Analysis of thoracic trauma patients transferred to Türkiye's largest hospital after Kahramanmaras earthquake.

BACKGROUND: On February 6, 2023, an earthquake in Türkiye caused massive destruction. Over 50.000 people are known to have lost their lives, and over 100.000 are known to have been maimed. In our study, we aimed to analyze the treatment process of 267 METHODS: The demographic characteristics, the time spent under the rubble, the duration of transfer to the hospital, and the treatment process of patients admitted to our hospital have been evaluated. RESULTS: There are 125 (46.8%) men and 142 (53.2%) women in the study. The rate of thoracic trauma was 21.8%. Of all the patients, 15.7% (n=42) had pneumothorax, 18% (n=48) had contusion, 28.8% (n=77) had hemothorax, and 73% (n=195) had rib fractures. The mean time spent under the rubble was 17.6±26.5 h, the duration of transfer to the hospital was 138.5±113.6 h, and the hospitalization time was 93.8±152.3 h. The duration of hospitalization and transfer has been statistically longer for the patients who were under the rubble (85.4%) than for those who were not. (14.6%) (p=0.048). There is a statistically weak positive correlation between the time spent under the rubble and the time of transfer (p=0.048). CONCLUSION: The state, the time spent under the rubble, and the presence of hemothorax and pneumothorax should be effectively evaluated in earthquake-induced thoracic traumas. Considering these criteria in the transfer of patients to the centers operating at full capacity in a short time will minimize morbidity and mortality.

Can tumour budding change the future of pulmonary adenocarcinoma?

BACKGROUND: Pulmonary adenocarcinoma shows different prognosis even in the same pathological subtype and stage. In this study, it is aimed to investigate the relationship between tumour budding and known prognostic values and clinicopathological features in pulmonary adenocarcinoma. METHODS: In this study, there have been 77 patients diagnosed with primary pulmonary adenocarcinoma. In the evaluation process, the number of budding between 0 and 4 is accepted as low budding (Bd1), the number of budding between 5 and 9 is considered as medium budding (Bd2), and the number of budding above 10 is considered as high budding (Bd3). RESULTS: According to the findings of the study, it can be seen that there is a statistical difference between tumour budding and stromal fibrosis (p < 0.001). The presence of pleural invasion, lymph vascular invasion and perineural invasion in patients with Bd3 is found to be statistically higher than the patients with Bd1 (p = 0.048) (p = 0.041) (p = 0.029). CONCLUSIONS: Tumour budding has been associated with pleural invasion, lymph vascular invasion, perineural invasion, and stromal fibrosis. This study is the first to show the relationship between tumour budding and stromal fibrosis in pulmonary adenocarcinomas. The role of tumour budding in lung cancers remains to be clarified.

A non-surgical option in large bronchopleural fistulas: Bronchoscopic conical stent application.

BACKGROUND: This study aims to compare the results of the open surgical approach versus endobronchial conical stent application in the treatment of extensive fistulas. METHODS: Between December 2004 and April 2016, a total of 36 patients (34 males, 2 females; mean age 59.6±8.1 years; range, 40 to 72 years) with a bronchopleural fistula of ≥8 mm in diameter and underwent either conventional open surgery with stump-supported intercostal muscle flap or endobronchial ultra-flex expandable stenting were retrospectively analyzed. The demographic and clinical characteristics of the patients, operative data including the length of hospital stay, thoracic drainage time, and early mortality, and survival data were recorded. RESULTS: The mean hospitalization time was 17.4±4.5 days for the bronchoscopic group and 22.5±6.7 days for the invasive surgery group (p=0.026). The median time to removal of thoracic drains was 15 (range, 10 to 30) days for the bronchoscopic group and 26 (range, 14 to 55) days for the surgical group (p=0.027). Early mortality rates of both approaches were in favor of the bronchoscopic approach (χ2=7.058; p=0.008). Two-year survival rate was 76.47% (n=13) in the bronchoscopic group and 70% (n=7) in the surgical group. There was no statistically significant difference in the survival rates between the two groups (χ2=0.132; p=0.716). CONCLUSION: Our study results suggest that bronchoscopic approach can be the first choice in the treatment algorithm of fistulas with a diameter of ≥8 mm presenting with empyema in selected cases.

Pitfalls and Challenges of Lung Transplant in a Patient With Kartagener Syndrome and Scoliosis.

We present a 22-year-old woman with Kartagener syndrome and scoliosis who died 112 days after single lung transplant. The classic thoracic involvement of situs inversus totalis and the asymmetric arrangement of the thoracic vascular structures might be a pitfall for surgeon. Anatomic obstacles have forced the surgeon to perform a single transplant. The period of primary graft dysfunction in a single transplanted lung patient was a challenge; supporting the patient with a high flow and long period of extracorporeal membrane oxygenation might lead to a vanishing bronchus. Immotile cilia, a feature of Kartagener syndrome, were another challenge and patient needed several daily aspiration bronchoscopies. Vanishing bronchus is a gradual process with high mortality rates; commonly, stenosis is at the non anastomotic bronchial tree because of insufficient nourishment of the bronchial cartilages. Several repeat bronchoscopic balloon dilatations accompanied with medical treatment were unsuccessful.

Surgical treatment of pulmonary arteriovenous malformations.

BACKGROUND/AIM: Pulmonary arteriovenous malformations (PAVMs) are direct communications between the branches of pulmonary arteries and veins. This study evaluates surgically treated cases of pulmonary arteriovenous malformations. MATERIALS AND METHODS: We retrospectively examined 41 cases of PAVM that were operated in our clinic between 1995 and 2012. We obtained the clinical, radiological, and surgical data of the patients from their files. RESULTS: The 41 cases comprised 27 males and 14 females. Their mean age at diagnosis was 39.8 years (range: 9-71). The symptoms were hemoptysis in 28 cases, dyspnea in five, cough in three, and epistaxis in two; three patients were asymptomatic. Twenty-three right and 19 left posterolateral thoracotomies were performed, including one case which was operated bilaterally. Lower lobectomy was performed in 17 patients, lower lobectomy and lingulectomy in two, upper lobectomy in ten, middle lobectomy in two, segmentectomy in seven, and wedge resection in four. Postoperative histopathology was arteriovenous malformation in all cases. CONCLUSION: PAVMs are rare clinical conditions. Surgery remains the first choice when embolization treatment cannot be performed or is not successful, in symptomatic and complicated patients with PAVM, and/or in cases where the PAVM diagnosis cannot be established.

Can Sericin Prove Useful as a Pleurodesis Agent or Tissue Glue?

Background Sericin is a natural, gum-like, macromolecule protein, synthesized from silkworms for the formation of cocoon shells. The aim of the present study is to describe the effects of sericin when used for pleurodesis and/or as tissue glue. Methods Adult, male, 12-week-old Wistar albino rats, weighing 257 to 395 g were used in the present study (n = 12). The animals were randomly divided into two equal groups as the sericin and the control group. After intramuscular administration of the anesthetic agent, the rats were intubated and mechanically ventilated. A left thoracotomy was performed and 30 mg sericin powder was instilled into the thoraxes of the sericin group. The remaining rats were allocated to a sham thoracotomy group. The animals were housed in individual cages, fed ad-libitum, and sacrificed 8 days after. After sacrifice, the left hemithoraxes were removed en bloc and underwent histopathologic examination. Results Masson trichrome staining was applied on the visceral pleura sections of all the animals. Each animal specimen (n = 6, 100%) in the control group showed minimal collagen deposition, while only one rat (16.67%) in the sericin group had minimal collagen deposition. However, in the sericin group, five animals (83.33%) showed dense collagen deposition, fibroblastic activity, and fibrosis. According to the test method, independent t-test, developing fibroblastic activity and fibrosis are statistically significant between the two groups (p < 0.01). There were no foreign-body reactions and no evidence of biological glue on the specimens in the sericin group. The rats in the sericin group had lower inflammatory reactions compared with those in the control group. Emphysema was observed in two rats (33.33%) in the sericin group and in four rats (66.67%) in the control group. Therefore, sericin was found to be associated with an increase in fibroblastic activity and fibrosis in visceral pleura without exerting any adverse effect on the lung parenchyma. Conclusion Sericin is a new and researchable protein for chest diseases and thoracic surgery. To develop an effect of dense collagen deposition, fibroblastic activity, and fibrosis in the visceral pleura, without significant adverse effects, is remarkable. Therefore, sericin may be useful as a pleurodesis agent or natural biological glue in the future. Sericin treatment can add value to the disciplines of pulmonology and thoracic surgery.

Is surgical plication necessary in diaphragm eventration?

BACKGROUND: Diaphragm plication surgery is conducted to remove dyspnea, which results from mediastinal shift, atelectasia, and ventilation/perfusion dyssynchrony in lungs that occur because of an eventrated diaphragm. This study aims to determine whether diaphragm plication has any effect on respiration by analyzing the patients' changing values in the respiratory function test (RFT) after plication surgery. METHODS: Sixteen patients who underwent diaphragm plication surgery in our clinic because of plication eventration or paralysis were examined prospectively. Diaphragm eventration values were assessed using a calculation method that uses posteroanterior pulmonary radiographies taken during patient admission and control; then, these data were recorded. The amount of changes in the eventration levels and in restrictive respiratory failure parameters-forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC) of RFTs-conducted in pre- and postoperative control periods were compared using statistical analysis methods. The compatibility between the amounts of RFT changes was examined through a satisfaction survey-using a questionnaire that consisted of multiple choice questions with answer options such as "better," "the same," and "worse"-to understand preoperative and postoperative symptom levels in the 12(th) month of postoperative control. RESULTS: According to postoperative levels, a decrease between 19% and 23% was observed in eventration amounts within the 1(st) postoperative month, 6(th) postoperative month, and 12(th) postoperative month. In addition, the highest average increase in FEV1 liter (lt) values was 0.2 lt and 0.25 in FVC (lt) values. CONCLUSION: Researchers of this study believe that more distinctive decisions need to be taken while identifying patients for surgery in unilateral diaphragm eventrations, especially in the adult patient group; surgical option should be used for cases in which the eventrated diaphragm results in mediastinal shift and respiratory failure.

Management of Massive Hemoptysis: Analyses of 58 Patients.

OBJECTIVES: The objective was to describe changing patterns of etiological factors and treatment modalities for massive hemoptysis. MATERIAL AND METHODS: From January 2008-December 2012, the medical records of 58 massive hemoptysis patients were reviewed. RESULTS: Fifty-eight patients, 44 were men (75.9%) and 14 were women (24.1%), with a mean age of 51.4 years (range= 19-84 years), were divided into three groups; surgical management (n= 37, 63.8%), conservative management (n= 14, 24.1%) and bronchial artery embolization (n= 6, 10.4%). One case (1.7%) had combined treatment modality; bronchial artery embolization was followed by surgical resection. Anatomical lung resections were the most preferred resection type in the surgical management group (n= 34, 91.9%). The most common etiological factor was bronchiectasis (n= 19, 32.8%); followed by bronchial cancer (n= 14, 24.1%). The duration of hospitalization in the surgical management group was 11.4 days (range= 4-24); whereas in the bronchial artery embolization group, hospitalization was only four days (range= 2-7) (p< 0.01). Prolonged air leak (n= 7; 18.9%) was the most common complication in the surgical management group. CONCLUSION: We emphasize that bronchiectasis was leading cause of massive hemoptysis. Surgical treatment remains the definitive therapy in the management of massive hemoptysis with decreased mortality rates over decades; whereas bronchial artery embolization is an effective therapeutic tool.

Calcifying fibrous pseudotumor of lungs.

Calcified fibrous pseudotumors can generally be detected as solitary masses in various regions of the body, and were first described in 1988. In this case report, we discuss an adult patient whose tumor was localized in the lung, which has not been reported in the literature before.

Intrathoracic Castleman disease.

AIM: To analyze patients with Castleman disease who were diagnosed by surgery. MATERIALS AND METHODS: We retrospectively investigated the postoperative pathological records of operations performed between January 1992 and December 2012 in our hospital. Files of 19 patients with the diagnosis of Castleman disease were analyzed. RESULTS: There were 13 male and 6 female patients with a mean age of 40.1 + 11.4 (range: 20-57) years. Fifteen thoracotomies and 3 video-assisted thoracoscopies, 12 on the right side and 6 on the left side, and 1 mediastinoscopy were performed. Biopsies and mass excisions were performed in 2 and 17 cases, respectively. Histopathological findings were hyaline vascular-type (n = 16), plasma cellular- type (n = 2), and hyaline vascular plus plasma cellular-type (n = 1) Castleman disease. CONCLUSION: Castleman disease can occur in all areas of the thorax, but the mediastinum and hilum are the most common locations. Surgical excision is the best method of diagnosis and treatment. Complete excision is curative for local forms of the disease. However, complete excision may not be possible at all times due to local invasion and hypervascularization. Multimodal treatment, including chemotherapy, is recommended in patients with a multicentric form of the disease, and they should be followed closely.

Intrathoracic neurogenic tumors.

BACKGROUND: Intrathoracic neurogenic tumors are uncommon neoplasms arising from nerve tissues. This study reports on our 24-year single-center experience with intrathoracic neurogenic tumors. PATIENTS AND METHODS: We retrospectively analyzed the postoperative pathological records of 19,378 operations performed in our clinic between January 1988 and December 2011 and included cases with diagnosis of neurogenic tumors. RESULTS: The study included 149 patients (90 females and 59 males) with an average age of 24.5 years (7 months to 77 years). The study group comprised 29 infants and children, and 120 adults. Of the patients, 72 had benign schwannomas, 10 malignant schwannomas, 17 neurofibromas, 24 ganglioneuromas, 9 ganglioneuroblastomas, 4 neuroblastomas, 9 primitive neuroectodermal tumors, and 4 paragangliomas. Concerning the location of these lesions, 131 were located in the posterior mediastinum, 8 in the lung parenchyma, 5 in the chest wall, 3 in the anterior mediastinum, and 2 in the thoracic inlet. The majority of nerve cell tumors were in infants and children (79.3%), whereas the nerve sheath tumors most commonly occurred in adults (78.3%). There were 117 benign and 32 malignant tumors across all age groups. The rate of malignancy was 41.4% in infants and children, compared with 16.7% in adults. Symptoms were seen in 65% of the adult patients and 79.3% of the infant and children patients. Seven tumors were associated with von Recklinghausen's disease. In six patients (4.0%), the tumor showed an intraspinal extension. Surgical resection of the tumor was complete in 142 of 149 patients (95.3%). CONCLUSION: The treatment of choice for malignant and benign thoracic neurogenic tumors is complete resection. The objective of resection is to avoid local invasion, facilitate differential histopathological diagnosis to determine other treatment options, and to prevent malignant degeneration.

Intrathoracic fibrodysplasia ossificans progressiva.

Fibrodysplasia ossificans progressiva is an extremely rare disease that is usually seen in the form of sporadic cases and seems to be localized outside of the thoracic cavity. Inflammation and trauma are accused in the etiology, and too many diagnostic mistakes are done. The disease, which may present genetic transmission and has not a definitive treatment, was seen as an intrathoracic mass for the first time. Intrathoracic mass was excised, and the cure was achieved in our patient, who was defined to be sporadic as a result of familial screening.

A strange bullet which caused chylomediastinum and chyloptysis.

Chyloptysis and chylomediastinum are uncommon complications of various kinds of thoracic operations, malign and nonmalign diseases. In the English language medical literature, there were no cases of both chylomediastinum and chyloptysis following trauma. We discuss a case of chylomediastinum and chyloptysis after penetrating trauma. The patient sustained a bullet wound that caused chylomediastinum and chyloptysis without damaging major structures apart from the thoracic duct in the mediastinum. Following surgical intervention, the patient has remained problem-free for 5 months.

Can exercise capacity assessed by the shuttle walk test predict the development of post-operative complications in patients with lung cancer?

INTRODUCTION: The objective of this study was to assess the role of shuttle walk test in predicting post-operative complications in lung cancer resection surgery. PATIENTS AND METHODS: A consecutive series of patients who were candidate for lung resection surgery with the diagnosis of early stage lung cancer were included to this study. All patients in this study evaluated for exercise capacity testing with shuttle walk test. RESULTS: Twenty for patients were included in this study. Mean age was 61.5 ± 8.6 years. Pneumonectomy, lobectomy, bilobectomy and wedge resection were performed in 11 (46%), 10 (42%), 2 (8%), and 1 (4%) patients, respectively. Complications occurred only in six patients. There was no statistically significant relationship between risk for development of post-operative complication and age, incremental shuttle walk test, endurance shuttle walk test and exercise capacity evaluated with peak VO2 (mL/kg/minute) (p> 0.05). CONCLUSION: Shuttle walk tests (incremental and enduronce) had a limited role in predicting post-operative complications in lung cancer resections.

Treatment of persistent postpneumonectomy empyema by vacuum-assisted management: an analysis of nine patients.

BACKGROUND: Conventional treatment methods in postpneumonectomy empyemas (PPE) are associated with long stay in hospital, poor patient comfort, and high rate of postoperative mortality. Vacuum-assisted management (VAM) may be helpful in solving these problems. METHODS: VAM was performed on nine patients with PPE in our clinic between July 2010 and September 2011 to provide continuous drainage of empyema in the pouch and to improve empyema with obliteration of the pouch by accelerating tissue granulation. RESULTS: All nine patients were men (mean age: 54.5 years; range: 18-68 years). Empyema resolution and obliteration of the pouch were achieved with VAM in the cases with empyema without fistula (n = 7) after the pneumonectomy. In the patients with fistula (n = 2), VAM was performed after closure of the fistula. Mean duration of hospital stay was 36.5 (12-57) days. The treatment was successful in eight of nine patients (88.9%). Mean duration of follow-up in the successfully treated patients was 10.9 (3-17) months. CONCLUSION: Intrathoracic VAM was effective and safe in the treatment of PPE.

Pulmonary Langerhans cell histiocytosis; characteristics of 11 cases.

INTRODUCTION: Pulmonary Langerhans cell histiocytosis (PLCH) is a rarely seen disease of younger population. Almost all of the patients were smoker. In this study we aimed to evaluate the characteristics, diagnosis, treatment modalities and prognosis of 11 cases with PLCH. MATERIALS AND METHODS: We retrospectively reviewed our case series of eleven patients who were pathologically diagnosed as PLCH. The median age was 35 years (19-51) and male to female ratio (M/F) was 5/6. All of the patients were symptomatic. The most common symptoms were dyspnea (81.8%) and dry cough (72.7%). Mean duration of the symptoms was 10.8 months. All patients except two of them were smoker (81.8%). All patients were also passive smokers. RESULTS: Bilateral cystic appearance (n= 9, 81.8%), interstitial findings [septal and peribronchovascular thickening (72.7%) and nodular pattern (54.5%)] were common radiological findings. Spontaneous pneumothorax was present in two cases. All patients were diagnosed with surgical biopsies (90.9%) or transbronchial parenchymal biopsy (9.1%). Smoking cessation (81.8%) and immunosupression therapy (methylprednisolone) were the treatment modalities. Mean follow-up period was 5.40 ± 1.78 years. Generally, symptoms were improved with smoking cessation or methylprednisolone therapy. One patient was readmitted to our clinic with recurrent pneumothorax. In conclusion, it should be kept in mind that passive smoking is also responsible in the pathogenesis of PLCH. CONCLUSION: Exact consensus for PLCH treatment was not present except a few recommendations. In the future, with the understanding of the pathogenesis of the disease, new therapeutic agents will be discovered for this rare condition.

Primary classical hemangiopericytomas of thorax.

BACKGROUND: Hemangiopericytoma, an uncommon hypervascular tumor, occurs anywhere in the body with capillary vessels originating from the pericyte. These tumors most frequently occur in the musculature of the lower extremities and retroperitoneum, but are rarely seen in the thoracic cavity. The objective of this study is to present primary classical hemangiopericytomas of the thorax together with a literature review. METHODS: The postoperative pathologic records of 17,165 operations that were performed between January 1990 and December 2010 in the clinic were retrospectively searched, and the files of 6 cases with the diagnosis of primary classical hemangiopericytoma were analyzed for clinical characteristics of patients, surgical procedures, histopathologic features, treatments after surgery, and morbidity and mortality results. RESULTS: There were 4 female and 2 male patients with an average age of 30.3 years (range, 15 to 60 years). Three patients had thoracic wall lesions, 2 patients had intrathoracic extrapulmonary lesions, and 1 patient had mediastinal lesion. Four left and two right posterolateral thoracotomies were performed. Chest wall resection was performed in 3 patients, intrathoracic extrapulmonary mass excision in 2 patients, and mediastinal mass excision and left lower lobectomy in 1 patient. Postoperative histopathologic diagnoses were primary classical hemangiopericytomas in 4 patients and primary classical malignant hemangiopericytomas in 2 patients. Four patients underwent reoperation for recurrence. In the follow-up period, 2 patients are still alive at 30 months and 14 years postoperatively; 3 patients died at 7, 8, and 16 years postoperatively. One patient was lost to follow-up. All 3 mortalities were related to the recurrence or distant metastasis of the tumor. CONCLUSIONS: Although hemangiopericytomas are benign or malignant tumors, they generally display malignant behaviors. The risk of recurrence and distant metastasis occurs even many years after resection, suggesting that the prognosis becomes worse after each recurrence.