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.

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.

An unusual recurrent bilateral posterior mediastinal goiter after subtotal thyroidectomy: Case report.

INTRODUCTION: Surgical treatment of benign thyroid diseases need to be followed up closely, since recurrent thyroid nodules can be seen after subtotal thyroidectomy. Intrathoracic goiter (ITG) occurs in 10-30% of patients following subtotal thyroidectomy. In general these goiters are benign, having a malignant rate of only 2-22%. ITG grows slowly but steadily and in its process of development, it narrows the thoracic inlet by compressing the surrounding structures. Most of these can not located in the anterior mediastinum, others located in posterior retrovascular area. Bilateral posterior retrovascular goiters are very rare. PRESENTATION OF CASE: We report a case involving a 61-year-old woman with history of gradual-onset dyspnea who was referred to us for evaluation of a large mediastinal mass. She had undergone bilateral thyroid lobectomy for a cervical goiter 10 years ago. The mass was removed successfully via median sternotomy without complication. The patient recovered well and was discharged in 1 week. DISCUSSION: Most anterior mediastinal goiters can be resected through a transcervical approach, but if those extending beyond the aortic arch into the posterior mediastinum are better dealt with by sternotomy or lateral thoracotomy. CONCLUSION: Bilateral recurrent posterior mediastinal and retrovascular large goiters are better resected via sternotomy rather than lateral thoracotomy. The reason for that are the possibility of injury to large vascular structures and the difficulty of their management through lateral thoracotomy when cardiopulmonary bypass needed.

How does the type of thoracotomy affect the patient quality of life? A short form-36 health survey study.

PURPOSE: We evaluated whether the quality of life was affected in patients who had undergone various types of thoracotomy using the Short Form-36 Health Survey. METHODS: The patients who had undergone thoracotomy for diagnosis or treatment between January and September 2011 in the Thoracic Surgery Department were investigated to determine the effect of the type of thoracotomy on the quality of life using the Short Form-36 Health Survey. The patients were classified into three groups. In Group I, the latissimus dorsi and the serratus anterior had both been preserved, and there was no muscle dissection, in Group II the latissimus dorsi muscle had been dissected and only the serratus anterior muscle has been preserved, and in Group III both muscles had been dissected, and the standard posterolateral muscle dissection had been performed. RESULTS: A total of 101 patients comprising 64 males (63.37 %) and 37 females (36.63 %), with a median age of 38 years, were included in this study. There were significant differences in all quality of life subscales between Groups I and III and between Groups II and III. The patients in Group I had the highest scores, while the patients in Group III had the lowest scores. There were no significant differences in five of the eight Short Form-36 subscales and one of the two summary scores values between Group I and Group II in females. CONCLUSIONS: We investigated the effect of the type of thoracotomy on the patient quality of life using the Short Form-36 Health Survey, and found that the standard posterolateral thoracotomy had a marked adverse effect on the quality of life compared to muscle-sparing thoracotomy. We also found that it is possible to use thoracotomy with serratus preservation rather than muscle-sparing thoracotomy in cases with benign diseases where a large field of view is required, such as for decortication and pulmonary hydatid cysts, without any significant decrease in the quality of life, especially in females.

Single-incision thoracoscopic surgery of pleural effusions for diagnosis and treatment.

BACKGROUND: Several procedures such as video-assisted thoracoscopic surgery (VATS) are used to make a definite diagnosis in recurrent pleural effusions so that appropriate treatment can be arranged. Single-incision thoracoscopic surgery (SITS) is the most appropriate procedure that can be used for this purpose. The contribution of SITS to diagnosis and treatment is evaluated in this study that we conducted using a single thoracoport in patients with pleural effusion. METHODS: Nineteen consecutive patients with pleural effusion that was recurrent or refractory to medical treatment were included in the study to be diagnosed and treated with SITS. Thoracentesis was performed and pleural fluid samples obtained in all patients before the procedure. Pleural effusion drainage was performed from the 11-mm single skin incision by using a 10.5-mm single thoracoport, and biopsy or talc pleurodesis was performed in the same session when needed. RESULTS: The median age of the patients was 56.68 ± 3.05 years and there were 11 males and 8 females. The total amount of fluid drained by SITS was 1,436 ± 227 mL and the surgery lasted 81.05 ± 5.36 min. In addition, partial decortication and/or deloculation were performed in six patients and talc pleurodesis in nine patients. Fifteen patients were diagnosed with benign and four patients with malignant pleural effusion by thoracentesis, while nine patients were diagnosed with benign and ten patients with malignant pleural effusion by SITS. We therefore had six cases diagnosed as benign with thoracentesis who were diagnosed with malignant disease after SITS. CONCLUSIONS: SITS presents both diagnosis and treatment options together for pleural effusions. We believe SITS should be preferred to conventional three-port VATS to minimize the spread of infection and tumor cells to the chest wall in infectious and malignant diseases.

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.

Giant mediastinal mass: thymolipoma.

A 26-year-old man presented with shortness of breath on exertion that was gradually getting worse. His history revealed a mass in the left hemithorax that had been growing on follow-ups. Physical examination only showed that the respiratory sounds were fainter on the left. Thoracic computerized tomography was performed to elucidate the left hemithorax lesion seen on chest x-ray and a giant mass of lipid density extending from the anterior mediastinum to the diaphragm and filling almost the entire left hemithorax was observed. Total excision of the 25 × 21 × 8 cm mass weighing 1580 g was performed with a left thoracotomy. The histopathology investigation of the mass was reported as thymolipoma. The case was presented because it is a rare mediastinal mass.

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.

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.

Congenital lobar emphysema: differential diagnosis and therapeutic approach.

BACKGROUND: Congenital lobar emphysema (CLE) is a rare anomaly of lung development that usually presents in the neonatal period with respirator distress and pulmonary lobar hyperinflation. It is commonly confused with pneumothorax. The aim of the present paper was to review the authors' experience in order to emphasize the importance of differential diagnosis with pneumothorax. METHODS: Children with CLE treatment at Department of Thoracic Surgery, Dicle University School of Medicine, Turkey, between January 1993 and June 2004, were reviewed. RESULTS: Ten children consisting of six boys and four girls (age range, 6 h-12 months) had CLE. Major presenting symptoms were tachypnea(n = 100%) and respiratory distress in (n = 80%). On chest radiograph, emphysema was seen in all patients, and shift-herniation to the opposite lung, atelectasis were observed. Computed tomography was performed in all patients, which indicated emphysema in the affected lobes in all cases. Pulmonary perfusion scan was performed in two patients, showing loss of perfusion in the affected lobe. The most common affected lobe was the left upper lobe (50%). In the present series, three patients were mistakenly diagnosed as pneumothorax and intercostal drains were inserted in the emergency department. Eight patients underwent lobectomy, and postoperative course was uneventful. Two patients were followed conservatively. Emphysema was detected in all pathological specimens. One patient was lost to follow up. Mean follow-up duration of all patients was 26.8 +/- 29.24 months (range, 1-89 months). CONCLUSIONS: CLE is established on combined clinical, radiological and scintigraphic imaging. Surgical excision of the affected lobe is the appropriate treatment. Particularly, differential diagnosis should be made between CLE and pneumothorax.

Surgical treatment of pulmonary hydatid cysts: report of 139 cases.

Hydatid disease is a parasitic infestation that is endemic in many sheep- and cattle-raising areas and is still an important health problem in the world. The aim of our study was to present our surgical experience and strategy in the management of pulmonary hydatid disease. One hundred thirty-nine patients with pulmonary hydatid cysts underwent surgical treatment in our clinic between January 1990 and April 2002. A total of 169 cysts were present in 139 patients. Fifteen patients had concomitant hydatid cysts in liver and lung. Our series consisted of 76 male and 63 female patients, and mean age was 28.6 +/- 17 years (range, 5-65 years). Only pulmonary hydatid cysts were seen in 123 patients (88.5%), whereas there were 15 patients (10.8%) with combined pulmonary and hepatic disease. Hydatid cyst was found in a patient both in lung and spleen (0.7%). Lateral thoracotomy was performed in 115 patients (82.73%), bilateral thoracotomy in 9 patients (6.48%), thoracophrenotomy in 11 patients (7.91%), and median sternotomy and phrenotomy in 4 patients (2.88%). Resection techniques were used only in 10 patients. The most common complication was atelectasis (5.0%). The mortality rate was 1.8% (3 patients). Surgery is the treatment of choice for most patients with pulmonary hydatid cysts. Thoracaphrenotomy can be chosen as the surgical procedure in management of hepatic and pulmonary hydatid cysts.

Primary epithelioid angiosarcoma of the lung presenting as pulmonary hemorrhage.

Pulmonary angiosarcomas are usually secondary tumors, and only a few primary cases have been reported. We report a unique case of epithelioid angiosarcoma presenting as a solitary mass in the right upper lobe with pulmonary hemorrhage. Because of its epithelioid histology, this tumor may resemble a carcinoma or a variety of vascular lesions with epithelioid endothelial cells. Therefore, the diagnosis of epithelioid angiosarcoma should be based on immunohistochemical staining.

The value of open surgical approaches for aspirated pen caps.

PURPOSE: The aim of this study was to present the therapeutic approach of aspirated pen cap foreign bodies, with emphasis on the importance of open surgical intervention. METHODS: The records of patients who underwent bronchoscopy and bronchoscopy and surgical therapy for pen cap foreign bodies between January 1997 and June 2003 were reviewed retrospectively. Diagnosis was made based on history, physical examination, radiological methods, and bronchoscopy. Age, sex, symptoms, radiological methods, surgical procedure, complications, and outcomes were recorded. RESULTS: A total of 24 bronchoscopies were performed on 19 patients (10 boys, 9 girls) with a median age of 11 years (range, 8-15 years). Pen caps were localized in the right bronchial tree in 14 cases (74%). Pen caps were extracted successfully by forceps during bronchoscopy in 9 patients. Of the remaining 10 patients, 5 underwent bronchoscopy and tracheostomy and 5 patients underwent thoracotomy and bronchotomy. Significant complications were observed in 2 patients (10.53%) (severe bronchospasm in one and pneumothorax and subglottic edema in another). CONCLUSIONS: Pen caps aspiration is a challenging problem because of the difficulties during extraction and higher morbidity compared with other foreign body aspirations. In such cases in which classic bronchoscopy failed and/or pen caps could not be removed via vocal cords, open surgical approaches, either bronchoscopy and tracheostomy or thoracotomy and bronchotomy, may be an alternative procedure of choice.

Combined late diagnosed right main bronchial disruption and chylothorax from blunt chest trauma.

Both main bronchial disruption and chylothorax are uncommon injuries associated with blunt thoracic trauma. We report the case of a patient who presented late after traumatic rupture of the right main bronchus who also had a traumatic chylothorax.

Intrapleural fibrinolytic treatment of multiloculated pediatric empyemas.

Our objective was to compare the efficacy of adjunctive intrapleural fibrinolytic agents (IPFA) (streptokinase, urokinase) on fibrinopurulent stage empyema and chronic stage empyema in children. IPFA were used in 78 pediatric patients with empyema (36 fibrinopurulent stage empyemas, 42 chronic stage empyemas) between December 1994 and September 2002. Pleural biopsy was done for staging in all cases. Streptokinase 250,000 units in 100 ml normal saline (62 patients) or 100,000 units urokinase in 100 ml normal saline (16 patients) was instilled daily into the patient's chest tube, and the tube was clamped for 4 h, followed by suction. This treatment was continued daily for 2-8 days until resolution was demonstrated by chest radiographs and/or computed chest tomography. Success of treatment was 97.2% (complete response 24/36, partial response 11/36) in the fibrinopurulent stage and 9.4% (complete response 2/42, partial response 2/42) in chronic empyema cases. In one patient with fibrinopurulent empyema, the treatment was stopped due to allergic reaction and pleural hemorrhage; this patient died 1 day later in a septic condition. Although an invasive method, the pleural biopsy technique may be an alternative way of more properly staging thoracic empyema in selected children in whom staging based on radiographic and biochemical findings is doubtful. Intrapleural fibrinolytic treatment is an effective and safe therapy of choice and may have significant benefit in most children with fibrinopurulent phase empyema, except for those with bronchopleural fistula. IPFA do not seem to be effective in children with chronic phase empyema.

Management of postpneumonic empyemas in children.

OBJECTIVES: Despite continued improvement in medical therapy, pediatric empyema remains a challenging problem for the surgeon. Multiple treatment options are available; however, the optimal therapeutic management has not been elucidated. The aim of this study is to assess different treatment options in the management of postpneumonic pediatric empyemas. METHODS: A retrospective review was performed of pediatric patients admitted to Dicle University School of Medicine Thoracic and Cardiovascular Surgery Department between 1990 and 2002, with the diagnosis of empyema. Data tabulated included patient demographics, presentation, treatment and outcome. RESULTS: There were 515 children (289 boys and 226 girls) with a mean age of 4.7 ranging from 18 days to 15 years. Empyema was secondary to pneumonia in all children. The most common radiologic finding was pleural effusion in 285 patients (55.32%). Staphylococcus aureus was the most frequently encountered organism and found in 105 patients (20.38%). Pleural fluid cultures were negative in 195 patients (37.86%). In addition to antibiotic therapy, initial treatment included serial thoracenthesis (n = 29), chest tube drainage alone (n = 214), chest tube drainage with intrapleural fibrinolytic therapy (n = 72), chest tube drainage with primary operation (n = 191), and primary operation without chest tube drainage (n = 9). Overall response rate with fibrinolytic treatment (complete and partial response) was obtained in 58 patients. In addition to decortication pulmonary resections were performed in 12 patients. Overall mortality rate was 1.55%. There was no operative mortality. Postoperative morbidity included wound infection in 21, delayed expansion in 8, and atelectasis in 35 patients. CONCLUSIONS: Multiple therapeutic options are available for the management of pediatric empyema. Depending on stages, every option has a role in the treatment of postpneumonic pediatric empyema. In the absence of bronchopleural fistula, intrapleural fibrinolytic treatment should be tried in all patients with multiloculations in stage II empyema. In the absence of pneumonia, decortication for empyema is a safe approach with low mortality and morbidity rates.

Fibrovascular polyp of the esophagus: diagnostic dilemma.

A 51-year-old female patient was admitted to our department. She had symptoms of dysphagia, regurgitation of a fleshy mass into the mouth, and attacks of dyspnea. Every effort was made for diagnosis. At cervical exploration, upper esophageal polyp was discovered incidentally, and removed. We present this case because of rarity and emphasize the clinical presentation. The physician should be aware of the presence of this rare esophageal tumor.

Nohl-Oser type tracheobronchoplastic procedure in the treatment of advanced carcinoma of the right upper lobe.

Two male patients were admitted with right upper lobe tumor. In both cases, standard upper lobectomy or sleeve lobectomy was not applicable because of the invasion of lateral wall of the lower trachea. The standard surgical option was tracheal sleeve pneumonectomy. Avoidance of pneumonectomy could be achieved by Nohl-Oser tracheobronchoplasty. Both patients had smooth postoperative course. We present these cases because of rarity and to emphasize the alternative techniques. The surgeon should be aware of the possibility of an alternative technique.

Surgical correction of postpneumonectomy syndrome by intrapleural expandable prosthesis in a child.

We report a case of postpneumonectomy syndrome in a 10-year-old boy operated on for right-sided destroyed lung 1 year previously. The treatment involved the insertion of saline-filled expandable prosthesis in the postpneumonectomy cavity. A favorable outcome was observed. We think that an intrapleural inflatable prosthesis has several advantages for postpneumonectomy syndrome seen in childhood.

Intrapleural fibrinolytic treatment of multiloculated postpneumonic pediatric empyemas.

BACKGROUND: Progression of empyema, with the development of fibrinous adhesions and loculations, makes simple drainage difficult or impossible. The appropriate management remains controversial. Intrapleural fibrinolytic treatment to facilitate drainage of loculated empyema instead of open thoracotomy has been advocated since the 1950s. The aim of this study was to assess the effectiveness of intrapleural fibrinolytic treatment in postpneumonic pediatric empyemas. METHODS: In our clinic, we used intrapleural fibrinolytic agents in 72 pediatric patients with multiloculated empyema between 1994 and 2002. Streptokinase, 250,000 U in 100 mL of 0.9% saline solution (59 patients), and urokinase, 100,000 U in 100 mL of 0.9% saline solution (13 patients), were instilled daily into the chest tube, and the tube was clamped for 4 hours followed by suction. This treatment was continued daily for 2 to 10 days until resolution was demonstrated by chest radiograms or computed chest tomography. RESULTS: The rate of drainage after fibrinolytic treatment was increased 73.77%. Treatment was ineffective in 14 (19.44%) of 72 patients who underwent fibrinolytic instillation. Treatment was discontinued because of allergic reaction and pleural hemorrhage in 1 patient, and because of development of bronchopleural fistula in another one. The regimen was completely successful in 43 (59.72%) patients, and partially successful in another 15 (20.83%). Twelve of those patients who had failure eventually required decortication and recovered completely. One patient died of sepsis and pleural hemorrhage; another patient died because of food aspiration. CONCLUSIONS: In all patients with loculations except those with a bronchopleural fistula, intrapleural fibrinolytic treatment should be tried. Thus, the majority of children with loculated empyemas can be treated successfully without invasive interventions, such as thoracoscopic debridements or open surgery.