Effects of Cilostazol and Diltiazem Hydrochloride on Ischemia-Reperfusion Injury in a Rat Hindlimb Model.

OBJECTIVE: Free radicals and neutrophils are potent sources of ischemia-reperfusion injury (I/R) and they can be limited by the use of exogenous application of some therapeutic agents. The objective of this study was to compare the effects of cilostazol and diltiazem hydrochloride in a rat hind limb model of I/R injury. Methods: Skeletal muscles submitted to 2 hours of ischemia by placing an aneurysm clip to femoral artery and reperfused after 1, 2 and 4 hours. Seventy-two Wistar-Albino rats were randomly divided into mainly four groups according to treatment agents:  Group I (control group) was treated with saline; Group II was treated with diltiazem hydrochloride; Group III was treated with cilostazol in 30% dimethyl sulphoxide; and Group IV was treated with 30% dimethyl sulphoxide intraperitoneally. These four main groups also subdivided into three subgroups according to duration of the reperfusion times.  Blood samples were taken and all rats were sacrificed. Results: Cilostazol-treated groups demonstrated a significant decrease in tissue and serum malondialdehyde (MDA) levels, and tissue myeloperoxidase (MPO ) activity compared with other groups. Increase in serum nitric oxide (NOx) level was significantly higher in all subgroups of cilastazol, diltiazem hydrochloride, and dimethyl sulphoxide groups versus the control group. CONCLUSION: Although these results suggest the beneficial effects of cilostazol and diltiazem hydrochloride on I/R injury, the effect of cilostazol on I/R injury seems to be more efficient than diltiazem hydrochloride.

It is feasible to operate on pathological Masaoka stage I and II thymoma patients with video-assisted thoracoscopy: analysis of factors for a successful resection.

BACKGROUND: The objectives of this study were to evaluate the feasibility of video-assisted thoracoscopic (VATS) thymoma resection and to analyze the factors contributing to a successful perioperative period. METHODS: Fifty-one patients with thymoma underwent VATS with the aim of thymoma resection. Four patients underwent minithoracotomy [due to technical difficulties, including small chest cavity, high body mass index (BMI), and disintegration of the capsule] and three patients underwent sternotomy (due to invasion of major vascular structures). The seven open-converted patients and seven other patients who underwent complete VATS thymoma resection but experienced prolonged hospital stay (≥7 days) formed Group B (n = 14), namely, the unsuccessful group, while successful VATS thymoma resection patients formed Group A (n = 37). The groups were compared with each other in terms of the characteristics of patients, tumors, and perioperative period. RESULTS: Patients' characteristics, tumor size, WHO histologic type, and complications were similar in both Groups A and B (p > 0.05). Patients with Masaoka stage I and II thymomas were significantly more frequent in Group A (p < 0.01). Tumor size was a statistically insignificant variable for the determination of a successful VATS thymoma resection (p = 0.3). Masaoka stage and the size of the thymoma did not have any correlation with each other (p > 0.05). CONCLUSIONS: The size of the thymoma was not observed to be correlated with Masaoka stage and it was not noted to be an important factor in successful VATS thymoma resection. A higher Masaoka stage (III and IVa) was found to be the only variable that predicted unsuccessful situations. Thus, Masaoka stage, rather than the size of the thymoma, should be the main concern for the surgeon.

Delayed presentation of posttraumatic diaphragmatic hernia.

BACKGROUND: Missed diaphragmatic injuries after trauma may present with herniation of intraabdominal organs into the thoracic cavity. We aimed to review our patients who presented with delayed posttraumatic diaphragmatic hernia. METHODS: A retrospective review of the medical records of patients with delayed diagnosis of posttraumatic diaphragmatic hernia between 2001 and 2009 was performed. RESULTS: Ten patients with a mean age of 44.3 years were included. Six patients were female. Blunt injuries (n: 7) were more common. Mean duration between trauma and presentation to the hospital was 5.9 years (4 months - 19 years). Nine patients had left-sided diaphragmatic hernia. All patients had chest X-ray and most were diagnostic (n: 8). Additional diagnostic imaging with computerized tomography (CT) and magnetic resonance (MR) was used in seven patients. For the repair, laparotomy incision was chosen for seven patients and thoracotomy incision for two patients. One patient underwent left thoracoabdominal approach. Mesh repair was used in seven patients. Postoperative mean hospitalization was 10.6 days. Empyema and atelectasis were the morbidities in one patient. No postoperative mortality was detected. CONCLUSION: Delayed presentation of posttraumatic diaphragmatic hernia is a serious challenge for trauma surgeons. Prompt diagnosis and treatment prevent serious morbidity and mortality associated with complications such as gangrene and/or perforation of the herniated organ.

Extended resection: is it feasible for pulmonary metastases?

BACKGROUND: Extended resections may be necessary to achieve tumor-free borders for secondary pulmonary malignancies. This study was performed to analyze the outcomes that result from extended resections of pulmonary metastases. METHODS: Between February 1991 and December 2008, a total of 25 extended pulmonary resections (resection of the chest wall and diaphragm, vascular procedures, sleeve resections, pneumonectomies, atrial resections, and completion pneumonectomies) were performed on 250 patients undergoing 319 metastasectomy procedures. The extended resection group was analyzed in terms of disease-free interval, type of resection, operative morbidity, mortality, and survival and was then compared with patients who underwent lobar or sublobar resections. RESULTS: The extended resection group consisted of 14 male and 11 female patients. The mean disease-free interval was 36.02 (minimum 6, maximum 132) months. The extended resection rate was 10%. After 30 days, all patients were alive. For all extended metastasectomy groups, actuarial 5-year survival rates from the time of the extended metastasectomy were 16.3%. Mean survival times of patients who underwent extended resection and lobar or sublobar resection were 40 months (SD = 11) (95% confidence interval, 19-61) and 20 months (SD = 3) (95% confidence interval, 14-26), respectively. This difference was not statistically significant (P = 0.09) (Fig. 2). In the subgroup analysis, survival in the extended resections and lobar or sublobar resections groups was not statistically significant (osteosarcoma, P = 0.758; epithelial tumor, P = 0.11). CONCLUSIONS: Extended resections, which can be performed during pulmonary metastasectomies of patients with tumor-free surgical borders, may establish curative benefits, with low rates of mortality and morbidity.

Cardioprotective effects of erythropoietin in diabetic rats determined by CD34 and vascular endothelial growth factor levels.

INTRODUCTION: In this study, the effects of diabetes mellitus on the cardiovascular system were investigated by assessing the stem cell levels in serum and heart and compared with the normal population. Additionally, efficacy of erythropoietin, which is known to increase stem cells, was studied in diabetic rats. MATERIAL AND METHODS: Twenty-five male Sprague Dawley rats were divided into three groups as a control group (group 1), diabetic group (group 2) and erythropoietin induced diabetic group (group 3). A diabetes model was created with streptozocin. In group 3 rats received 3000 U/kg of erythropoietin. At the end of 1 month blood reticulocyte levels, degree of tissue fibrosis and immunohistochemical assessment of reliable stem cell markers, CD34 and vascular endothelial growth factor (VEGF), were analyzed. RESULTS: The increase in the blood glucose levels resulted in a significant decrease in reticulocyte levels in group 2. The increase in blood glucose levels resulted in a statistically significant increase in tissue level of fibrosis, CD34 and VEGF. When the rats in groups 1 and 2 were compared, the fibrosis, CD34 and VEGF levels were found to increase significantly. When group 2 and group 3 were compared, the amount of fibrosis was lower and the levels of CD34 and VEGF were significantly higher in group 3 than group 2. CONCLUSIONS: The results of our study indicated that the amount of CD34 and VEGF which function in cellular protection and tissue regeneration may be enhanced with safely applicable erythropoietin leading to increase in reticulocyte levels in serum, and CD34 and VEGF levels in right atrium, right ventricle, left atrium, and left ventricle as a protective mechanism in diabetic rats.

Learning curve in videothoracoscopic thymectomy: how many operations and in which situations?

OBJECTIVE: Videothoracoscopic learning curve is known to vary among different surgeons, and may be influenced by patients and various situations. We aimed to analyze the learning curve of a surgeon in videothoracoscopic thymic surgery for myasthenia gravis. METHODS: This is a descriptive single-center study using collected clinical data from 90 patients undergoing videothoracoscopic thymic surgery between June 2002 and September 2006. Cumulative summation (CUSUM) model was used to evaluate the learning curve for videothoracoscopic thymectomy operations. Unsuccessful situations were accepted as longer operation time, surgeon-related open conversions, readmissions and postoperative complications. Factors affecting longer operation time (patients with operation time longer than the average) and longer postoperative stay (patients with postoperative hospital stay longer than average) were analyzed. RESULTS: Body mass index (BMI) was the only predictor of longer operation time (23.04+/-2.93 vs 25.61+/-2.70 (p=0.001) independent samples test). The amount of prescribed pyridostigmine was the only factor for longer hospital stay (213.3+/-101.5 mg vs 270. 0+/-122.6 mg (p=0.044) Mann-Whitney U-test). CUSUM analysis demonstrated a learning curve with success rates of 80%, 90% and 98%, respectively in the first 30 patients, the next 31-60 patients and after 60 patients. Median operative time declined with surgeons' experience (p<0.001). CONCLUSIONS: A chest surgeon can have a high success rate in videothoracoscopic thymectomy (98%) after 60 operations.

Clinical Significance of the Glasgow Prognostic Score for Survival after Colorectal Cancer Surgery.

Glasgow prognostic score (GPS) has been found to be a useful tool in various cancer types. Our aim was to evaluate the significance of GPS in patients operated on for colorectal cancer (CRC). Patients with CRC who underwent radical resections between April 2010 and January 2015 were retrospectively evaluated. GPS was estimated based on the preoperative measurement of C-reactive protein and serum albumin levels. Data including demographics, laboratory and pathological parameters, surgical outcomes, and late-term follow-up results were analyzed. The study group of 115 patients consisted of 51 (44 %) women and 64 (56 %) men with a median age of 66 (range 32-91) years. The mean follow-up period was 20 (range 7-41) months. Tumor size and wound infection rates were significantly increased in patients with higher GPS (p = 0.019 and p = 0.003, respectively). According to multivariate analyses, CEA and GPS were found to be independent risk factors significantly effecting mortality (p = 0.001 and p = 0.009, respectively). At the end of the late-term follow-up period, it was detected that cancer-specific survival significantly decreased as the GPS increased (p = 0.016). The GPS is a significant prognostic factor in CRC and should be included in the routine preoperative assessment of all surgically treated CRC patients.

Incidental detection of prostate-specific antigen-negative metastatic prostate cancer initially presented with solitary pulmonary nodule on fluorodeoxyglucose positron emission tomography/computed tomography.

A 71-year-old male patient with solitary pulmonary nodule underwent fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) showing slightly increased FDG uptake in this nodule. In addition, PET/CT detected hypermetabolic sclerotic bone lesions in the right second rib and 7(th) thoracic vertebrae, which were interpreted as possible metastases, and mildly increased FDG uptake in the prostate gland highly suspicious of malignancy. The patient's prostate-specific antigen (PSA) level was within normal range (3.8 ng/dL). The histopathological examination of the lung nodule and right second rib lesion proved metastases from prostate cancer, then the prostate biopsy-confirmed prostate adenocarcinoma. The unique feature of this case is to emphasize the importance of performing PET/CT for solitary pulmonary nodule in detecting PSA-negative metastatic prostate cancer. This case indicated that it should be kept in mind that, even if the PSA is negative, a lung metastasis of prostate cancer may be an underlying cause in patients evaluated for solitary pulmonary nodule by FDG PET/CT.

Nontuberculous pulmonary cavitary diseases of childhood.

We describe the demographic, clinic and radiologic features of nontuberculous cavitary pulmonary diseases in 42 patients with a mean age of 91.1±6.8 months. Infectious etiology was the most common cause (64%), including necrotizing pneumonia (n=15), ruptured hydatid cyst (n=5), lung abscess (n=5) and fungal infection (n=2). Other causes were bronchiectasis, congenital anomalies, foreign body aspiration, sarcoidosis and tumor.

Causes of death within 1 year of resection for lung cancer. Early mortality after resection.

OBJECTIVES: Some of the lung cancer patients who are treated surgically with curative intent ultimately die in the early postoperative period. The aim of this study is to analyze the causes of death within 1 year of resection for lung cancer in our patients. METHODS: Six hundred and twenty patients, who underwent resection for lung cancer with a curative intent were reviewed retrospectively. Eighteen patients (2.9%) died due to postoperative complications or within the first month and 51 (8.4%) patients (group 1) died within the first year after operation. Fifty-one patients (group 1) were compared with the survivors (group 2) in terms of age, gender, preoperative FEV 1, pathological tumor node metastasis (TNM), histopathological subtypes, type of resection, completeness of the resection, preoperative Karnofsky performance status and application of postoperative radiotherapy. RESULTS: Pathological TNM (P<0.001) type of resection (P<0.01) histopathological subtype (P<0.001) completeness of the resection (P<0.05) and postoperative radiotherapy (P<0.001) were determined to be significant factors in mortality within 1 year after resection for lung cancer. CONCLUSIONS: The patients with pathological stage 3 disease, with large cell histology or who had undergone pneumonectomy have a higher risk of mortality within 1 year. These patients require detailed preoperative work up in terms of metastatic disease and cardiopulmonary physiological status.

Chest wall invasion in lung cancer patients.

This study was performed to assess the prognosis in patients with non-small cell lung cancer invading the chest wall. In this study, the data from 43 patients who were operated on between January 1990-January 1998, for non-small cell lung cancer with pathologically verified parietal pleural and chest wall invasion were retrospectively reviewed. The median and 3-year survival of the population was calculated to be 16.8 months and 34%. The pathologic stages were T3N0 in 31 (72.09%) patients, T3N1 in 5 (11.62%) and T3N2 in 7 (16.27%). The median survival of the T3N0M0 patients was 24 months but in the same T3 population with pathologically verified N1 and N2, the median survival was 7.4 months (p < 0.01). A complete resection was achieved in 37 (86.84%) patients. The median and 3-year survival of the patients with complete resection were 20.60 months and 41% respectively. In six patients, who had incomplete resection, median survival was noted to be 7.4 months. Patients who received adjuvant radiotherapy in the N2 positive group and the incomplete resection group, did not benefit (p > 0.05). The results of this study confirmed that the lung cancer patients with chest wall invasion had different survival curves. The survival of patients changed according to the completeness of the resection and lymphatic metastases of either N1 or N2.

Leiomyoma of the esophagus: open versus thoracoscopic enucleation.

BACKGROUND/AIM: To describe a novel, easy, and secure thoracoscopic surgical approach for esophageal leiomyomas. MATERIALS AND METHODS: We retrospectively analyzed 18 cases in which patients were treated at a single center between 1991 and 2011 for esophageal leiomyoma. We compared our results of patients who were treated by open surgery with those who were treated by the thoracoscopic approach, and we also compared our results with the results of resection of the leiomyoma of the esophagus in the literature. RESULTS: Eighteen patients were studied. Eight patients were treated with 3-port thoracoscopic surgery, 8 with open thoracotomy, 1 with surgical incision, and 1 with esophagectomy. The mean operating time was 167.5 min and 92.5 min in the thoracotomy and thoracoscopy groups, respectively (P = 0.0012). The average hospital stay was 9 days and 6 days for the thoracotomy and thoracoscopy groups, respectively (P = 0.016). Rupture of esophageal mucosa occurred preoperatively once in both groups and was repaired immediately, and postoperative esophageal leak was not seen in any patient. CONCLUSION: Thoracoscopic enucleation of esophageal leiomyomas is a safe and feasible procedure with decreased hospital stay and operating time. The 3-port technique that we used is a safe and effective procedure, as well.

Parameters That May Be Used for Predicting Failure during Endoscopic Retrograde Cholangiopancreatography.

Aim. Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used for the diagnosis and treatment of hepatic, biliary tract, and pancreatic disorders. However, failure during cannulation necessitates other interventions. The aim of this study was to establish parameters that can be used to predict failure during ERCP. Methods. A total of 5884 ERCP procedures performed on 5079 patients, between 1991 and 2006, were retrospectively evaluated. Results. Cannulation was possible in 4482 (88.2%) patients. For each one-year increase in age, the cannulation failure rate increased by 1.01-fold (P = 0.002). A history of previous hepatic biliary tract surgery caused the cannulation failure rate to decrease by 0.487-fold (P < 0.001). A tumor infiltrating the ampulla, the presence of pathology obstructing the gastrointestinal passage, and peptic ulcer increased the failure rate by 78-, 28-, and 3.47-fold, respectively (P < 0.001). Conclusions.Patient gender and duodenal diverticula do not influence the success of cannulation during ERCP. Billroth II and Roux-en-Y gastrojejunostomy surgeries, a benign or malignant obstruction of the gastrointestinal system, and duodenal ulcers decrease the cannulation success rate, whereas a history of previous hepatic biliary tract surgery increases it. Although all endoscopists had equal levels of experience, statistically significant differences were detected among them.

Endobronchial nocardiosis in an 11-year-old child.

Pulmonary nocardiosis is a rare infection and overwhelmingly limited to immunocompromised individuals. Endobronchial nocardiosis is even more rare. Nocardiosis is rarely seen in immunocompetent hosts mostly as cutaneous infection. Here we report an immunocompetent child with endobronchial nocardiosis presenting as nonresolving pneumonia and lung abscess. To our knowledge, this is the first case reported in the literature of endobronchial nocardiosis in a child.

Determination of standard number, size and weight of mediastinal lymph nodes in postmortem examinations: reflection on lung cancer surgery.

BACKGROUND: Mediastinal lymph node dissection is an essential component of lung cancer surgery. Literature lacks established information regarding the number and size of the healthy lymph nodes. In this postmortem autopsy study, we aim to define the number, size and weight of the lymph nodes in each mediastinal lymph node station. To implement the data for the clinical practice, we analyzed the possible number of nodes to be dissected in a systematic mediastinal lymph node dissection from the right and left sides during lung cancer surgery. METHODS: Sixty-two samples obtained from cadavers who did not die from chest malignancies, extrathoracic malignancies, any kind of infections or previous hospitalization before the death were included to the study. The locations of the nodes were recorded according to the American Thoracic Society Mediastinal Lymph Node Map. The number, size and weight of the nodes were determined at each station. RESULTS: Median age of the cadavers was 39 years. Primary causes of death were asphyxia in 10 (16.1%) subjects, trauma in 29 (46.8%) subjects, cardiovascular problems in 10 (16.1%) subjects, and undetermined in 13 (21%) subjects. The median number of lymph nodes resected from each patient was 23 (range: 11-54). The right sided paratracheal lymph nodes (Station 2R and 4R) were more frequent, heavier and longer than left sided lymph nodes (Station 2L and 4L) at the paratrecheal region. Right sided inferior mediastinal lymph nodes were heavier and longer than the left ones; however, their availability was more often on the left. CONCLUSIONS: The properties of mediastinal lymph nodes at particular stations are different for number, size and weight. Station 4R and 7 have the highest number of nodes followed by stations 5 and 6. We recommend removing the lymph nodes of these stations completely in lung cancer patients to rule out the possibility of micrometastatic disease. Diameter of normal lymph node may be 1 cm for the stations other than 4R and 7, but the definition of normal diameter of a lymph node at the stations 4R and 7 may be changed as 1,5 cm and 2,0 cm, respectively. Weight of the nodes may be a new subject to study and may be defined as a new modality to define a staging to be more accurate and the issue needs further investigations.

Management of sternal segment dislocation in a child with closed reduction.

Trauma may lead to sternal fracture or dislocation. Dislocation of a sternal segment in the childhood period is very rare as for sternal fractures in children. There are only six case reports regarding the issue in the literature. Additionally, there is not an established consensus for the treatment of the pathology. In this paper we present traumatic dislocation of a sternal body segment in a 10-year-old child who was successfully managed conservatively by closed reduction together with the review of the literature. Surgical treatment is not necessary especially in acute cases. Pathology may be treated with closed reduction. Callus formation usually supports the dislocated part of the sternum in time.

Aspirin: from a historical perspective.

Aspirin is one of the oldest medicines. Due to its wide range usage in different fields of medicine, we aimed to present the history, effects and different uses of aspirin in this review. Furthermore, recent patents of novel pharmaceutical interventions in the field of acetylsalicylic acid, expanding treatment options are presented. Literature search was performed in order to reach data and present information about aspirin from a historical perspective. Since its first use as a pain killer, aspirin has found a broad range of use in general medicine, cardiovascular medicine, neurology, obstetrics and gynecology, dentistry, gastroenterology, oncology with its different effects. Aspirin, a painkilling gift of history to mankind, with a history dating back to BC and various healing effects, promises to be of greater use in different fields of medicine with the light of recent studies, inspiring more research and gaining more popularity.

Leiomyoma of the extrapleural chest wall: an atypical location.

Tumours of the thoracic wall constitute a wide histological spectrum. However, the literature includes very few reports of a leiomyoma occurring at the extrapleural chest wall. In this report we present our experience together with a review of the literature. Our patient was a 33-year-old woman who was diagnosed with leiomyoma of the chest wall and treated accordingly and successfully. To the best of our knowledge, this is the seventh report in the literature defining the clinical entity.

Does a relationship exist between the number of thoracoscopic thymectomies performed and the learning curve for thoracoscopic resection of thymoma in patients with myasthenia gravis?

This study aimed to analyze surgeons' learning curve for thymoma resection with video-assisted thoracoscopic surgery (VATS). Two hundred and eleven myasthenia gravis patients had VATS thymic resections, including 25 patients with a thymoma. Three groups of surgeries, according to the order of operations, were analyzed: Group A comprised the first 70 thymectomies, Group B comprised the second 70 thymectomies, and Group C comprised the final 71 thymectomies. We compared the groups on a set of preoperative (age, gender, body mass index, and Osserman stage), operative (number in each group, size, and Masaoka stage), and postoperative (complications and length of stay) variables. A significant difference was observed in the number of thymoma operations (Group A: four patients, Group B: seven patients, and Group C: 14 patients; P: 0.031) and the duration of operation (Group A: 66 min, Group B: 52 min, and Group C: 48 min; P: 0.024). A strong correlation was found between the duration of operation and order of patients (Pearson r: -0.554, P: 0.000). We recommend the start of a program for the resection of thymoma with VATS after surgical staff have performed 70 VATS thymectomy operations.