The Cukurova score in the prediction of primary cytoreduction in ovarian cancer.

OBJECTIVE: Primary debulking surgery has been the preferred surgical route and is still considered a quality indicator for advanced ovarian cancer surgery. However, a significant number of patients are not amenable to upfront surgery. Neoadjuvant chemotherapy and interval debulking surgery may be the most suitable approach for this group. This study aimed to evaluate a novel score for prediction of the cytoreduction results at primary debulking surgery for ovarian cancer patients. METHODS: This observational prospective study was conducted at a tertiary gynecologic oncology center between December 2020 and August 2022. Presumed primary stage III-IV epithelial ovarian carcinoma cases were included. Borderline tumors, and metastatic or non-epithelial ovarian malignancies, were excluded. Based on imaging findings, points were assigned to each anticipated surgical procedure required for complete cytoreduction. The sum of these points was multiplied by the patient's Eastern Cooperative Oncology Group (ECOG) score, and thus, the Cukurova-clinic score was established. Furthermore, the required surgical procedures based on laparoscopic evaluation were recorded, and the score was readjusted and calculated to obtain the Cukurova score. RESULTS: One hundred and fourteen patients were included in the study. Primary debulking surgery was performed in 70% of cases. Among them, complete cytoreduction (Cukurova score ≤12) was obtained in 97.3% of cases. Complete cytoreduction was not achieved in cases with Cukurova score >12. The odds ratio of 90-day mortality was 13.4 for patients with Cukurova score >12, compared with those with Cukurova score ≤12. CONCLUSION: The Cukurova score is a model for classifying advanced ovarian cancer patients who may be candidates for primary debulking surgery.

Surgical treatment of pediatric thoracic Ewing tumors.

Background: This study aims to determine the thoracic surgery techniques, surgical indications, the role and effectiveness of surgical treatment in multimodal treatment applied to pediatric Ewing sarcoma patients. Methods: Between A pril 2004 a nd November 2020, a total of 15 pediatric patients ( 9 males, 6 females; mean age: 10.1±4.5 years; range, 3 to 18 years) who were diagnosed with primary thoracic Ewing sarcoma and operated were retrospectively analyzed. Tumor-related factors and treatment modalities for Ewing sarcoma originating from the chest wall and mediastinum were examined. Results: The most common complaint was pain in nine patients. While the tumor originated from the ribs in nine patients, it originated from the soft tissue (n=2), mediastinum (n=2), and extra-thoracic tissue (n=2) in six patients. Complete resection was achieved in 10 patients. While neoadjuvant chemotherapy was applied to eight patients, chemotherapy and radiotherapy was applied to 14 and five patients, respectively. Bone marrow transplantation was performed in one patient. The mean follow-up was 54.2±44.9 months. Recurrence was seen in six patients in a mean duration of 17.8±7.4 months. Conclusion: The most effective treatment for thoracic Ewing sarcoma is complete resection. Multimodal therapy in the form of surgical resection, chemotherapy and/or radiotherapy provides optimal efficacy and the most favorable survival. The follow-up period should be kept short, since recurrences are common.

Effects of Ketamine Infusion on Oxygenation in Patients with Chronic Obstructive Pulmonary Disease Undergoing Lung Cancer Surgery.

OBJECTIVE: Ketamine changes respiratory mechanics, provides airway relaxation, and alleviates bronchospasm in patients with pulmonary disease. This study investigated the effect of a continuous infusion of ketamine during thoracic surgery on arterial oxygenation (PaO2/FiO2) and the shunt fraction (Qs/Qt) in patients with chronic obstructive pulmonary disease. METHODS: Thirty patients older than 40 years, diagnosed with chronic obstructive pulmonary disease, and undergoing lobectomy were recruited for this study. Patients were allocated randomly to 1 of 2 groups. At the induction of anaesthesia, group K received intravenous (iv) 1 mg kg-1 ketamine as a bolus and followed by 0.5 mg kg-1 h-1 infusion until the end of the operation. Group S received the same amount of 0.9% saline as a bolus at induction and followed by a 0.5-mL kg-1 h-1 infusion of 0.9% saline until the end of the operation. PaO2 and PaCO2 values, FiO2 levels, PaO2/FiO2 ratio, peak airway pressure (Ppeak), plateau airway pressure (Pplat), dynamic compliance, and shunt fraction (Qs/Qt) were recorded during two-lung ventilation as a baseline and at 30 (one-lung ventilation, OLV-30) and 60 (OLV-60) minutes during one-lung ventilation. RESULTS: PaO2, PaCO2, PaO2/FiO2 values, and Qs/Qt ratio were similar between the 2 groups at OLV-30 minute (P = .36, P = .29, P = .34). However, at OLV-60 minute, PaO2, PaO2/FiO2 values were significantly increased, and Qs/Qt ratios were significantly decreased in group K than in group S (P = .016, P = .011, P = .016). CONCLUSIONS: Our data suggest that a continuous infusion of ketamine and desflurane inhalation in patients with chronic obstructive pulmonary disease during one-lung ventilation increase arterial oxygenation (PaO2/FiO2) and decrease shunt fraction.

Slug and Vimentin downregulation at the metastatic site is associated with Skip-N2 metastasis of lung adenocarcinoma.

OBJECTIVE: Lung cancer displays heterogeneity both in the tumor itself and in its metastatic regions. One interesting behavior of the tumor is known as Skip N2 metastasis, which N2 lymph nodes contain tumor cells while N1 are clean. In this study, mRNA levels of epithelial mesenchymal transition (EMT) related genes in skip N2 and normal N2 involvements of non-small cell lung cancer tissues were investigated to evaluate the possible molecular background that may contribute to the pathogenesis of Skip N2 metastasis. MATERIALS AND METHODS: Eighty-three surgically resected and paraffin embedded lymph node samples of lung cancer patients were analyzed in this study, which 40 of them were Skip N2. N2 tissues were sampled from 50% tumor containing areas and total RNA was extracted. mRNA levels for 18S, E-cadherin, Vimentin, ZEB1 and SLUG were analyzed via qPCR and E-cadherin and vimentin protein levels via immunohistochemistry (IHC). Bioinformatic analysis were adopted using online datasets to evaluate significantly co-expressed genes with SLUG in lung cancer tissue samples. RESULTS: Skip-N2 patients who had adenocarcinoma subtype had better survival rates. Comparative analysis of PCR results indicated that Skip N2 tumor tissues had increased E-Cadherin/Vimentin ratio and ZEB1 mRNA expression, and significantly decreased levels of SLUG. E-cadherin IHC staining were higher in Skip N2 and Vimentin were in Non-Skip N2. TP63 had a strong correlation with SLUG expression in the bioinformatics analyses. CONCLUSION: The results indicate that, at molecular level, Skip N2 pathogenesis has different molecular background and regulation of SLUG expression may orchestrate the process.

Effect of One-Lung Ventilation on Blood Sevoflurane and Desflurane Concentrations.

OBJECTIVE: To determine the blood sevoflurane and desflurane concentrations during one-lung ventilation (OLV). DESIGN: Randomized, single-blind study. SETTING: Single university hospital. PARTICIPANTS: The study comprised 24 patients, 35 to 70 years old who were scheduled for either a major abdominal surgery or thoracotomy. INTERVENTIONS: The patients were divided into the following 4 groups: sevoflurane two-lung ventilation (TLV), sevoflurane OLV, desflurane TLV, and desflurane OLV. Vaporizers were set at 1.5% sevoflurane or 6% desflurane. MEASUREMENTS AND MAIN RESULTS: In the TLV groups, blood samples were taken in 10-minute intervals starting 40 minutes after the start of TLV (T1-T9) for blood gas analysis and gas chromatography. In the OLV groups, the first sample was collected at 40 minutes of TLV (T1), and other samples were collected in 10-minute intervals from the start of OLV (T2-T9). Saturation of peripheral oxygen (SpO2), hemodynamic variables, and inspired and end-tidal volatiles were recorded. The fraction uptake of the volatile agents (F) was calculated for each patient at the same time points. The mean arterial sevoflurane concentration in the sevoflurane OLV group at T1 decreased from 40.7 ± 4.4 to 30.2 ± 2.5 µg/mL at T3 (p = 0.014, 26% decrease). In the OLV desflurane group, the mean arterial desflurane concentration at T1 declined from 224.6 ± 44.8 to 159.8 ± 32 µg/mL at T3 (p=0.018, 29% decrease). However, the reduction of sevoflurane concentration compared with that of desflurane at T3 was not statistically significant (p = 0.31). In addition, the fraction uptake of the volatile agents values significantly increased at the start of OLV (p = 0.001). CONCLUSION: An OLV procedure causes a decrease in the both arterial and venous blood concentrations of sevoflurane and desflurane. This reduction is believed to be due to ventilation-perfusion mismatch.

Risk factors affecting post-traumatic acute respiratory distress syndrome development in thoracic trauma patients.

BACKGROUND: This study aims to investigate the risk factors affecting post-traumatic acute respiratory distress syndrome development in thoracic trauma patients. METHODS: This two-centered, retrospective study included 3,080 thoracic trauma patients (2,562 males, 518 females; mean age 33.9±19.4 years; range, 2 months to 91 years) treated between January 2005 and January 2019. Demographic characteristics, mechanisms of injury, traumatic injuries, injury severity score and new injury severity score results, treatments, comorbidities, complications, morbidity and mortality rates, and durations of hospital stay were collected. Data were used to predict the risk factors for development of post-traumatic acute respiratory distress syndrome by univariate and multivariate statistical analysis. RESULTS: Acute respiratory distress syndrome was detected in 81 patients. In multivariate logistic regression analysis; age, pulmonary contusion, intracranial hemorrhage, rib fracture (unilateral and four-five pieces), femur and tibia fracture, diabetes mellitus, chronic obstructive pulmonary disease, blood transfusion (≥3 units), high white blood cell count at admission, sepsis, and hepatic injury were detected as independent risk factors (p<0.05). Optimal cutoff points (sensitivity/specificity ratios) for acute respiratory distress syndrome development risk were ≥16 (79%/68%) for injury severity score, ≥27 (90%/68.7%) for new injury severity score, and ≥16,000 (75.3%/71.6%) for admission white blood cell count. New injury severity score was superior than injury severity score to predict the development of acute respiratory distress syndrome. CONCLUSION: Acute respiratory distress syndrome causes significant mortality and morbidity in trauma patients. In addition to the well-known risk factors, diabetes mellitus and chronic obstructive pulmonary disease were independent risk factors. We defined a cutoff value for new injury severity score to predict post-traumatic acute respiratory distress syndrome.

PD-1 and PD-L1 expression in thymic epithelial tumours and non-neoplastic thymus.

AIMS: We explored the relationships between programmed death-1 (PD-1) and programmed death-ligand 1 (PD-L1) expression and the pathological and clinical features of thymic epithelial tumours and thymic hyperplasia. METHODS: We evaluated PD-1 and PDL-1 expressions within epithelial and microenvironmental components in thymic epithelial tumours (n=44) and thymic hyperplasias (n=8), immunohistochemically. We compared the results with demographic, clinical and histopathological features of the cases. RESULTS: We found 48% epithelial expression and 82.7% microenvironment expression for PD-1 and 11.5% epithelial expression and 34.6% microenvironment expression for PD-L1. There was no PD-1 expression, in either the epithelial or microenvironment, in the thymic hyperplasia group. PD-1 and PD-L1 positivity was more significant in thymic epithelial tumours than thymic hyperplasia. Patients with PD-1-positive microenvironments exhibited significantly shorter mean estimated survival time than their negative counterparts. CONCLUSION: These findings suggest that anti-PD-1 and anti-PD-L1 therapies may benefit patients due to high release of PD-1 and PD-L1 in thymic epithelial tumours.

The role of mediastinoscopy in the diagnosis of non-lung cancer diseases.

BACKGROUND: Mediastinoscopy is a good method to evaluate mediastinal lesions. We sought to determine the current role of mediastinoscopy in the investigation of non-lung cancer patients with mediastinal lymphadenopathy. MATERIALS AND METHODS: We retrospectively reviewed clinical parameters (age, gender, histological diagnosis, morbidity, mortality) of all patients without lung cancer who consecutively underwent mediastinoscopy in Hospital of Faculty of Medicine of Dicle University between June 2003 and December 2016. RESULTS: Two-hundred twenty nine patients without lung cancer who underwent mediastinoscopy for the pathological evaluation of mediastinum during the study period were included. There were 156 female (68%) and 73 male (32%) patients. Mean age was 52.6 years (range, 16 to 85 years). Mean operative time was 41 minutes (range, 25 to 90 minutes). Mean number of biopsies was 9.3 (range, 5 to 24). Totally, 45 patients (19.6%) had previously undergone a nondiagnostic bronchoscopic biopsy such as transbronchial needle aspiration or endobronchial ultrasound-guided transbronchial needle aspiration. Mediastinoscopy was diagnostic for all patients. Diagnosis included sarcoidosis (n=100), tuberculous lymphadenitis (n=66), anthracosis lymphadenitis (n=44), lymphoma (n=11) metastatic carcinoma (n=5), and Castleman's disease (n=1); there was a diagnosis of silicosis in one patient and tymoma in one patient. Neither operative mortality nor major complication developed. The only minor complication was wound infection which was detected in three patients. CONCLUSION: Although newer diagnostic modalities are being increasingly used to diagnose mediastinal diseases, mediastinoscopy continues to be a reliable method for the investigation of mediastinal lesions.

The anesthesia of trachea and bronchus surgery.

The trachea and bronchus surgery is generally performed due to stenosis, traumatic injury, foreign body and tumors. Preoperative evaluation and anesthesia management are very important issues because of higher mortality and morbidity rates. Patients may be asymptomatic, but airway difficulties, hypoxia, stridor, cough, hemoptysis are common conditions in these patient population. The collaboration between the surgeon and the anesthesiologist is very substantial and necessary. Anesthetic techniques include various applications such as one lung ventilation, fiberoptic intubation, jet ventilation, and apneic oxygenation, general anesthesia with or without neuromuscular blockade. In this review, anesthesia management of the trachea and bronchus surgery is evaluated in the light of new knowledge.

Cusum analysis for learning curve of videothoracoscopic lobectomy.

BACKGROUND: Video assisted thoracoscopic (VATS) lobectomy has a demanding learning curve due to its technical complexity and risk of uncontrollable bleeding. We investigated the case number required for gaining technical proficiency by applying cumulative sum analysis on initial VATS lobectomy operations of a single surgeon. METHODS: CALGB definition was used for the definition of VATS lobectomy. The data of the initial cases evaluated and cumulative sum (CUSUM) analysis was applied to duration of the operations and length of hospital stay. RESULTS: Fifty-eight patients underwent VATS lobectomy. Of those 51 were malignant and 7 were benign. Fifty-five of the procedures were lobectomy, 2 were inferior bi-lobectomy and 1 was left upper lobectomy with chest wall resection. CUSUM analysis reached to proficiency at 27 cases for duration of the operations. CONCLUSIONS: The length of learning curve depends on previous experience of the surgeon on open lobectomy and simpler VATS operations, potential number of VATS lobectomy cases and VATS capability of the surgeon. Depending on these factors, it is possible to obtain technical proficiency with an inferior number of procedures compared with existing literature (50-200).

Hydatid cysts in muscles: clinical manifestations, diagnosis, and management of this atypical presentation.

INTRODUCTION: Hydatid cysts are rarely detected in muscle tissue (0.7-0.9%), even in endemic countries. The aim of this study was to present information regarding the clinical manifestations, diagnosis, and management of muscle echinococcosis. METHODS: Twenty-two patients with hydatid cysts in the muscle were followed from January 2006 through December 2014. RESULTS: Twenty-four sites of muscle involvement were observed in the 22 patients. Fifteen (68%) of our patients were women, while seven (32%) were men. The mean age was 28.1 ± 15.4 (6-61) years. The most frequent locations were the thigh (27.2%) and the paravertebral region (13.6%). Most patients reported a painless slow-growing mass with normal overlying skin. Most (90.2%) cases were treated by surgical excision and fine-needle aspiration. CONCLUSIONS: Primary muscle hydatid cyst should be considered in the differential diagnosis in cystic masses of the muscular system without pain and localized enlargement of soft tissue, especially in endemic areas. Hydatid cyst should be investigated using serological tests and imaging modalities. If possible, total surgical excision of hydatid cyst in the muscle should be performed.

Hydatid cysts in muscles: clinical manifestations, diagnosis, and management of this atypical presentation

ABSTRACTINTRODUCTION: Hydatid cysts are rarely detected in muscle tissue (0.7-0.9%), even in endemic countries. The aim of this study was to present information regarding the clinical manifestations, diagnosis, and management of muscle echinococcosis.METHODS: Twenty-two patients with hydatid cysts in the muscle were followed from January 2006 through December 2014.RESULTS: Twenty-four sites of muscle involvement were observed in the 22 patients. Fifteen (68%) of our patients were women, while seven (32%) were men. The mean age was 28.1 ± 15.4 (6-61) years. The most frequent locations were the thigh (27.2%) and the paravertebral region (13.6%). Most patients reported a painless slow-growing mass with normal overlying skin. Most (90.2%) cases were treated by surgical excision and fine-needle aspiration.CONCLUSIONS: Primary muscle hydatid cyst should be considered in the differential diagnosis in cystic masses of the muscular system without pain and localized enlargement of soft tissue, especially in endemic areas. Hydatid cyst should be investigated using serological tests and imaging modalities. If possible, total surgical excision of hydatid cyst in the muscle should be performed.

Urgent thoracotomy for penetrating chest trauma: analysis of 158 patients of a single center.

BACKGROUND: Penetrating injuries to the chest present a frequent and challenging problem, but the majority of these injuries can be managed non-\operatively. The aim of this study was to describe the incidence of penetrating chest trauma and the ultimate techniques used for operative management, as well as the diagnosis, complications, morbidity and mortality. METHODS: A retrospective 9-year review of patients who underwent an operative procedure following penetrating chest trauma was performed. The mechanism of injury, gender, age, physiological and outcome parameters, including injury severity score (ISS), chest abbreviated injury scale (AIS) score, lung injury scale score, concomitant injuries, time from admission to operating room, transfusion requirement, indications for thoracotomy, intra-operative findings, operative procedures, length of hospital stay (LOS) and rate of mortality were recorded. RESULTS: A total of 1123 patients who were admitted with penetrating thoracic trauma were investigated. Of these, 158 patients (93 stabbings, 65 gunshots) underwent a thoracotomy within 24 h after the penetrating trauma. There were 146 (92.4%) male and 12 (7.6%) female patients, and their mean age was 25.72 9.33 (range, 15­54) years. The mean LOS was 10.65 8.30 (range, 5­65) days. Patients admitted after a gunshot had a significantly longer LOS than those admitted with a stab wound (gunshot, 13.53 9.92 days; stab wound, 8.76 6.42 days, p < 0.001). Patients who died had a significantly lower systolic blood pressure (SBP) on presentation in the emergency room (42.94 36.702 mm Hg) compared with those who survived (83.96 27.842 mm Hg, p = 0.001). The overall mortality rate was 10.8% (n = 17). Mortality for patients with stab wounds was 8/93 (8.6%) compared with 9/65 (13.8%) for patients with gunshot wounds (p = 0.29). Concomitant abdominal injuries (p = 0.01), diaphragmatic injury (p = 0.01), ISS (p = 0.001), chest AIS score (p < 0.05), ongoing output (p = 0.001), blood transfusion volume (p < 0.01) and SBP (p = 0.001) were associated with mortality. CONCLUSION: Penetrating injuries to the chest requiring a thoracotomy are uncommon, and lung-sparing techniques have become the most frequently used procedures for lung injuries. The presence of associated abdominal injuries increased the mortality five-fold. Factors that affected mortality were ISS, chest AIS score, SBP, ongoing chest output, blood transfusion volume, diaphragmatic injury and associated abdominal injury.

Resection of intercostal hemangioma with involved chest wall and ribs: in an 11-year-old girl.

We report a case of an 11-year-old girl who presented with a slowly enlarging mass in the right posterolateral chest wall. Computed tomography showed a soft-tissue mass 8.5 × 7.5 × 5.5 cm in size, arising from the right posterolateral 9th, 10th, and 11th intercostal spaces. Magnetic resonance imaging confirmed a vascular mass. The patient underwent complete resection of the tumor, together with the right 8th, 9th, 10th, 11th, and 12th ribs and their intercostal muscles. Reconstruction of the chest wall was performed with methyl methacrylate and Marlex mesh. Histopathologic examination of the tumor confirmed an intercostal cavernous hemangioma. At last examination, 6 months after the operation, the child was doing well, with no evidence of recurrence.

Factors affecting the outcome of surgically treated non-iatrogenic traumatic cervical esophageal perforation: 28 years experience at a single center.

BACKGROUND: We reviewed our experience with non-iatrogenic traumatic cervical esophageal perforations, paying particular attention to factors affecting the outcome of such cases. METHODS: In total, 30 patients treated surgically between 1980 and 2008 for non-iatrogenic traumatic cervical esophageal perforation in our clinic were reviewed. RESULTS: There were 25 male and 5 female patients with a median age of 27.5 years. The type of injury was external trauma in 21 (70%) patients and endoluminal injury in the remaining 9 (30%) patients. The mechanism of injury was gunshot in 16 patients, stabbing in 4, falling in 1 (extraluminal injury), and foreign body in 9 (endoluminal injuries). The overall mortality rate was 16.6% (5/30). The mortality rate for extraluminal injuries was 19%, and for endoluminal injuries was 11.1%. Mortality in patients treated within 24 h of sustaining injury was substantially less than in those for whom diagnosis and treatment were delayed (12.5 and 21.4%, respectively). The mortality rate was 33.3% (3/9) for patients with tracheal injuries and 9.5% (2/21) for those without tracheal injuries. CONCLUSIONS: A treatment delay greater than 24 h, the presence of tracheal injury, or extraluminal perforation significantly affected the outcome of surgically treated non iatrogenic traumatic cervical esophageal perforation.

Life-threatening giant mediastinal cystic teratoma in a 4-month-old male baby.

Cystic teratomas of the mediastinum are rare and present with severe respiratory distress during childhood. Aspiration of the cyst is indicated to reduce the cyst volume, alleviate the patient's symptoms, and secure an operative field. This report describes a 4-month-old male baby with a large anterior mediastinal teratoma presenting with severe respiratory distress. The cystic teratoma was large enough to cause pectus carinatum. Respiratory distress secondary to airway obstruction was markedly reduced by percutaneous aspiration of the cyst. Surgical excision is indicated for a malignant or benign well-demarcated mass in any part of the mediastinum. In our patient, total surgical excision was performed. Preoperatively, percutaneous aspiration was performed twice, with the symptoms being reduced after each aspiration. Surgical excision is the best means of diagnosing and treating a benign teratoma. Percutaneous cyst aspiration not only improved ventilation but also facilitated easy excision of the cyst during surgical management.

Hemangioma of the sternum.

Primary tumors of the sternum are rare and most of them are malignant. Benign lesions are typically chondromas, bone cysts, or hemangiomas. Among these tumors, hemangiomas are extremely rare. We report a rare case of hemangioma of the sternum. The patient was successfully treated with complete resection of the tumor and sternum stability was obtained by polypropylene mesh and methylmethacrylate.

Risk factors affecting outcome and morbidity in the surgical management of bronchiectasis.

OBJECTIVE: Bronchiectasis continues to be a major cause of morbidity and mortality in developing countries. The purpose of this study was to present the results of our 14 years of surgical experience to re-evaluate our indications for using surgical therapy and to analyze several factors that might affect the outcome and postoperative complications of this disease. METHOD: Age, sex, etiologic factors, symptoms, the duration of symptoms, radiologic and radionuclide examinations, preoperative evaluation, surgical procedures, postoperative morbidity and mortality, and the follow-up results from 143 patients operated on for bronchiectasis between January 1992 and January 2006, were reviewed retrospectively. RESULTS: One hundred forty-three patients underwent 148 operations for bronchiectasis. The mean age was 23.4 years. Complete resection was achieved in 118 patients. The morbidity rate was 23.0% and the mortality rate was 1.3%. Postoperatively, 75.9% of the patients were free of symptoms, 15.7% were improved, and 8.2% showed no improvement or were worse. The logistic regression analysis showed that a history of tuberculosis and incomplete resection were independent predictors of the operative result. Moreover, the lack of a preoperative bronchoscopic examination, a forced expiratory volume in 1 second of less than 60% of the predicted value, a history of tuberculosis, and incomplete resection were independent predictors of postoperative complications. CONCLUSIONS: A history of tuberculosis and incomplete resection were risk factors both for postoperative complications and for a worse operative result. The lack of a preoperative bronchoscopic examination and a low forced expiratory volume in 1 second were risk factors for postoperative complications. Surgery for multiple segments on different lobes should be performed whenever possible.