisting of extrapleural pneumonectomy, adjuvant high-dose (54 Gy) hemithoracic irradiation, and platin-based chemotherapy in a multi-institutional setting. Preoperative pulmonary function tests, echocardiogram, chest computed tomography, and magnetic resonance imaging scans were performed in all patients. Twenty patients have been treated with this protocol during 2003–2007. Seventeen had a history of environmental asbestos/erionite exposure. Clinical stages were T1-3N0-2. Results: Median age was 56 (41–70, 8 female). There was one postoperative mortality (% 5) due to ARDS. Morbidity occurred in 11 patients (% 55). Histology was epithelial in 17, mixed in 2, and sarcomatoid in 1. Sixteen patients underwent extrapleural pneumonectomy. Microscopic margin positivity was present in 14 patients with macroscopic complete resection. Twelve patients completed all three treatments. Median follow-up was 16 months (1–43). Overall median survival was 17 months (24% at 2 years). Eight patients had extrapleural lymph node involvement (internal mammary [n = 3], subcarinal [n = 2], pulmonary ligament [n = 1], diaphragmatic [n = 1], subaortic [n = 1]). There was better survival in patients without lymph node metastasis (24 versus 13 months median survival, p = 0.052). Currently, 7 patients are alive, 6 without recurrence, and 2 patients at 40 and 45 months. Conclusions: Trimodality treatment in malignant pleural mesothelioma seems to prolong survival in patients without lymph node metastasis. Novel techniques are needed for preoperative assessment of extrapleural lymph nodes.

Minimally invasive repair after inefficient open surgery for pectus excavatum.

OBJECTIVE Pectus excavatum is the most common chest wall deformity, and both open surgery and minimally invasive repair have been proposed for primary correction. The aim of this study was to show the feasibility of minimally invasive repair of recurrent pectus excavatum in patients with inefficient previous open surgery. METHODS A total of 135 patients underwent minimally invasive repair of pectus excavatum between June 2006 and February 2010. Ten patients had a previous unsatisfactory open surgical repair of the deformity. Operation duration, length of hospital stay, complications and the need for a revision operation were compared between the primary Nuss (N) and the Nuss after Ravitch (RN) groups. RESULTS The N group consisted of 125 patients, requiring 133 operations, whereas 10 patients in the RN group underwent 11 minimally invasive correction operations. For the N and RN groups, medians of operation duration and length of hospital stay were 60 (20-180) and 60 (30-120) min, and 5 (2-15) and 5 (3-10) days, respectively. The differences between the two values were found to be statistically insignificant (p > 0.05). Development of perioperative or postoperative complications in both groups was found not to be associated with primary or redo minimally invasive surgery (p > 0.05). CONCLUSIONS Minimally invasive repair is a safe and easy operation for the correction of pectus excavatum. Previous open surgical repair is not a contraindication for the redo minimally invasive surgery, and it can be performed with acceptable morbidity and length of hospital stay.

Pulmonary resection in the treatment of life-threatening hemoptysis.

PURPOSE Massive hemoptysis is a life threatening situation with high mortality rates. Surgery is effective, however generally an avoided treatment. We report our experience with patients undergoing lung resection for life-threatening hemoptysis. METHODS Records of all surgically treated patients for hemoptysis between June 2009 and June 2012 were reviewed and analyzed retrospectively. RESULTS Anatomical resection was performed on 31 (15.3%) patients out of 203 patients referred to our intensive care unit for life-threatening hemoptysis. 25 (80.6%) were male and six (19.4%) were female; with mean age of 46.4 ± 13.7 (21-77). Pneumonectomy was performed in four (12.9%), lobectomy in 24 (77.4%), segmentectomy in two (6.5%) and bilobectomy in one case. Postoperative complications developed in eight (25.8%), and mortality was observed in two (6.5%) patients. Etiology was bronchiectasis in 13 (42.0%), tuberculosis in eight (25.8%), carcinoma in four (12.9%), aspergilloma in four (12.9%), hydatid cyst in one (3.2%) and lung abscess in one (3.2%) of the cases. CONCLUSIONS Although lung resection in the treatment of massive hemoptysis is accompanied with high morbidity and mortality rates, surgery is the only permanent curative modality. Acceptable results can be achived in the company of a multidisciplinary approach, through avoidance of pneumonectomy and urgent surgery.

Is Video-Assisted Thoracoscopic Surgery Adequate in Treatment of Pulmonary Hydatidosis?

BACKGROUND Surgical management of pulmonary hydatid cyst disease has been well established. However, there are still limited data on the role of video-assisted thoracoscopic surgery in treatment of this disease. The aim of this study is to identify the advantages and disadvantages of minimally invasive surgery and compare the outcomes with patients undergoing thoracotomy in this parasitic disease. METHODS The medical records of 77 patients (53 male, 24 female) undergoing surgery for pulmonary hydatid cyst disease between January 2011 and January 2014 were reviewed. Removal of the hydatid cyst was completed using video-assisted thoracoscopic surgery in 39% (n = 30) of the patients, whereas open thoracotomy was used in 61% (n = 47). Conversion rate was 21%. Statistical analysis was used to assess differences in drainage amount, time to drain removal, length of surgery, length of hospital stay, and pain scores. Probability values of less than 0.05 were considered significant. RESULTS The drainage amount, time to drain removal, length of surgery, duration of narcotic analgesics usage, and visual analog scale scores in the thoracotomy group were significantly longer than those of the thoracoscopy group. Postoperative complications occurred in 4.3% of thoracotomy and in 13.3% of thoracoscopy patients. There was no mortality in either group. During the follow-up period, no recurrence was detected. CONCLUSIONS Video-assisted thoracoscopy for surgery of pulmonary hydatid cyst disease is superior to open thoracotomy causing less postoperative pain, a better cosmetic result, a shorter surgical time, a lower drainage volume, and a shorter time to drain removal in a selected group of patients. The fear of recurrence because of incomplete isolation of the cyst during removal was not a concern regarding our technique.

The efficacy and economical benefits of blood patch pleurodesis in secondary spontaneous pneumothorax patients.

Introduction Prolonged air leak in secondary spontaneous pneumothorax (SSP) patients remains one of the biggest challenges for thoracic surgeons. This study investigates the feasibility, effectiveness, clinical outcomes, and economical benefits of the autologous blood patch pleurodesis method in SSP. Material and methods First-episode SSP patients undergoing autologous blood patch pleurodesis for resistant air leak following underwater-seal thoracostomy, between January 2010 and June 2013 were taken into the study. Timing and success rate of pleurodesis, recurrence, additional intervention, hospital length of stay, and complications that occurred during follow-up were examined from medical records, retrospectively. Results Thirty-one (27 male, 4 female) SSP patients with expanded lungs on chest X-ray and resistant air leak on the 3rd post-interventional day were enrolled. Mean age was 53.7 ± 18.9 years (range: 23-81). Twenty-four patients were treated with tube thoracostomy, 2 with pezzer drain, and 5 with 8 F pleural catheter. 96.8% success was achieved; air leak in 29 of 31 patients (93.5%) ceased within the first 24 hours. No procedure-related complication such as fever, pain or empyema was seen. Late pneumothorax recurrence occurred in 4 (12.9%) patients; 1 treated with talc pleurodesis where the other 3 necessitated surgical intervention. Conclusions Autologous blood patch pleurodesis is a safe, effective, and easily performed procedure with no need of any additional equipment or extra cost. This method can be applied to all patients with radiologically expanded lungs and continuous air leak after 48 hours following water-seal drainage thoracostomy, to reduce hospital stay duration, unnecessary surgical interventions, and the expenses.

Management and Surgical Outcomes of Concurrent Tuberculosis and Lung Cancer

Background Concurrent pulmonary tuberculosis (TB) and lung cancer are rarely encountered in Western countries; however, it is more common in developing countries. We aim to share the diagnostic and treatment approaches in this study. Materials and Methods Clinical files of all patients undergoing lung resection for non-small cell carcinoma with concurrent pulmonary TB between February 2006 and December 2012 were investigated retrospectively in terms of patient characteristics, operation methods, definite pathology and stage of tumor, postoperative treatment schemes, and associated complications. Results TB was detected in 17 (1.3%) of 1,266 operated carcinoma patients. Eleven had squamous cell carcinoma and six had adenocarcinoma. Mean age was 54.9 years. Two patients received anti-TB treatment preoperatively. Fifteen patients were given anti-TB treatment postoperatively, as soon as definite microbiological confirmation was obtained, and concurrently given adjuvant therapy after 3 weeks of sole four-drug TB treatment. Pneumonectomy was performed in four (23.5%), sleeve lobectomy in three (17.6%), lobectomy in eight (47%), and bilobectomy in two (11.7%) patients. Postoperative complications occurred in four (23.5%) patients, with bronchopleural fistula being seen in only one pneumonectomy patient. No postoperative mortality or reactivation of TB was seen. Mean survival time was 32 ± 2 months. Conclusion Resection following a 3-week anti-TB treatment or concurrent anti-TB and postoperative adjuvant chemotherapy does not constitute an additional postoperative risk for patients with concomitant lung malignancy and pulmonary TB. The determination of optimum treatment for these patients presents a challenge in developing countries, where TB is still a common disease.

The Feasibility of Thoracoscopic Resection in Bronchiectasis

Introduction: Minimally invasive surgery is the treatment of choice in early-stage lung cancer. However, experience in infectious lung disease, primarily bronchiectasis, is limited probably because of the presence of dense pleural adhesions, multiple lymph nodes, and spiral bronchial arteries. The present study shows our experience of video-assisted thoracoscopic surgery (VATS) lobectomy and segmentectomy in the treatment of bronchiectasis. Materials and Methods: Patients who underwent VATS lobectomy or segmentectomy in our clinic between April 2008 and 2015 were retrospectively evaluated. Surgery was indicated in patients with radiologic localized bronchiectasis who also had a history of recurrent lower respiratory tract infection or expectorating mucopurulent secretion. The patients were analyzed in terms of age, sex, thoracotomy conversion rate, postoperative drainage amount, chest tube removal time, length of hospital stay, morbidity, and mortality. Results: A total of 44 patients initially underwent VATS pulmonary anatomic resection and 41 procedures were completed on 40 patients. One patient had bilateral resection. Fifteen patients were male individuals and 26 were female individuals. The average age was 31.4 (15 to 57) years. Forty lobectomies and 1 segmentectomy were performed. The conversion rate was 6.8%. VATS was performed on 28 patients by 3 ports, 8 patients by 2 ports, and 5 patients by a single port. In terms of anatomic resections, 18 patients underwent left lower lobectomy, 8 right lower lobectomy, 8 middle lobectomy, 6 right upper lobectomy, and 1 patient underwent lingular segmentectomy. No major postoperative complication or mortality was observed. Prolonged air leak was observed in 2 patients and subcutaneous emphysema occurred in 2 patients. The average postoperative drainage amount, chest tube removal time, and length of hospital stay were 320 mL, 3.1 (1 to 11) days, and 4.6 (2 to 11) days, respectively. Conclusions: VATS pulmonary resection is a safe, feasible, and effective treatment in the surgery of bronchiectasis with low morbidity and mortality rates. Moreover, because of cosmetic results, patients with benign diseases such as bronchiectasis could be initiated by minimally invasive surgery options just like patients with malignancies.

A Bronchopleurocutaneous Fistula Caused by Unexpected Foreign Body Aspiration: False Barley (Hordeum murinum)

A 13-year-old boy with no previous history of foreign body aspiration, presenting with side pain, was referred to our clinic with a pneumonia diagnosis by an external medical facility where he had been started on antibiotic treatment. Consolidation in the right inferior lobe and minimal pleural effusion were found on the lung radiograph and computed tomography scan. Skin hyperemia and abscess formation in the right chest were observed subsequently. A drain was placed; bronchoscopy, sampling for cultures, and a biopsy were performed. Four months after this first episode ended with inconclusive results, the patient returned, reporting that a spike of grass was protruding from the continued abscess drainage. The skin lesion closed after emptying of the abscess cavity; a check-up bronchoscopy was unremarkable. The extrusion from the skin of the foreign body, a rare event in the published literature, was our first such case.

Spontaneous pneumothorax and ozone levels: is there a relation?

Study objectivesAlthough links between meteorological conditions and spontaneous pneumothorax (SP) have been proposed, the reports are controversial. In this study ozone levels, which are known to have some adverse effects on lung tissues, were investigated as a potential triggering factor of SP. At present there is not sufficient information about the effects of ozone on SP.MethodsOf a total 79 pneumothorax patients recruited for the study, 21 secondary pneumothorax cases were excluded. In the remaining 58 SP patients, meteorological data at the time of SP occurrence were recorded.ResultsThe number of SP patients was higher in spring than in the other seasons (p < 0.05). There was an association between the SP frequency and the average ozone level at different seasons (F 3,52 = 19.45, p = 0.001). The average ozone level was higher in spring (363 ± 25 Dobson) than during the other seasons (autumn 296 ± 18 Dobson; summer 321 ± 26 Dobson; winter 324 ± 32 Dobson) (p = 0.001). There was a positive correlation between SP frequency and the average ozone values for each season (r = 0.301, p = 0.024). There was no significant correlation between the severity of SP and ozone level (r = 0.236, p = 0.16).ConclusionsThe number of SP patients increases in spring when ozone levels are highest. Ozone is known to affect alveolar cells and cause interstitial edema. Ozone causes damage to the lung interstitium by way of oxidative stress. Rupture of unrecognized underlying blebs/bullae has been proposed as a cause of SP. Increased levels of ozone may be a triggering factor for these ruptures.RiassuntoObiettiviSebbene siano state proposte possibili connessioni tra le condizioni meteorologiche e lo pneumotorace spontaneo (SP), i risultati sono ad oggi contoversi. In questo studio i livelli di ozono, del quale sono noti gli effetti dannosi per le strutture polmonari, sono stati oggetto di valutazione come possibili fattori causali nel SP. Al momento attuale le informazioni sugli effetti dell’ozono sul SP non sono sufficienti.MetodiSu un totale di 79 pazienti con pneumotorace reclutati per lo studio ne sono stati esclusi 21 perché lo pneumotorace era secondario. Nei rimanenti 58 pazienti con SP sono stati registrati i dati meteorologici alla data dell’evento.RisultatiIl numero dei pazienti con SP era maggiore in primavera rispetto alle altre stagioni (p < 0,05). Si è rilevata un’associazione tra la frequenza di SP e i livelli medi di ozono nelle varie stagioni (F 3,52 = 19,45; p = 0,001). Il livello medio di ozono era maggiore in primavera (363 ± 25 Dobson) rispetto alle altre stagioni (autunno 296 ± 18 Dobson; estate 321 ± 26 Dobson; inverno 324 ± 32 Dobson) (p = 0,001). Si è rilevata una correlazione positiva tra frequenza di SP e valori medi di ozono in ogni stagione (r = 0,301, p = 0,024), mentre non vi erano correlazioni significative tra la gravità del SP ed i livelli di ozono (r = 0,236, p = 0,16).ConclusioniIl numero di pazienti con SP aumenta in primavera quando i livelli di ozono sono massimi. È risaputo che l’ozono provoca danni sulle cellule dell’alveolo polmonare e causa edema interstiziale, danneggiando l’interstizio polmonare mediante stress ossidativo. La rottura di bolle e bollicine di cui il paziente è portatore inconsapevole è il meccanismo abitualmente attribuito come causa del SP: i maggiori livelli di ozono potrebbero essere un fattore scatenante di queste rotture.

The Effect of Pregabalin and Methylcobalamin Combination on the Chronic Postthoracotomy Pain Syndrome

BACKGROUND Chronic postthoracotomy pain (CPTP) consists of different types of pain. Some characteristics of CPTP are the same as those of recognized neuropathic pain syndromes. We aimed to determine the safety and efficacy of pregabalin and methylcobalamin combination (PG-B12) in comparison with diclofenac potassium (DP) in patients with CPTP. METHODS One hundred consecutive patients with CPTP after posterolateral/lateral thoracotomy were prospectively randomly assigned and evaluated. Fifty patients were given PG-B12 and another 50 patients were given DP treatment. Visual Analogue Scale (VAS) and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scorings were performed previous to the treatment (day 0) and on the 15th, 30th, 60th, and 90th days. Adverse events were questioned. RESULTS The mean ages were 58.7 ± 12.2 and 54.6 ± 14.5 years, and the mean durations of pain were 4.01 ± 1.04 and 3.8 ± 1.02 months, respectively. The number of patients with a VAS score less than 5 at the latest follow-up (VAS90 < 5) was 44 (88%) and 18 (36%) in the PG-B12 and DP groups, respectively (p < 0.05). Forty-four patients (88%) in the PG-B12 group and 16 patients (32%) in the DP group had a LANSS score less than 12 at the latest follow-up (p < 0.05). Minor adverse events that did not mandate discontinuation of the treatment were observed in 14 patients (28%) in the PG-B12 group and 2 patients (4%) in the DP group. CONCLUSIONS PB-B12 is safe and effective in the treatment of CPTP with minimal side effects and a high patient compliance. These results should be supported by multidisciplinary studies with larger sample sizes and longer follow-ups.