Şinasi Yavuzer

Management of Esophageal Perforation

Abstract Despite recent advances in thoracic surgery, the management of esophageal perforation remains problematical and controversial. Thirty-one patients were treated for an esophageal perforation between 1986 and 1998. The esophageal perforation was iatrogenic in 25 cases, spontaneous in 2, traumatic in 2, and caused by a tumor and tuberculous lymphadenitis in 2 patients. There were 10 cervical, 19 thoracic, and 2 abdominal perforations. The interval from perforation to operation was less than 24 h in 12 patients and more than 24 h in 19 patients. The surgical procedures included a primary repair in 12 patients, a resection in 8, and conservative treatment with minor surgical approaches in 11. The mortality rate was 20% (4/20 patients) in the surgical treatment group and 45.5% (5/11 patients) in the conservative treatment with minor surgery group. The overall mortality was 29% (9/31 patients). The prognosis is thus concluded to depend on the cause and location of the perforation, the presence of underlying esophageal diseases, and the surgical procedure chosen.

Single-stage transthoracic approach for right lung and liver hydatid disease.

OBJECTIVE Human echinococcosis remains a serious health problem for the Mediterranean countries. Synchronous pulmonary and hepatic hydatid disease may occur in 4% to 25% of cases. Our experience on simultaneous surgical treatment of right lung and liver hydatid disease in patients was reviewed. METHODS Between 1990 and 2000, 48 patients (33 female patients and 15 male patients) with synchronous right lung and liver dome hydatid cysts were operated with a 1-stage procedure. RESULTS Six patients had previous surgical treatment of hepatic (n = 2) or pulmonary (n = 4) hydatid cyst. The pulmonary cysts were diagnosed with radiography in 18 patients and thoracic computed tomography scan in 30. The pulmonary cysts of 9 patients were bilateral. Seventy-five pulmonary cysts were seen in radiological examinations. The diagnosis of hepatic cysts was established with ultrasonography in 18 patients and upper abdominal computed tomography in 30. The total number of hepatic cysts was 48. In cases with pulmonary cysts, cystotomy and capitonnage were performed in 32 patients, only cystotomy was done in 14 patients, and wedge resection was performed in 2. Liver cysts were approached to transdiaphragmatically after the lung cysts had been dealt with and were managed with evacuation of the cysts. In the remaining cases, marsupialization (n = 2), pericystectomy (n = 1), and enucleation (n = 1) were performed. Major postoperative complications were hemorrhage (n = 1) and biliocutaneous fistula (n = 1). Hepatic recurrence was seen in 3 patients (6.2%) and pulmonary recurrence in 1 (2.1%). CONCLUSION Transthoracic approach is a useful and a safe surgical management of both pulmonary and upper surface of hepatic hydatid cysts.

Predictors of clinical outcome following extended thymectomy in myasthenia gravis

OBJECTIVE Thymectomy remains as the optimal treatment of choice in patients with myasthenia gravis (MG), however, the selection criteria for surgery remains controversial. METHODS We examined the data charts of patients with MG underwent extended thymectomy. We investigated the possible correlations between the clinicopathologic features and clinical outcomes, and analyzed the data to clarify the effect of prognostic factors on clinical outcome. RESULTS A total of 61 patients with a mean age of 35.8 +/- 12.2 years (range, 13-66 years) were analyzed. The overall improvement/remission and clinical worsening rates were 81.9 and 18.1%, respectively. Ossermann stage (P = 0.011) and presence of mediastinal ectopic thymic tissue (P = 0.007) showed a significant correlation with the clinical outcome. Multivariate analysis confirmed Ossermann stage (P = 0.0158), and presence of mediastinal ectopic thymic tissue (P = 0.0100) as independent predictors on clinical outcome. CONCLUSION Ossermann stage and the presence of mediastinal ectopic thymic tissue are potential predictors on clinical outcome in patients with MG undergoing extended thymectomy.

Surgical treatment of peripheral lung cancer adherent to the parietal pleura

OBJECTIVES The objective of this paper is to assess the results of surgical treatment retrospectively in a consecutive series of 85 patients with peripheral non-small cell lung cancer (NSCLC) invading parietal pleura and chest wall. METHODS From 1994 to 1998, of the 572 patients having pulmonary resection for NSCLC, 29 patients with neoplasm involving the parietal pleura (group I) and 56 with that invading the chest wall (group II) underwent resection. RESULTS The operative mortality rate was 3.4% in group I and 1.8% in group II. In groups I and II, pathologic N status was N0 in 20 (69%) cases, N1 in five (17%), N2 in four (13.8%) and 44 (78.6%), seven (12.5%), five (8.9%), respectively. An incomplete resection (R1) was performed in two (6.9%) patients in group I and seven (12.5%) in group II. Postoperative radiotherapy was carried out in 18 patients in group I and 46 in group II. Systemic chemotherapy was also administered in seven patients in group I and eight in group II. There was a significant difference in adjuvant therapy between the groups (P<0.05). Two patients (R1) in group I (7.4%) and 12 patients (seven patients R1+5 R0) in group II (24%) had local recurrence. There was no significant difference in local recurrence between the groups (P=12). Follow-up was completed in 79 cases (28 in group I and 51 in group II). Median survival for groups I and II were 27+/-6 and 16+/-4.6 months, respectively. Five-year survival was longer in group I than in group II (33 vs. 14%), but there was no significant difference (P=13). CONCLUSIONS We found similar survival rates for extrapleural resection in limited parietal pleura invasion and chest wall resection in exceeded-beyond-parietal pleura invasion. The completeness of resection is important in both groups.

Fibrohistiocytic tumor of the trachea in a child

A 10-year-old girl who had been treated for presumed asthma during the previous year, was admitted to our hospital with dyspnea and wheezing. An endotracheal tumor was detected and a tracheal resection was performed. The tumor was diagnosed as a fibrohistiocytic tumor. Biologic behavior of fibrohistiocytic tumors of the trachea is not clear and morphologically similar cases are interpreted as malignant or benign by different authors. However, an analysis of the present case and 11 well documented cases in the literature shows that this tumor must be evaluated as a low-grade malignancy and initial complete tumor resection is necessary.

Female and male differences in the survival of patients undergoing resection for lung cancer.

Abstract Objective: In recent years much attention has been focused on the rapidly increasing incidence of primary lung cancer in women. The aim of this study was to determine gender differences in patients treated surgically for lung cancer. Methods: We performed a retrospective review of patients who had lung resection for primary lung cancer from January 1994 to December 1998. Results: There were 530 men and 42 women. Women were younger than men (55.6 ± 10 versus 57 ± 9.9). The difference was not statistically significant (p = 0.9). The mean cigarette consumption was greater in men than in women (p < 0.001). We observed a higher operative morbidity and mortality rate in men compared to women (p < 0.05). Men had more squamous cell carcinoma (61.7%). In female patients, squamous cell cancer and adenocarcinoma were found with almost the same incidence (35.7% versus 33.3%). There was a significant difference in the distribution of cell types (p < 0.001). Pathologic stages for women were; I = 38.2%, II = 21.4%, IIIa = 21.4%, IIIb = 9.5%, IV = 9.5% and for men; I = 40.4%, II = 26.6%, IIIa = 24%, IIIb = 6%, IV = 3%. There was no significant difference in the stage distribution between genders (p = 0.2). Median survival for female and male patients were 38 ± 9.2 and 35 ± 3.2 months. Female patients’ survival was longer than male patients but the difference was not statistically significant (p > 0.05). Conclusions: This study emphasizes sex differences in cigarette consumption, operative mortality and the distribution of cell types of patients with primary lung cancer. These initial results should strongly encourage additional studies in different countries on the interaction between sex and lung cancer characteristics to improve clarity.