Yener Aydin

Current management of esophageal perforation: 20 years experience

Esophageal perforations are surgical emergencies associated with high morbidity and mortality rates. No single strategy has been sufficient to deal with the majority of situations. We aim to postulate a therapeutic algorithm for this complication based on 20 years of experience and also on data from published literature. We performed a retrospective clinical review of 44 patients treated for esophageal perforation at our hospital between January 1989 and May 2008. We reviewed the characteristics of these patients, including age, gender, accompanying diseases, etiology of perforation, diagnosis, location, time interval between perforation and diagnosis, treatment of the perforation, morbidity, hospital mortality, and duration of hospitalization. Perforation occurred in the cervical esophagus in 14 patients (31.8%), thoracic esophagus in 18 patients (40.9%), and abdominal esophagus in 12 patients (27.3%). Management of the esophageal perforation included primary closure in 23 patients (52.3%), resection in 7 patients (15.9%), and nonsurgical therapy in 14 patients (31.8%). In the surgically treated group, the mortality rate was 3 of 30 patients (10%), and 2 of 14 patients (14.3%) in the conservatively managed group. Four of the 14 nonsurgical patients were inserted with covered self-expandable stents. The specific treatment of an esophageal perforation should be selected according to each individual patient. To date, the most effective treatment would appear to be operative management. With improvements in endoscopic procedures, the morbidity and mortality rates of esophageal perforations are significantly decreased. We suggest that minimally invasive techniques for the repair of esophageal perforations will be very important in the future treatment of this condition.

The management of esophagogastric anastomotic leak after esophagectomy for esophageal carcinoma

Esophagogastric anastomotic leaks are the most feared surgical complications following resection of esophageal cancers. We aimed to develop a therapeutic algorithm for this complication characterized by high morbidity and mortality using our 20 years of experience and the published literature. A total of 354 patients who had undergone an esophagectomy and esophagogastric anastomosis due to esophageal carcinoma were evaluated retrospectively. The incidence for anastomotic leak was 15.5% (n = 90) in the cervical region and 4.2% (n = 264) in the thoracic region (mean: 7.1%). Cervical anastomotic leaks were detected after a mean period of 7.2 days following the procedure. Fourteen patients with cervical leaks were treated conservatively. Four out of 14 patients (28.6%) died due to sepsis and multi-organ failure related to fistula. Thoracic anastomotic leaks were detected after a mean period of 4.7 days following the procedure. Emergency reoperation, resection and reconstruction procedures were performed in one patient. Self-expanding metallic coated stents were placed at the anastomosis region in two patients. A more conservative approach was employed in other patients with thoracic anastomotic leaks. Six of them (46.2%) died due to fistula. General mortality rate was 37.0%, and the duration of hospitalization was 40.0 days for patients with anastomotic leaks. Cervical anastomotic leaks are more common than thoracic anastomotic leaks, but most of them are successfully treated with conservative approaches. Thoracic anastomotic leaks that in the past were related to high mortality rates despite conservative or surgical procedures might be successfully treated nowadays with the use of self-expanding metallic coated stents.

Complications of metallic stent placement in malignant esophageal stricture and their management.

Objective At the present time, covered self-expandable metallic stent placement is the palliative treatment method for inoperable esophageal cancer. However, life-threatening early and late complications are seen related to esophageal stent placement. In this study, we discuss complications of esophageal stent placement with their management and present our own experience. Methods Between January 2000 and February 2009, 215 covered esophageal stent placements were performed in 174 inoperable esophageal cancer and/or esophagorespiratory fistula patients in the Department of Thoracic Surgery at the Ataturk University Hospital. Results Major complications related to stent placement developed in 24 patients (11 bleeding, 6 aspiration pneumonia, 3 tracheal compressions, 2 perforations, and 2 esophagorespiratory fistulas). Two hundred and thirty minor complications were observed among 174 patients (165 chest pain, 29 tumoral overgrowth, 17 stent migration, 6 gastroesophageal reflux, 3 failure in stent placement, 3 hiccup, 2 foreign body sensation, 2 failure in stent expansion, 1 tumor ingrowth, 1 granulation tissue formation, and 1 food bolus obstruction). Reintervention was required in 56 (32.2%) patients who experienced complications. Stent-related mortality was seen in 4 (2.3%) patients (2 aspiration pneumonia, 1 tracheal compression, and 1 esophagorespiratory fistula). One hundred sixty-two of 174 patients died during follow up. The mean survival time was 177.3±59.3 days (range: 2 to 993 d). Conclusions The complication rate of self-expandable metallic stent placement is high in inoperable esophageal cancer patients. Although some of these complications are life threatening, many of them can be managed successfully with endoscopic reintervention.

Palliative management of esophagorespiratory fistula in esophageal malignancy.

Introduction Esophagorespiratory fistula (ERF) is a complication of an esophageal malignancy that has serious effects on the mortality of a patient, whose survival is limited to weeks. Sealing of fistula and recovery of swallowing has greater importance than treating underlying primary malignancy. In this study, we aimed to present our clinic experience in patients with ERF and to discuss the findings together with the literature. Materials and Methods Between January 2003 and December 2008, 326 patients with malignant esophageal disorder were admitted to our clinic, and ERF detected in 18 (5.5%) patients. There were 10 men and 8 women with a mean age of 54.7±11.9 years (range: 34 to 75 y). Metastases in the lung and liver were detected in 4 and 2 patients, respectively. Empyema was found in 3 of the ERF patients. Pneumonic infiltration was detected via radiologic evaluation in 7 (38.9%) of the 18 patients. Two patients did not accept any intervention. A feeding gastrostomy tube was placed in 2 other patients. Fluoroscopy-guided Ultraflex esophageal stent placement was applied to the remaining 14 patients. Eleven (78.6%) patients underwent stent placements during generalized anesthesia via rigid esophagoscopy, and the remaining 3 (21.4%)patients via flexible esophagoscopy with sedation. Results One of the patients who did not accept intervention died after 2 weeks, and the other died 6 weeks after admission. One of the patients who received a feeding gastrostomy tube died 17 weeks after admission, and the other was still alive after a month, when this article was written. Closure of the ERF was seen in all 14 patients who underwent palliative covered self-expandable metallic stent placement in the esophagus. No complications occurred in the stent-placed patients either during or after the procedure. Dyspeptic complaints and pain were treated successfully with medical therapy in 6 and 5 patients, respectively. Symptoms of aspiration disappeared after stent placement. No reopened fistulae were observed during follow-up. Thirteen of the 14 stent-replaced patients died during follow-up. The mean survival rate for these 13 patients was 11.2 weeks (range: 1to 49 wk). The mean length of hospital stay after stent placement in the 14 patients was 3.7 days (1 to 15 d). Discussion Covered self-expandable metallic stent placement in malign ERF patients is a technically simple and safer method for fistula closure and seems to be the most effective method that is easily available.

The Role of Dynamic Magnetic Resonance Imaging in the Evaluation of Pulmonary Nodules and Masses

Objective: The aim of our study was to determine whether or not dynamic magnetic resonance imaging (MRI) with kinetic and morphological parameters can reveal significant differences between malignant and benign pulmonary lesions, and thus to evaluate the use of dynamic MRI in the management of pulmonary nodules. Patients and Methods: Thirty-one patients (4 women and 27 men) underwent 1.5 T MRI, where 10 consecutive dynamic series were performed every 30 s by using 3D fast low-angle shot sequences. The percentage increase in the signal intensity of the lesions was determined for each time point. Time-enhancement curves of the lesions were drawn and classified into four types: A, B, C and D. Early peak (EP) and maximum peak (MP) values of the curves were calculated and compared with the diagnoses of the patients. The usefulness of these parameters was tested statistically. In addition to the comparison of the parameters between the groups, receiver-operating characteristic analysis was used to assess sensitivity, specificity, and both positive and negative predictive values of EP and MP parameters. Results: Of the 31 pulmonary lesions, 16 (52%) were malignant. These showed a stronger enhancement with higher median values of EP and MP (77.08 and 123.15, respectively) than those corresponding to the benign lesions (14.45 and 32.53, respectively). There were significant differences between the benign and malignant lesions (p < 0.001). Sensitivity, specificity, positive predictive value and negative predictive value were 75, 93, 92 and 78% for EP and 93, 86, 88 and 93% for MP, respectively. Conclusion: A combination of kinetic and morphological evaluation in dynamic MRI provided accurate differentiation between benign and malignant pulmonary lesions. It was a useful and noninvasive method of evaluating pulmonary nodules.

Effectiveness of the STIR turbo spin-echo sequence MR imaging in evaluation of lymphadenopathy in esophageal cancer

PURPOSE We have investigated the utility of the STIR TSE sequence in the differentiation of benign from malignant mediastinal lymph nodes in patients with esophageal cancer. PATIENTS AND METHODS This study included 35 consecutive patients who were diagnosed as esophageal cancer and were undergone surgery. STIR TSE sequences were obtained as the ECG trigger. The signal intensity of the benign and malign lymph nodes, normal esophagus, and pathologic esophagus can be calculated on STIR sequence. RESULTS Pathologically, the number of total lymph nodes in 35 operated cases was 482. Approximately 152 lymph nodes were detected with MR imaging. Of these, 28 were thought to be malignant, and 124 were thought to be benign, although 32 were malignant and 120 were benign according pathological results. The ratio of benign lymph node intensity value to normal esophagus intensity value was 0.73±0.3. The ratio of malignant lymph node intensity value to normal esophagus intensity value ratio was 2.03±0.4. According to these results, the sensitivity of MR was 81.3%, the specificity was 98.3%. CONCLUSION We think that if motionless images can be obtained with MRI, we may be able to differentiate benign lymph nodes from malignant ones.

Morgagni Hernia: Transabdominal or Transthoracic Approach ?

Abstract Background : Morgagni hernias are rare and constitute less than 2% of all diaphragmatic hernias. Treatment is primarily surgical and transthoracic or transabdominal route approach methods are amenable. In this study, we compared the results of our Morgagni hernia cases, which underwent either transabdominal or transthoracic method of surgery. Methods : We retrospectively analyzed the records of 20 patients we operated on for Morgagni hernias between 1997 and 2011 in our clinic. Age, sex, presenting symptoms, lesion location, diagnoses, applied surgical method, duration of the hospital stay, morbidity and mortality rates were reviewed. Six of the cases were (30%) approached via thoracotomy and 14 (70%) were laparotomy. The hernial sac was resected in all cases. Diaphragmatic defects were repaired using nonabsorbable sutures in all cases except in one case where prolen mesh used. Results : Thirteen cases (65%) were female and seven (35%) were male. Mean age was 44.1 ± 25.3 years (1–73 years). Hernias were located on the right side in 18 cases, the left side in one, and bilaterally located in one case. Herniated organs were: omentum in 19 (95%), transverse colon in 18 (90%), small bowel in 4 (20%), stomach in 3 (15%), and left lobe of the liver in one (5%) case. No complication was observed in patients who underwent laparotomy, and wound infection occurred in one patient who underwent thoracotomy. Hospital stays in thoracotomy and laparotomy groups are 7 and 6.2 days, respectively. There were no mortalities observed. There was no recurrence during the follow-up of 36.4 months (10–116 months). Conclusion : Our findings showed that both surgical methods have similar and satisfactory results. Although transthoracic approach was preferred in previous cases, the transabdominal approach was preferred in later ones because we assumed that the later procedure is less invasive for the patient. We prefer and propose the abdominal approach for the surgical management of Morgagni hernias.

A new risk factor in oesophageal cancer aetiology: hyperthyroidism.

Abstract Purpose: In individuals with malignant disease, many qualitative and quantitative hormonal changes have been detected. Although there are many studies showing that there is a relationship between thyroid hormone disorders and certain tumours, no study investigating the association between oesophageal cancer and thyroid diseases has been reported. The present study was designed to evaluate whether there is a relationship between oesophageal cancer and thyroid hormones. Methods: In a prospective study conducted between December 2006 and February 2008, thyroid functions were studied in a group of 102 sequential patients with oesophageal cancer and a control group of 160 sequential patients without oesophageal cancer, presenting to the Thoracic Surgery Department of Ataturk University. Age, gender, tumour location and histological type in patients with oesophageal cancer were recorded. Results: Of 102 patients with oesophageal cancer, 21 (20.58%) had hyperthyroidism, 2 (1.96%) had hypothyroidism and 6 (5.88%) exhibited nodular/multinodular goitre on ultrasonography and computed tomography. In the control group, 8 patients (5.0%) had hyperthyroidism, 4 (2.5%) had hypothyroidism and 7 (4.38%) showed nodular/multinodu-lar goitre. In patients with oesophageal cancer, the incidence of hyperthyroidism was found to be significantly higher compared to the control group (p < 0.001). Conclusion: Data show that there may be an important relationship between oesophageal cancer and hyperthyroidism. We believe that thyroid hormone levels should be measured in all cases of oesophageal cancer. In further prospective and experimental studies, the physiopathology of this relationship can be fully explained.

Total occlusion of the superior vena cava due to bronchogenic cyst.

Abstract Bronchogenic cysts are the most common form of congenital cystic lesions in the mediastinum. Of all cases with bronchogenic cysts, 1/3 are symptomatic. The symptoms vary depending on the location and compression of the adjacent structures of the cyst. Some mediastinal bronchogenic cysts can cause severe respiratory distress due to airway and vascular compression. We herein present a case with a bronchogenic cyst that required venoplasty to the superior vena cava (SVC) due to total occlusion of the SVC.

Frequency of Class I and II HLA alleles in patients with lung cancer according to chemotherapy response and 5-year survival

Lung cancer is the most common cause of cancer death in the world, and the most common type is non‐small‐cell lung cancer (NSCLC). At present, surgical resection, chemotherapy, and radiation therapy are the main treatments for patients with NSCLC, but unfortunately outcome remains unsatisfactory.