Prognosis in patients with non-small cell lung cancer and satellite tumors.

BACKGROUND: Aim of the study was to identify factors affecting survival in patients with lung cancer and satellite tumors (ST). METHODS: Between 2001 and 2008, there were 102 patients with synchronous multiple lung cancers among the 1355 lung resections performed in lung cancer patients. Satellite tumors were found to be near the primary lung cancer (PLC) in 29 patients. RESULTS: Complete resection was achieved in all patients, and the 5-year survival rate was 52 %. The independent "T" stages of the PLCs and STs did not affect survival ( P = 0.98 and P = 0.54, respectively). A distance between the PLC and ST longer or shorter than 2, 3, or 4 cm also did not affect survival ( P = 0.78, P = 0.57, and P = 0.62, respectively). The survival of patients treated with adjuvant therapy was significantly higher than that of patients who did not receive adjuvant therapy ( P = 0.0043). CONCLUSIONS: Satisfactory survival was achieved after surgical therapy for non-small cell lung cancer associated with ST. While the PLC and ST characteristics and the distance between tumors did not affect survival rates, the introduction of adjuvant chemotherapy with/without radiotherapy positively affected survival.

Benign posterior mediastinal neurogenic tumors: results of a comparative study into video-assisted thoracic surgery and thoracotomy (13 years' experience).

OBJECTIVE: Mediastinal neurogenic tumors originate from the nerve tissues of the thorax and are generally located in the posterior mediastinum. The present study was performed to compare the results of thoracotomy with those of video-assisted thoracic surgery (VATS) for the surgical treatment of posterior mediastinal neurogenic tumors. METHODS: Twenty patients who underwent surgical resection for posterior neurogenic tumors between January 1996 and January 2009 were examined retrospectively. Thirteen (65%) patients were treated by thoracotomy (group T) and VATS was used in seven (35%) patients (group V). RESULTS: The duration of surgery was shorter in group V (83.5 ± 19 min) than in group T (124.6 ± 16.6 min; P < 0.0001). Chest drains were withdrawn earlier in group V (after 1 day) than in group T (1.6 ± 0.5 days; P = 0.005). The hospital stay was shorter for group V (1 day) compared with group T (3 ± 0.9 days; P < 0.0001) and group V required fewer analgesics than group T (P < 0.0001). CONCLUSION: VATS is the preferred treatment for posterior neurogenic tumors that show no preoperative signs of malignancy and do not involve the medulla spinalis.

Diagnosis and treatment of spontaneous pneumomediastinum.

BACKGROUND: Due to its rarity there is no clear policy on the management of spontaneous pneumomediastinum (SPM). METHODS: We treated 23 SPM patients between January 1 996 and November 2 006. There were 20 males and 3 females and their mean age was 27. Clinical records of the patients were collected and analyzed. RESULTS: The most frequent symptoms were neck swelling (n = 20) and rhinolalia (n = 15). Onset of the symptoms was acute. A preceding factor was found in 19 (83 %) patients; these included vigorous cough, forced physical activity, vigorous sneezing and enormous efforts during spontaneous vaginal delivery. Chest X-ray was sufficient to show mediastinal free air in 18 patients. Computerized chest tomography showed pneumomediastinum in all patients. Twenty patients were treated expectantly. Subcutaneous air drainage was needed to drain massive subcutaneous emphysema in three patients. CONCLUSIONS: Acute onset of typical symptoms, the existence of a preceding factor and the exclusion of other possible causes of pneumomediastinum with the help of CT are sufficient to make a diagnosis of SPM. A surgical intervention is generally not needed for the treatment of this entity.

Surgical treatment of superior sulcus tumors: results and prognostic factors.

BACKGROUND: This study aims to investigate the treatment modalities and factors influencing survival in surgically treated superior sulcus tumors. PATIENTS AND METHOD: Sixty-five cases of surgically treated non-small cell carcinoma of the lung occurring as superior sulcus tumors between 1994 and 2007 were retrospectively reviewed. Twenty-five patients underwent induction radiotherapy (RT), 10 had induction chemoradiotherapy (CT/RT). In thirty patients surgery was performed directly. The mortality rate was 6.2 %. Pathological stage was T3 in 55, T4 in 10, N0 in 52, and N1 in 5 and N2 in 8 patients. RESULTS: Overall 5- and 10-year survival rates were 31 % and 28 %, respectively. Complete resection rate was 90 % for patients who received induction CT/RT and 80 % for patients who either received induction RT alone or patients in whom surgery was performed directly. In patients who received neoadjuvant therapy with complete tumor resection, the median survival time was 33 months (28 months for patients who received induction RT alone and 36 months for patients who received induction CT/RT), and the 5-year survival rate was 41 %. Median survival time and 5-year survival rate of patients treated by direct surgery with complete resection was 24 months and 37 %, respectively ( P = 0.87). Five-year survival and 10-year survival rates were significantly higher after complete resection than after incomplete resection (38 % and 34 % vs. 0 %, P = 0.0001). In multivariate analysis, only N2 disease ( P = 0.04) and incomplete resection ( P = 0.03) were found to be poor prognostic factors. CONCLUSION: The presence of N2 disease and incomplete resection are the two most important factors affecting survival. Induction CT/RT may increase the ability to achieve complete surgical resection.

Factors affecting morbidity in chronic tuberculous empyema.

BACKGROUND: Chronic empyema is not a rare complication of pulmonary tuberculosis. Various treatment modalities ranging from open drainage to pneumonectomy, depending on the status of the disease, have been used to treat this complication. However, the best strategy for this disease remains unknown. This study examined the results of different treatment strategies for chronic tuberculous empyema. METHODS: Between January 1993 and December 2002, 36 patients (29 male and 7 female) with an average age of 29.3 years (range 13 - 52 years) presented with chronic tuberculous empyema characterized by empyema cavity and persistent pleural infections that were secondary to tuberculosis. The series consisted of patients who had had tube thoracostomy and underwater drainage without complete re-expansion. All patients were treated with open drainage. Of these, 6 patients had Eloesser flap for complete drainage of pleural pus and resolution of pleural infection. RESULTS: Eloesser-flap drainage resulted in a higher morbidity compared to the open-drainage-only method ( P = 0.011). Pneumonectomy, used as a final therapeutic option, resulted in more complications postoperatively ( P = 0.034). Antituberculosis therapy lasting six months or longer reduced the morbidity rate (54 % vs. 33.3 %), but the difference was not significant. CONCLUSIONS: Our findings indicate that open drainage leads to better results compared to those of Eloesser flap in patients with chronic tuberculous empyema. Patients who underwent pneumonectomy were expected to have higher complication rates and the procedure must therefore be avoided when possible.

Elective pneumonectomy for non-small cell lung cancer: factors affecting early operative mortality and morbidity.

BACKGROUND: The aim of this study was to investigate the factors influencing the morbidity and mortality of the non-small cell lung cancer (NSCLC) cases where pneumonectomy was performed. MATERIAL & METHODS: All 101 patients who had underwent a pneumonectomy for NSCLC between 1994-2001 in our hospital were included in the retrospective study. There were 97 males and 4 females with a mean age of 56+/-9.6. Factors affecting morbidity and mortality were analysed by univariate and multivariate analysis. RESULTS: The morbidity rate was 53% and the mortality rate was 9%. Morbidity was related to cardiopulmonary complications in 40% of the cases. The risk factors for cardiopulmonary morbidity with univariate analysis were age > 60 years (p = 0.004), FEV1 < 2 lt (p = 0.016), early bronchopleural fistula (p = 0.0001), tumour size > 4 cm (p = 0.033), vital capacity < 3.7 lt (p = 0.016), forced vital capacity < 3.5 lt (p = 0.033).. With multivariate analysis the risk factors cardiopulmonary morbidity were age (60 >) (p = 0.012) and tumour size > 4 cm (p = 0.043). The risk factors mortality with univariate analysis were right pneumonectomy (p = 0.025), respiratory morbidity (p = 0.0001), cardiac morbidity (p = 0.002), cell type (Epidermoid CA) (0.047), tumour size > 6 cm (p = 0.036), fluid infusion (p = 0.009), forced vital capacity < 78% (p = 0.039), forced expiratory volume in 1 second < 75% (p = 0.039), PO2 (p = 0.037), PCO2 > 42 mmHg (p = 0.023). CONCLUSION: Among the pneumonectomies performed for NSCLC, the causes of postoperative morbidity were multifactorial, however, multivariate analysis did not show any significant factor affecting the mortality, related to this procedure.

Prediction of morbidity after lung resection in patients with lung cancer using fuzzy logic.

BACKGROUND: Preoperative evaluation of patients with potentially resectable non-small cell lung cancer aims to estimate the risk of planned surgery. Evidence of several factors that identify patients at risk for complications from thoracotomy is controversial. The aim of this study was to introduce and implement in medical practice a fuzzy system used in risk assessment of pulmonary resection for lung cancer. METHODS: Ninety-one consecutive patients who underwent pulmonary resection for lung cancer were investigated. The overall complication rate was 39.6 % (a total of 63 complications were seen in 36 patients). A fuzzy logic model was created with 9 input (presence of chest pain, weight loss, clinical T stage of the tumor, FEV 1, serum protein, preoperative arterial partial oxygen pressure and cigarette smoking, erythrocyte sedimentation rate and peripheral blood leukocyte count) and two output classes (high-risk and low-risk groups). The fuzzy classifier's performance was tested. RESULTS: The model was able to predict correctly the occurrence of complications in 22 out of 29 patients in the high-risk group with a sensitivity of 76 %, while 9 out of the 52 patients from the low-risk group developed complications (17 %). CONCLUSION: The fuzzy classification system provides an accurate tool to predict complications of resections in patients with non-small cell lung cancer.

Spontaneous hemopneumothorax: is conservative treatment enough?

PURPOSE: Spontaneous hemopneumothorax is a rare disorder, occurring in 1% to 12% of patients with spontaneous pneumothorax. The present review was undertaken to emphasize the potential life-threatening condition of spontaneous hemopneumothorax and reassess the benefit of conservative treatment with chest tube drainage. MATERIAL AND METHODS: From 1997 to 2002, 291 cases of spontaneous pneumothorax were treated in our department. Of these, 9 (3.09%) developed hemopneumothorax (> 400 ml). The clinical features of these patients and the results of conservative and surgical management were retrospectively reviewed. RESULTS: Seven patients were treated conservatively and two required VATS and thoracotomy because of worsening clinical condition. The amount of aspirated blood ranged from 400 to 3700 ml (mean, 1533 ml). Six patients received a homologous blood transfusion. CONCLUSIONS: In conclusion, hemopneumothorax is a serious condition complicating spontaneous pneumothorax. Conservative treatment is adequate in most cases and should be performed if bleeding persists for less than 24 hours after chest tube placement.

Emergency surgery for massive haemoptysis.

BACKGROUND: Massive haemoptysis (600 ml in 24 hours) results in considerable mortality and deserves appropriate management. Since it is life threatening, lung resection remains the surgical treatment of choice in unrelenting haemoptysis. MATERIAL AND METHODS: We retrospectively reviewed all patients (n = 29) who were referred to our clinic between January 1994 to September 2001 with massive haemoptysis (> 600 ml/24 h). All patients had uncontrollable haemorrhage and/or failure of conservative treatment. After initial resuscitation, assuring adequate airway and providing adequate intravenous access, emergency thoracotomy was performed in all patients following rigid bronchoscopy (n = 27) in order to localize the bleeding. RESULTS: The most common underlying cause of the massive haemoptysis was pulmonary tuberculosis (n = 10) followed by emphysema in 4, lung cancer in 3, collagenous vascular disease in 2 and aspergilloma in one patient. Seventeen lobectomies (58.6%), 5 pneumonectomies (17.2%), 3 segmentectomies and 3 bilobectomies were done whereas physiological lung exclusion was performed in one patient. Haemoptysis could be controlled in all patients. Rate of operative morbidity and hospital mortality were 27.5% and 11.5% respectively. We recorded one patient with recurrent haemoptysis who was treated by completion pneumonectomy. CONCLUSION: Despite the debate over definition of massive haemoptysis and indication for surgery in these patients, emergency pulmonary resection provides an effective treatment with acceptable morbidity and mortality in patients with massive haemoptysis.

Chylothorax: a complication following lung resection in patients with NSCLC - chylothorax following lung resection.

BACKGROUND: Chylothorax following lung resection is not as rare as a postoperative complication as previously reported due to systematic lymph node dissection in patients undergoing lung resection for NSCLC. METHODS: We retrospectively reviewed our cases that had undergone lung resection for NSCLC and investigated the frequency and outcome of chylothorax in these patients. The factors investigated were the site and type resection, technique of systematic lymph node dissection, tumour histology and disease stage. RESULTS: Seven of 673 patients that had undergone lung resection were complicated by chylothorax (1.04 %), following lobectomy in 5 (1.28 %) and pneumonectomy in 2 (0.7 %) (p = 0.36). The fistula closed spontaneously in 5 patients between 4 - 17 days postoperatively (71 %). One of the patients in the conservative management group died on the 28th day postoperatively due to pneumonia (14 %). The remaining 2 patients underwent rethoracotomy on the 5th and 6th days. CONCLUSIONS: These results suggest that the site of operation, type resection, and technique of systematic nodal dissection, tumour histology and disease stage do not influence the development of chylothorax in patients with NSCLC. The chylous fistula following lung resection for NSCLC tends to close spontaneously.

Antibiotic prophylaxis in elective thoracic surgery: cefuroxime versus cefepime.

BACKGROUND: Infection is one of the major morbidity factors after thoracic surgery. Although different prophylactic regimens have been used to prevent this complication, the ideal prophylactic agent, dose and duration of administration remain unknown. METHODS: All patients included underwent elective lung resection. 102 selected patients consecutively scheduled for major thoracic surgery were enrolled in this study and randomized into either the cefuroxime group (n = 50) or the cefepime group (n = 52). RESULTS: Twelve pathologic bacterium strains were isolated in the cefepime group, whereas only 5 pathogenic strains were isolated in the cefuroxime group; the difference was statistically significant (p = 0.04). Two empyemas (3.8 %) in the cefepime group were noted, while the cefuroxime group showed no cases of empyema (p = 0.16). Overall infection rate (pneumonia + bronchopneumonia + empyema) were 14.0 % and 26.7 % in the cefuroxime and the cefepime groups, respectively (p = 0.12). Using chest radiography, pulmonary infiltration was found to be more frequent in the cefuroxime group (p=0.002). CONCLUSION: Cefuroxime as a prophylactic agent in major thoracic surgical operations was marginally more effective than cefepime, and presented an additional cost advantage.

The value of mediastinoscopy in preoperative evaluation of mediastinal involvement in non-small-cell lung cancer patients with clinical NO disease.

BACKGROUND: The efficacy of mediastinal lymph node examination using cervical mediastinoscopy in operable non-small cell lung cancer patients without radiological nodal involvement on computerized tomography (CT) has been elusive. METHODS: The value of mediastinoscopy as a staging modality for assessing the mediastinal lymph node status was evaluated in 79 patients with presumed resectable non-small-cell lung cancer (NSCLC) with mediastinal nodes smaller than 1 cm (NO) form the CT scan. Sixty-one patients who did not have nodal involvement at mediastinoscopy and had complete medical records underwent complete resection. RESULTS: Negative predictive value (NPV) of the CT scan according to mediastinoscopy was 92.4 %. Histopathological examination of the surgical specimen showed the NPV of mediastinoscopy to be 93.4 %. Only 4 patients (3 patients with N2, 1 patient with N3 disease) were not correctly staged using CT scanning and mediastinoscopy. According to the pathological examination, the NPV of CT was found to be lower (76.5 %) in patients with adenocarcinoma, but the difference was not statistically significant (p > 0.128) CONCLUSION: Although the likelihood of surgical-pathological N2 is slightly higher in patients with adenocarcinoma, radiological examination of patients with cNO NSCLC disease can be as accurate as mediastinoscopy in appropriately staging mediastinal lymph node involvement.

Video-assisted repair of an eventrated left hemidiaphragm.

Video-assisted thoracoscopic surgery is emerging as a viable approach to increasingly complex intrathoracic therapeutic procedures. Here, we present a case of eventrated left hemidiaphragm caused by a blunt trauma in an elderly man. The diaphragm was repaired successfully using a video-assisted procedure, thus giving the patient the advantages of a minimally invasive operation.

Aprotinin reduces postoperative bleeding and the need for blood products in thoracic surgery: results of a randomized double-blind study.

OBJECTIVE: Bleeding complications have been a major concern in certain thoracic surgery operations, especially decortication and pulmonary resection for inflammatory pulmonary infection. Prevention of plasminogen activation and fibrinolysis by aprotinin administration has been shown to reduce perioperative bleeding during operations associated with high blood consumption. METHODS: Use of blood products (packed red cells, whole blood), chest tube drainage, analgesic requirement, chest tube duration for the patients undergoing major thoracic operations were recorded. In a double blind randomized fashion, patients were assigned to two groups receiving aprotinin (n=51) at a loading dose of 10(6) kallikrein inhibitory units (KIU) followed by an infusion of the same dose during chest closure or receiving placebo (n=52). On a daily basis, red-cell percentages of total fluid from drainage bottles were recorded and using the blood hematocrit level of the patient of the day before, the corrected value for the patient's blood volume equivalent of daily drainage was calculated. RESULTS: There was a significant reduction in perioperative use of donor blood (0.98+/-0.92 vs. 0.45+/-0.32 unit; P=0.0026), and total chest tube drainage (corrected value for the corresponding blood volume) (28.2+/-36.9 vs. 76.9+/-53.3 ml, P=0.0004) (mean+/-standard deviation) in the aprotinin group. However, aprotinin did not reduce postoperative transfusion or decrease in hematocrit level due to thoracic operations. In high transfusion-risk thoracic surgery patients (patients who underwent decortication, pulmonary resection for inflammatory lung disease and chest wall resection), the perioperative transfusion was only 0.50+/-1.08 units in aprotinin group, compared with 1.94+/-0.52 units in control group (P=0.003). Postoperative transfusion was also reduced in aprotinin administrated group (0.53+/-0.56 vs. 1.38+/-0.97 units; P=0.02). The mean total blood loss was decreased to nearly one third of the blood loss of the control group (41+/-28 ml vs. 121+/-68 ml; P=0.001). CONCLUSION: Aprotinin significantly reduced perioperative transfusion requirement and postoperative bleeding during major thoracic operations. Aprotinin decreased perioperative transfusion needs. Moreover, patients who were at risk of greater blood loss during and after certain thoracic operations had a greater potential to benefit from prophylactic perioperative aprotinin treatment.

Unusual complication of femoro-popliteal saphenous vein bypass--aneurysm formation.

An aneurysm as an unusual complication of saphenous vein bypass for femoro-popliteal occlusive disease is reported. The aneurysm developed 1 year following the bypass procedure. A diagnosis of Behçet's disease based on microscopic immunological examination and the clinical picture was suspected following successful aneurysmectomy.

Arterial complications following orthopaedic reconstructions.

Arterial complications following orthopaedic reconstructions are quite rare. Three patients with the complication of pseudoaneurysm or migration of a Kirschner wire following an orthopaedic reconstruction are presented.