Awake sternal fixation; comparison of technical details and early results with sternal fixation methods performed via general anaesthesia.

OBJECTIVES: Isolated sternal fractures are rare pathologies that rarely require surgical fixation. Although different fixation techniques are used, it is routinely performed under general anaesthesia. In our study, we aimed to share the details of the awake sternal fixation technique performed in our clinic and to compare the early results with sternal fixation methods performed under general anaesthesia. METHODS: Between January 2009 and January 2023, 129 patients who were diagnosed with sternal fracture and who underwent investigations and follow-up in our clinic were evaluated retrospectively. Thirteen patients who underwent surgical fixation for isolated sternal fracture were included in the study. Patients were categorized according to fixation and anaesthetic technique; group 1: fixation with steel wire under general anaesthesia (n = 4), group 2: fixation with titanium plate-screw under general anaesthesia (n = 4) and group 3: fixation with awake titanium plate-screw with parasternal intercostal plane block (n = 5). Demographics, surgical indication, radiological findings, surgical incision, surgical time and hospital stay were statistically compared. RESULTS: The mean age of the patients included in the study was 55.15 ± 15.01 years and 84.6% (n = 11) were male. The most common reason for fixation was displaced fracture (53.8%). Fixation surgery was performed due to pain in 30.8% (n = 4) and non-union in 15.4% (n = 2) of the fractures. The mean duration of surgery were 98.75 ± 16.52, 77.5 ± 35 and 41 ± 14.74 min, respectively. Duration of surgery was significantly lower in group 3 compared to the other groups (P = 0.012). The hospital stay duration for group 1 was 6 days, group 2 was 4 days and group 3 was 1 day. A notable difference was observed among all groups (P = 0.019). CONCLUSIONS: Awake sternal fixation technique with titanium plate-screw system under superficial parasternal intercostal plane block is an easy and effective method for surgical treatment of isolated sternal fractures. This technique showed a direct positive effect on the duration of surgery and hospital stay.

COVID-19 and pneumothorax, pneumomediastinum, subcutaneous emphysema: Analysis of risk factors.

Background: In this study, we aimed to analyze the risk factors of barotrauma in patients who were followed in the intensive care unit due to novel coronavirus disease 2019 (COVID-19) pneumonia. Methods: Between March 2020 and January 2021, a total of 261 patients (155 males, 106 females; mean age: 63.3±15.3 years; range, 11 to 91 years) who were followed in the intensive care unit due to COVID-19 pneumonia and were diagnosed with pneumothorax, pneumomediastinum, and subcutaneous emphysema were retrospectively analyzed. Demographics data of the patients, past and current medical history, clinical management, patient progress, and survival data were obtained from medical records of our hospital. Results: Twenty-seven of the patients were diagnosed with barotrauma. A total of 88.8% of the patients were followed with intubation. The development of pneumothorax, pneumomediastinum, and subcutaneous emphysema due to barotrauma was not dependent on sex, smoking/non-smoking status, using/not using corticosteroids, or comorbid diseases. There was a significant correlation between pneumothorax, pneumomediastinum, and subcutaneous emphysema development in intubated patients with different ventilator modes. Changing the ventilator mode from synchronized intermittent mandatory ventilation to airway pressure release ventilation increased the possibility of barotrauma by 15 times. Conclusion: Despite all lung-protective applications, barotrauma is a common complication, particularly in mechanically ventilated patients who have COVID-19 pneumonia with severe acute respiratory distress syndrome. Mechanical ventilator pressure modes should be patientspecific and followed carefully and frequently for the risk of barotrauma.

Treatment options for synchronous lung and esophagus tumors: A difficult decision to make.

Synchronous lung and esophageal carcinomas are rare clinical entities. Curative resection with lymph node dissection is the most optimal treatment approach for both tumors. However, due to the high potential risk of postoperative complications, the right approach is to make a patient-specific decision via a multidisciplinary approach at all stages. In this article, we present three cases of synchronous lung and esophageal tumors treated with different approaches due to their specific circumstances and discuss their pre-, intra-, and postoperative stages.

A Rare Lesion of the Thoracic Wall: Giant Scapulothoracic Bursitis.

Scapulothoracic bursitis, a rare lesion of the thoracic wall, usually presents as a cystic mass growing at the scapulothoracic interface. Histopathologically, it is characterized by the presence of synovial cells lining the interior of the thickened fibrotic cystic wall and capillary proliferation. A 48-year-old male patient was admitted to our clinic with a complaint of swelling in the back. The magnetic resonance imaging of the lung and mediastinum showed a 43 mm × 130 mm axial lesion in the left infrascapular area between the external muscles and the serratus anterior muscle, hyperintense on T2 sequence, not suppressed on fat-suppressed sequences, with a peripheral minimally contrasted septated collection area. The patient underwent surgical total excision and was discharged on the second postoperative day with no morbidity. Histopathology of the tissue was reported as soft tissue compatible with an inflamed cyst wall with prominent fibroblastic proliferation. Scapulothoracic bursitis lesions can be treated with non-invasive or minimally invasive methods. However, when it becomes a giant lesion occupying space on the thoracic wall and has hemorrhagic content, surgical excision is the treatment of choice.

Awake Sternal Fixation Using the Ultrasound-Guided Superficial Parasternal Intercostal Plane Block in a Patient With Cervical Spine Fracture.

We present the use of a bi-level, bilateral ultrasound-guided (US-guided) superficial parasternal intercostal plane block (S-PIP) for main anesthetic method in a 71-year-old patient with a C2 vertebral fracture undergoing repair of a sternal fracture. Conscious sedation was provided using midazolam and a remifentanil infusion. The patient had an uneventful recovery and was discharged from the hospital on the first postoperative day without complications. An US-guided S-PIP should be considered when patients are deemed at high risk for general anesthesia, especially in trauma patients with a cervical spine fracture.

The effects of the degree of pleural invasion on survival in patients with non-small cell lung cancer undergoing surgical resection.

Background: The aim of this study was to evaluate the degree and size of pleural invasion in non-small cell lung cancer patients and to compare its relationship with the survival time. Methods: Between January 2008 and June 2019, a total of 164 patients (143 males, 21 females; median age: 64.65 years; range 39 to 92 years) who underwent surgical resection with a diagnosis of non-small cell lung cancer and who were found to have pleural invasion histopathologically were retrospectively analyzed. The control group consisted of 105 patients (95 males, 10 females; median age: 61.7 years; range, 32 to 82 years) who underwent surgical resection but who were not found to have pleural invasion histopathologically during the same time period. Survival time was compared between the groups. Results: Median survival was 52 months in the group with pleural invasion, while it was 70.6 months in the group without pleural invasion. In the pleural invasion group, the patients who underwent sublobar resection had shorter survival. The degree of pleural invasion (p=0.028), advanced age (p=0.022), and lymph node involvement (p=0.011) were found to be poor prognostic factors for survival. Conclusion: In non-small cell lung cancer patients, the increase in the degree and size of pleural invasion is negatively correlated with the survival time and this is thought to be associated with advanced disease stage.

Unclear Issues Regarding COVID-19.

Scientists from all over the world have been intensively working to discover different aspects of Coronavirus disease 2019 (COVID-19) since the first cluster of cases was reported in China. Herein, we aimed to investigate unclear issues related to transmission and pathogenesis of disease as well as accuracy of diagnostic tests and treatment modalities. A literature search on PubMed, Ovid, and EMBASE databases was conducted, and articles pertinent to identified search terms were extracted. A snow-ball search strategy was followed in order to retrieve additional relevant articles. It was reported that viral spread may occur during the asymptomatic phase of infection, and viral load was suggested to be a useful marker to assess disease severity. In contrast to immune response against viral infections, cytotoxic T lymphocytes decline in SARS-CoV-2 infection, which can be partially explained by direct invasion of T lymphocytes or apoptosis activated by SARS-CoV-2. Dysregulation of the urokinase pathway, cleavage of the SARS-CoV-2 Spike protein by FXa and FIIa, and consumption coagulopathy were the proposed mechanisms of the coagulation dysfunction in COVID-19. False-negative rates of reverse transcriptase polymerase chain reaction varied between 3% and 41% across studies. The probability of the positive test was proposed to decrease with the number of days past from symptom onset. Safety issues related to infection spread limit the use of high flow nasal oxygen (HFNO) and continuous positive airway pressure (CPAP) in hypoxic patients. Further studies are required to elucidate the challenging issues, thus enhancing the management of COVID-19 patients.

What We Learned about COVID-19 So Far? Notes from Underground.

The novel coronavirus pandemic poses a major global threat to public health. Our knowledge concerning every aspect of COVID-19 is evolving rapidly, given the increasing data from all over the world. In this narrative review, the Turkish Thoracic Society Early Career Taskforce members aimed to provide a summary on recent literature regarding epidemiology, clinical findings, diagnosis, treatment, prevention, and control of COVID-19. Studies revealed that the genetic sequence of the novel coronavirus showed significant identity to SARS-CoV and MERS-CoV. Angiotensin-converting enzyme 2 receptor is an important target of the SARS-CoV-2 while entering an organism. Smokers were more likely to develop the disease and have a higher risk for ICU admission. The mean incubation period was 6.4 days, whereas asymptomatic transmission was reported up to 25 days after infection. Fever and cough were the most common symptoms, and cardiovascular diseases and hypertension were reported to be the most common comorbidities among patients. Clinical manifestations range from asymptomatic and mild disease to severe acute respiratory distress syndrome. Several patients showed typical symptoms and radiological changes with negative RT-PCR but positive IgG and IgM antibodies. Although radiological findings may vary, bilateral, peripherally distributed, ground-glass opacities were typical of COVID-19. Poor prognosis was associated with older age, higher Sequential Organ Failure Assessment score, and high D-dimer level. Chloroquine was found to be effective in reducing viral replication in vitro. Likewise, protease inhibitors, including lopinavir/ritonavir, favipiravir, and nucleoside analogue remdesivir were proposed to be the potential drug candidates in COVID-19 management. Despite these efforts, we still have much to learn regarding the transmission, treatment, and prevention of COVID-19.

Diagnostic value of signal peptide-Complement C1r/C1s, Uegf, and Bmp1-epidermal growth factor domain-containing protein 1 on serum and tissue samples in non-small cell lung cancer.

BACKGROUND: This study aims to investigate whether there is any relationship between the type, stage and the extensiveness of lung cancer and levels of signal peptide-Complement C1r/C1s, Uegf, and Bmp1-epidermal growth factor domaincontaining protein 1 in serum and lung tissues of non-small cell lung cancer patients and also whether there is any difference in signal peptide-Complement C1r/C1s, Uegf, and Bmp1-epidermal growth factor domain-containing protein 1 levels of patients with malignant or benign diseases. METHODS: The study included 55 subjects (45 males, 10 females; mean age 57.8±15.9 years; range 18 to 82 years) who were separated into three groups as 25 resectable non-small cell lung cancer patients (21 males, 4 females; mean age 64.6±9.4 years; range, 41 to 79 years) who were operated with the purpose of diagnosis and treatment (group 1), 15 unresectable non-small cell lung cancer patients (10 males, 5 females; mean age 61.8±9.6 years; range, 48 to 82 years) (group 2), and 15 patients (14 males, 1 females; mean age 42.5±19.5 years; range, 18 to 76 years) who were operated with non-cancer related reasons (group 3; control group). RESULTS: Preoperative serum signal peptide-Complement C1r/C1s, Uegf, and Bmp1-epidermal growth factor domain-containing protein 1 levels in groups 1 and 2 were significantly higher compared to control group (p=0.045). Serum signal peptide-Complement C1r/C1s, Uegf, and Bmp1-epidermal growth factor domain-containing protein 1 levels in group 2 were significantly higher compared to the other two groups (p=0.008). Levels of signal peptide- Complement C1r/C1s, Uegf, and Bmp1-epidermal growth factor domaincontaining protein 1 in tissue samples were significantly higher in patients with non-small cell lung cancer and yielded a prognostic importance such that a 1 ng/mL rise in tissue signal peptide-Complement C1r/C1s, Uegf, and Bmp1- epidermal growth factor domain-containing protein 1 concentration caused a 1.4 fold increase in death risk (p=0.009). CONCLUSION: Concentration of signal peptide-Complement C1r/C1s, Uegf, and Bmp1-epidermal growth factor domain-containing protein 1 in serum and tumor tissue may be an important biomarker in determining the diagnosis and prognosis in non-small cell lung cancer patients.

The risk of tumor cell dissemination in mediastinoscopy: a cytological study.

BACKGROUND/AIM: Mediastinoscopy is an invasive procedure that is used in the diagnosis of mediastinal diseases and in staging lung cancer. Tumor cell seeding during mediastinoscopy along the mediastinum and the incision line is a very rare complication. This study aimed to test the safety of mediastinoscopy in terms of tumor seeding by cytological evaluation of mediastinal lavage samples taken before and after biopsy. MATERIALS AND METHODS: The patients who underwent mediastinoscopy in our hospital between 2011 and 2014 were studied prospectively. Seventy-three patients with a diagnosis of lung or mediastinal malignancy were included in the study. All patients underwent classical cervical mediastinoscopy and mediastinal lavages were taken before and after the biopsy. Both lavage samples were sent to the pathology department in syringes for malignant cell cytology screening. RESULTS: The results of the histopathological examinations of lymph node biopsies were reactive in 25 patients and positive for malignancy in 48 patients. In 2 of 48 patients whose lymph nodes were reported to be positive for malignancy, the mediastinal lavage sample was reported to be positive for malignancy after biopsy, although it was negative preoperatively. In two patients, both the pre- and postbiopsy lavage samples were reported to be positive for malignancy. CONCLUSION: While performing dissection and biopsy during mediastinoscopy, tumor seeding into the mediastinum may occur. Long follow-up periods and large patient series are needed to determine how cytopathological examination of both fluids would affect the prognosis.

Extrapleural hematoma cases treated with video-assisted thoracoscopic surgery.

Extrapleural hematoma is a rare clinical condition whose most common causes are blunt chest trauma, central venous catheterization and ruptured thoracic aortic aneurysm. This study aimed to present three cases that underwent video-assisted thoracoscopic surgery due to extrapleural hematoma. Etiologic factors in these cases were falls from height in two cases and a dialysis catheter placed into the right internal jugular vein in one case.