Tunc Lacin

Complications and management of long-term central venous access catheters and ports.

Purpose Although prolonged venous access devices (PVADs) are used in case prolonged intravenous therapy is required, implantation and use of these devices is associated with complications. The purpose of this study was to evaluate perioperative and long-term complications associated with PVADs and the management of these complications. Methods A retrospective review was undertaken of 225 PVADs implanted in 217 patients from February 1993 to June 2004. This included 144 single-lumen port infusion systems, 49 single-lumen Hickman® catheters and 32 double-lumen Groshong® catheters. The PVADs were inserted using either the percutaneous Seldinger method (n=183) or cutdown access to the subclavian vein (n=42). Indications for placement were as follows: chemotherapy in 66.2% of patients, drug-infusion treatment in 31.6% of patients and total parenteral nutrition in 2.2% of patients. Results Perioperative complications occurred in 13 patients (5.7%): catheter malposition in seven patients (3.1%), pneumothorax in three patients (1.3%), hemorrhage in two patients (0.9%) and catheter embolization in one patient (0.4%). Long-term complications appeared in 15 patients (6.6%): infection in five patients (2.2%), thrombosis in three patients (1.3%), extravasation in three patients (1.3%), and catheter fracture in four patients (1.8%). The fractured fragments were removed by the Amplatz® snare device. In 10 patients (4.4%) only were PVADs removed prior to completion of the intended therapy. Indications for removal were catheter infection in five patients (2.2%) and catheter fracture in five patients (2.2%). Conclusions PVAD implantation is associated with some risk of serious perioperative and long-term complications. Care of the catheter and the patient should be maintained with the proper and immediate evaluation of the perioperative and long-term complications.

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.

Approach to Fragmented Central Venous Catheters

Prolonged venous access devices are needed in cancer patients for central venous access. Catheter fragmentation leading to catheter malfunction represents a rare problem. Herein we present our experience in the management of fragmented catheters. Between 2001 and 2003, 183 catheters were placed via the subclavian vein, and five cases of fragmented catheters were observed. Fragments were removed by an Amplatz gooseneck snare (Microvena, St. Paul, MN) with angiographic intervention. The diagnosis of the breakage was made by chest radiography. The incidence of catheter rupture was 2.7%. All fragments were removed by the snare, without any complications. Catheter narrowing and breakage owing to its medial positioning in the subclavian vein were the main causes of catheter malfunction. In any case of catheter malfunction, radiologic evaluation of the catheter must be done to rule out its rupture. Removal of the fragments using the Amplatz snare is a safe and easily applied procedure.

The role of fluoroscopy in the removal of tracheobronchial pin aspiration.

In this study, we investigated the role of fluoroscopy in the bronchoscopic removal of aspirated pins. Of 373 patients who underwent bronchoscopy for presumed tracheobronchial foreign body aspiration, 56 pin aspiration cases were selected and divided into two groups according to whether fluoroscopic guidance was required (group I) or not (group II). The localisation of foreign bodies, mortality and morbidity ratios and the duration of the procedures were investigated. Pin aspiration percentage was 15. Pins were mostly located in peripheral airways in group I, and in central airways in group II (p < 0.05). The mean duration of the procedure was 42 ± 30 min in group I and 17 ± 13 min in group II (p < 0.01). There was no mortality. Morbidity percentage was 7 in group I and 12 in group II (p > 0.05). No thoracotomy was required in any cases. Fluoroscopic guidance is safe and carries no additional morbidity and mortality and can be used for pins in the tracheobronchial tree.

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.

Video-assisted thoracoscopic removal of pulmonary hydatid cysts

OBJECTIVES Pulmonary hydatid disease is a parasitic disease with a high prevalence in low-middle income countries. We report four patients who were treated surgically using video-assisted thoracoscopy (VATS). METHODS All patients were diagnosed with clinical and radiological findings on chest X-ray and computed tomography. Complete thoracoscopic removal by cystotomy and capitonnage was done in all four patients. The procedure included a standard thoracoscopy port incision and a 2-3 cm utility skin incision that was placed just superior to the cystic lesion. In the first case, a small-sized rib separator was used. The following three cases were operated without placing a rib separator on the utility incision. Conversion to open thoracotomy was not required. RESULTS The average duration of the procedure was 90 min, and the average length of hospital stay was 4 days. No complications were observed after the thoracoscopic removal. At mean follow-up of 4 months, all patients were asymptomatic. CONCLUSIONS VATS removal of the hydatid cysts can be done successfully in peripherally located cysts.

Risk of serious perioperative complications with removal of double bars following the Nuss procedure

Objectives The aim of this study is to present our experience with Nuss bar removal and evaluate potential risk factors. The Nuss procedure requires an operation to remove the bar 2-3 years after the initial correction. Although removal of the bar is generally believed to be safe, perioperative complications including major bleeding can occur. Methods All cases involving removal of the Nuss bar done since April 2007 were recorded in a prospective database. Data were collected on the amount of blood loss, the number of diagnostic interventions, operative management and postoperative course. Results Of a total of 246 (162 with single bars, 80 with double bars, 4 with triple bars) cases, 43 patients (17.5%) experienced perioperative complications. Five patients underwent secondary postoperative interventions; one patient required same-session emergency video-assisted thoracic surgery (VATS) due to major bleeding. Patients who had complications were significantly older than patients with no complications (20.5 ± 6.5 years vs 17.2 ± 5.9 years, P = 0.002). People having double bars removed were significantly more likely to have perioperative complications (12% vs 27%, P = 0.03) and complications requiring secondary interventions (n = 1 for a single bar, n = 5 for double bars, P = 0.01). Conclusions Major complications after removal of the Nuss bar occur with some frequency. Although the double-bar removals in our cohort were associated with major complications, the reasons are poorly understood. Immediate management of the complications may require multidisciplinary care. Multicentric pooling of cases is needed for better risk stratification.

Previously Complicated Nuss Procedure Does Not Preclude Blind Removal of the Bar.

BACKGROUND Nuss procedure has become the procedure of choice for well-selected patients with pectus excavatum. Perioperative complications may pose difficulty during the subsequent bar removal due to adhesions and tissue plane disruptions during the initial surgery and repair. This report describes bar removal experience in patients whose Nuss procedures were complicated by cardiac injury, pericardial breach, and lung parenchyma/diaphragm injury during the initial procedure. METHODS A total of 529 patients who underwent Nuss procedure between 2007 and 2014 were recorded in a prospective database. Twenty patients with complications (cardiac injury [n = 1], pericardial breach [n = 3], and lung parenchyma/diaphragm injury [n = 16]) were identified. All bars were removed via subcutaneous tissue dissection, without intrathoracic visualization. RESULTS Average duration of bars was 36 months (±16 months). All bar removal procedures were completed without any need for extra interventions with negligible blood loss. Eighteen patients were able to be discharged within 2 postoperative days. CONCLUSION Blind bar removal in patients with previously complicated Nuss procedure seems safe and no other interventions (videothoracoscopy, subxiphoid incision, etc.) during bar removal seem to be necessary.

Detection of reactive oxygen metabolites in malignant and adjacent normal tissues of patients with lung cancer

BackgroundDifferent types of reactive oxygen metabolites (ROMs) are known to be involved in carcinogenesis. Several studies have emphasized the formation of ROMs in ischemic tissues and in cases of inflammation. The increased amounts of ROMs in tumor tissues can either be because of their causative effects or because they are produced by the tumor itself. Our study aimed to investigate and compare the levels of ROMs in tumor tissue and adjacent lung parenchyma obtained from patients with lung cancer.MethodsFifteen patients (all male, mean age 63.6 ± 9 years) with non-small cell lung cancer were enrolled in the study. All patients were smokers. Of the patients with lung cancer, twelve had epidermoid carcinoma and three had adenocarcinoma. During anatomical resection of the lung, tumor tissue and macroscopically adjacent healthy lung parenchyma (control) that was 5 cm away from the tumor were obtained. The tissues were freshly frozen and stored at −20°C. The generation of ROMs was monitored using luminol- and lucigenin-enhanced chemiluminescence (CL) techniques.ResultsBoth luminol (specific for .OH, H2O2, and HOCl-) and lucigenin (selective for O2.-) CL measurements were significantly higher in tumor tissues than in control tissues (P <0.001). Luminol and lucigenin CL measurements were 1.93 ± 0.71 and 2.5 ± 0.84 times brighter, respectively, in tumor tissues than in the adjacent parenchyma (P = 0.07).ConclusionIn patients with lung cancer, all ROM levels were increased in tumor tissues when compared with the adjacent lung tissue. Because the increase in lucigenin concentration, which is due to tissue ischemia, is higher than the increase in luminol, which is directly related to the presence and severity of inflammation, ischemia may be more important than inflammation for tumor development in patients with lung cancer.