Comparison of intraoperative and post-operative effects of serratus anterior plane block performed with ultrasound and infiltration block in patients undergoing video-assisted thoracoscopic surgery.

OBJECTIVES: We aimed to compare the intraoperative and post-operative analgesic activities of the preventive applied serratus anterior plane (SAP) block and infiltration block in patients undergoing video-assisted thoracoscopic surgery (VATS). METHODS: The study was carried out in 60 patients aged between 18 and 80 who were eligible for elective VATS, with the American Society of Anesthesiologists classification I-II, following ethical committee approval and written informed consent form. Patients were divided into two groups as SAP (group serratus anterior plane block [SAPB]) and group infiltration block after routine monitoring and general anesthesia induction by recording demographic data after randomization. Hemodynamic data of all patients were recorded before, after induction and within intraoperative 30 min period. Patient controlled analgesia (PCA) prepared with morphine was applied to all patients postoperatively. Intraoperative hemodynamic data and opioid consumption of patients, resting time, and coughing visual analog scale, time to first PCA dose, post-operative opioid consumption, rescue analgesic requirement, mobilization times, opioid side effects, and patient and surgical team's satisfaction were evaluated. RESULTS: Intraoperative hemodynamic data and opioid consumption were similar between the two groups. Post-operative pain scores (0 and 30 min, 1, 2, 4, 8, and 12 h) were lower in the SAPB group (p<0.005) and time to use the first PCA (p=0.002) was longer in the SAPB group. Post-operative PCA and rescue analgesic requirement were lower in the SAPB group (p=0.002, p=0.00). It was found that the first mobilization time was shorter in the SAPB group (p=0.003), and opioid-related side effects were similar in both groups (p=0.067). Patient and surgical team satisfaction was high in the SAPB group (p=0.004, p=0.000). CONCLUSION: As a result, more effective post-operative analgesia was provided with preventively SAPB, compared to infiltration block in patients undergoing VATS.

Leptomeningeal pneumocephalus and pneumorrhachis: Signs of pneumothorax in case of syringopleural shunting.

In this article, we present a case of leptomeningeal pneumocephalus and pneumorrhachis secondary to pneumothorax that occurred six years after syringopleural shunting.

Intercostal Nerve Reconstruction for Severe Compensatory Hyperhidrosis: The Gebitekin Technique.

Compensatory sweating (CS) is the most common and disabling complication of endoscopic thoracic sympathectomy and represents an unmet clinical challenge. Our surgical hypothesis is to generate a parallel pathway to the damaged part of the sympathetic nerve, similar to the Kuntz nerve, by reconstructing the 2 healthy intercostal nerves, thus treating CS. Here, we present a novel videothoracoscopic technique involving bilateral intercostal nerve reconstruction in patients with severe CS after endoscopic thoracic sympathectomy.

Lung Cancer Surgery in Patients With a History of Coronary Artery Bypass Graft: A Multicentre Study.

BACKGROUND: Lung cancer surgery may be required for patients with a history of coronary artery bypass graft (CABG). In this study, we evaluated the general characteristics of patients, the difficulties experienced during and after lung cancer surgery and complications and mortality rates. METHOD: Patients who were operated on for primary lung cancer between January 2012 and July 2017 in the participating centres were analysed retrospectively (n=7,530). Patients with a history of CABG (n=220) were examined in detail. This special group was analysed and compared with other patients operated on for lung cancer who did not have CABG (n=7,310) in terms of 30-day mortality and revision for haemorrhage. RESULTS: Of the 7,530 patients operated on for primary lung cancer, 2.9% were found to have undergone CABG. Surgical revision was required in the early postoperative period for 6.8% of those who had CABG and 3.5% in those who did not have CABG (p=0.009). Thirty-day (30-day) mortality was 4.5% in those who had CABG and 2.9% in those who did not have CABG (p=0.143). Further analysis of patients who had undergone CABG demonstrated that video-assisted thoracoscopic surgery (VATS) resulted in fewer complications (p=0.015). Patients with a left-sided left internal mammary artery (LIMA) graft had a higher number of postoperative complications (p=0.30). CONCLUSIONS: Patients who had CABG suffered postoperative haemorrhage requiring a revision twice as often, and a tendency towards higher mortality (non-statistically significant). In patients with a history of CABG, VATS was demonstrated to have fewer complications. Patients with a LIMA graft who had a left-sided resection had more postoperative complications.

Comparison of survival results of patients with T0 and T1-2-3 in pathological T staging in patients with non-small cell lung cancer who underwent surgery after neoadjuvant treatment.

AIM: In this study, we aimed to compare the survival results of patients who underwent neoadjuvant treatment with NSCLC between March 1997 and August 2014 and were found to have T0N0 and T1-2-3/N0. MATERIAL AND METHODS: A hundred ninety-five patients who had complete neoadjuvant therapy, complete lung resection and lymph node dissection, and pathologically diagnosed as T0 or T1-2-3/N0, M0 were included in the study. RESULTS: Of the 195 patients included in the study, 181 were male, 14 were female and the mean age of the patients was 57.9. The mean age of the groups was as follows: group 1: 58.1, group 2: 57.7, group 3: 59.7 and group 4: 56.8. In our series the most common complication was atelectasis (n = 19). Others were prolonged air leak (n = 16), pneumonia (n = 12), apical pleural space (n = 6), wound infection (n = 3), cardiac problems (n = 3), hematoma (n = 3), bronchopleural fistula (n = 3), empyema (n = 2), chylothorax (n = 1). The 5-year survival rate for patients in the T0N0 group was 76.3%. This rate was 71.8% in group 2, 63.6% in group 3 and 44.1% in group 4. CONCLUSIONS: Survival was found to be better in patients who underwent surgery after neoadjuvant therapy and had a complete pathological response. We believe that we can provide better results with the increase in the number of cases detected as TxN0 after the neoadjuvant treatment and prolongation of the follow-up period.

Electrophysiological evaluation of efficacy of clipping in thoracic sympathectomy: An experimental cadaveric study.

BACKGROUND: This study aims to examine the efficacy of clipping in thoracic sympathectomy based on electrophysiological evaluation and to investigate whether nerve conduction can be formed by collateral nerve extensions as a result of the clipping procedure to different levels of sympathetic nerve. METHODS: Newly sacrificed six sheep hemithoraces were studied between August 2016 and October 2016. Thoracic sympathectomy was performed by clipping at T2, T3, T4, and T5 sympathetic chain levels and their branches. Electrophysiological studies were performed with an electromyography device and the filter range was 1 Hz with 20 µV/D amplification. Signals were processed digitally; bipolar subdermal needle electrodes were used as stimulation and recording electrodes (Ø 0.75 mm); and the ground electrode was placed in the intercostal muscle where the thoracic sympathectomy procedure would be performed. RESULTS: Electrophysiological evaluations showed that clips placed on the main sympathetic chain branches and sympathetic nerve trunk prevented collateral impulse conduction and stimulated potentials were not recorded. However, sympathetic conduction continued at the same intensity after removal of the clips. CONCLUSION: Clipping of different regions of the sympathetic nerve provides electrophysiological blockage of the sympathetic nerve, and conduction continues after removal of the clips. However, the shortand long-term postoperative electrophysiological results after removal of the clips over the sympathetic nerve is still a question mark.

Bronchial Carcinoid Tumors with Massive Osseous Metaplasia: A Case Report and Review of the Literature.

Bronchial carcinoid tumors are primary lung neoplasms thought to originate from neuroendocrine cells, i.e. Kulchitsky cells, in the bronchial mucosa, although the type of cellular origin has not been clearly understood. A 61-year-old male patient underwent surgery and microscopic examination of the specimen revealed an anastomosing trabecular bony structure among the nests of tumor cells with round nucleus, granular chromatin, and large eosinophilic cytoplasm. Our case has been deemed worthy of being presented as bronchial carcinoid tumor with exaggerated osseous metaplasia.

Pathological complete response after neoadjuvant/induction treatment: where is its place in the lung cancer staging system?†.

OBJECTIVES: Prognosis for patients with non-small-cell lung cancer (NSCLC) who, after neoadjuvant/induction and surgery, have a pathological complete response (pCR) is expected to be improved. However, the place of the pCR patients in the context of the tumour, lymph node and metastasis (TNM) staging system is still not defined. The aim of this study is to investigate the long-term survival of NSCLC patients with pCR and to find their appropriate staging category within the TNM staging system. METHODS: We retrospectively reviewed the prospectively recorded data of 1076 patients undergoing surgery (segmentectomy or more) for NSCLC between 1996 and 2016. Patients were divided into 2 groups. Group 1: clinical early-stage patients who underwent direct surgical resection (n = 660); group 2: patients who received neoadjuvant/induction treatment before surgical resection for locally advanced NSCLC (n = 416). Morbidity, mortality, survival rates and prognostic factors were analysed and compared. RESULTS: Postoperative histopathological evaluation revealed pCR in 72 (17%) patients in group 2. Overall 5-year survival was 58.7% (group 1 = 62.3%, group 2 = 52.8%, P = 0.001). Of note, 5-year survival was 72.2% for pCRs. In addition, 5-year survival for stage 1a disease was 82.6% in group 1 and 63.2% in group 2 (P = 0.008); 70.3% in group 1 and 60.5% in group 2 for stage 1b (P = 0.08). Patients with stage II had a 5-year survival of 53.9% in group 1 and 51.1% in group 2 (P = 0.36). CONCLUSIONS: This study shows that patients with locally advanced NSCLC developing a pCR after neoadjuvant/induction treatment have the best long-term survival and survival similar that of to stage Ib patients.

Thymic tumors and results of radiotherapy.

AIM: The aim of this study was to evaluate thymic epithelial tumors (TETs) for treatment outcomes and prognostic factors on survival. BACKGROUND: TETs are very rare neoplasms and multidisciplinary approach is recommended according to prognostic factors. MATERIALS AND METHODS: Between 1995 and 2013, 31 patients were treated with median 5400 cGy (range: 1620-6596 cGy) radiotherapy (RT). Eleven patients received adjuvant or concurrent chemotherapy. There were 25 thymomas, 4 thymic carcinomas and 2 thymic neuroendocrin carcinomas. According to Masaoka, staging and WHO classification, cases were divided to good (n: 10), moderate (n: 9) and poor (n: 12) prognostic risk groups. Survival was calculated from diagnosis. RESULTS: In January 2016, 22 cases were alive with median 51.5 months (range: 2-170.5) follow-up. Recurrences were observed in 29% of patients in median 29.5 months (range: 6.5-105). Local control, mean overall (OS) and disease-free survival (DFS) rates were 86%, 119 and 116 months, respectively. There was a significant difference for R0 vs. R+ resection (81% vs. 43%, p = 0.06, and 69% vs. 46%, p = 0.05), Masaoka stage I-II vs. III-IV (75% vs. 52%, p = 0.001, and 75% vs. 37%, p < 0.001), and also prognostic risk groups (100% vs. 89% vs. 48%, p = 0.003, and 100% vs. 87% vs. 27%, p = 0.004) in terms of 5-year OS and DFS, respectively. CONCLUSION: In our study, prognostic risk stratification was shown to be a significant predictor of survival. There is a need to investigate subgroups that may or may not benefit from adjuvant RT.

The success of surgery in the first 24 hours in patients with esophageal perforation.

OBJECTIVE: Esophageal perforation (EP) is a critical and potentially life-threatening condition with considerable rates of morbidity and mortality. Despite many advances in thoracic surgery, the management of patients with EP is still controversial. MATERIALS AND METHODS: We retrospectively reviewed 34 patients treated for EP, 62% male, mean age 53.9 years. Sixty-two percent of the EPs were iatrogenic. Spontaneous and traumatic EP rates were 26% and 6%, respectively. Three patients had EP in the cervical esophagus and 31 in the thoracic esophagus. RESULTS: Mean time to initial treatment was 34.2 hours. Twenty patients comprised the early group <24 h) and 14 patients the late group (>24 h). Management of the EP included primary closure in 30 patients, non-surgical treatment in two, stent in one and resection in one. Mortality occurred in nine of the 34 patients (26%). Mortality was EP-related in four patients. Three of the nine patients that died were in the early group (p<0.05). Mean hospital stay was 13.4 days. CONCLUSION: EP remains a potentially fatal condition and requires early diagnosis and accurate treatment to prevent the morbidity and mortality.

Can Thoracic Sympathetic Nerve Damage Be Reversed?

BACKGROUND: Function of the thoracic sympathetic chain (TSC) reportedly recovers after surgical clips are removed. Hence, this study was designed to study nerve regeneration after unclipping the TSC. METHODS: The bilateral TSCs of six goats were studied; the goats were separated into three groups (groups I, II, and III) during excision, clipping, and unclipping. During surgery, the TSCs were excised with a scalpel in group I and clipped in groups II and III. In group III, the clips were removed 1 month postoperatively and observed for possible nerve healing for 1 month. All TSCs were examined histologically following en block resection at 1 month postoperatively in groups I and II and at 2 months postoperatively in group III. RESULTS: Inflammation in nerve sections was noted following clip removal. Furthermore, there was significant degeneration and cell infiltration in the nerve fibers of the clipped regions. The Schwann cells around the peripheral nerve endings in the unclipped regions facilitated nerve transmission by reconstitution of myelin. CONCLUSION: Clipping the TSC can cause histologic degeneration; however, histologic nerve regeneration occurs after unclipping.

Molecular markers for patients with thymic malignancies: not feasible at present?

BACKGROUND: Thymomas and thymic carcinomas are rare malignancies and devising clinically effective molecular targeted therapies is a major clinical challenge. The aim of the study was to analyze BLC2 and vascular endothelial growth factor receptor (VEGFR) expression and KRAS and EGFR mutational status and to correlate them with the clinical characteristics of patients with thymomas and thymic carcinomas. MATERIALS AND METHODS: A total of 62 patients (mean age: 50.4 ± 13.2 years) with thymomas and thymic carcinomas were enrolled. The expression of BLC2 and VEGFR in tumor cells and normal tissues was evaluated by RT-PCR. The mutational status of the KRAS and EGFR genes was investigated by PCR with sequence specific primers. RESULTS: The BLC2 and VEGFR expression levels did not differ significantly between tumor and normal tissues. Moreover, there were no clearly pathogenic mutations in KRAS or EGFR genes in any tumor. None of the molecular markers were significantly related to clinical outcomes. CONCLUSIONS: Changes in levels of expression of BLC2 and VEGFR do not appear to be involved in thymic tumorigenesis. Moreover, our data suggest that KRAS and EGFR mutations do not play a major role in the pathogenesis of thymomas and thymic carcinomas.

Clinical outcomes of lung metastasectomy in patients with colorectal cancer.

AIM: To investigate prognostic factors of survival following curative, non-palliative surgical removal of lung metastases secondary to colorectal cancer (CRC). METHODS: Between 1999 and 2009, a radical metastasectomy with curative intent was performed on lung metastases in 21 patients with CRC (15 male and 6 female; mean age: 57.4 ± 11.8 years; age range: 29-74 years) who had already undergone primary tumour resection. RESULTS: The mean number of lung metastases ranged from one to five. The mean overall survival was 71 ± 35 mo (median: 25 mo). After adjusting for potential confounders, multivariable Cox regression analyses predicted only the number of lung metastases (1 vs ≥ 2; hazard ratio: 7.60, 95% confidence interval: 1.18-17.2, P = 0.03) as an independent predictor of poor survival following lung resection for metastatic CRC. CONCLUSION: Resection of lung metastases is a safe and effective treatment in selected CRC patients with single lung metastases.

Pericardial cysts: an analysis of 12 cases.

BACKGROUND: Pericardial cysts are usually asymtomatic, benign, congenital mediastinal lesions but may also be acquired after cardiothoracic surgery. The purpose of the study was to evaluate surgical approach and results of our experience with pericardial cysts. PATIENTS AND METHODS: A total of 12 patients who had undergone surgical treatment for pericardial cyst between February 1999 and August 2010 were retrospectively evaluated. All patients were analyzed according to the symptoms, method for the diagnosis, cyst location, management, and outcomes. RESULTS: The mean age was 50.4±17 years (range, 23-68 years) with a female-to-male ratio of 8:4. Pericardial cyst were located in the right hemithorax in 8 (67%) patients and left hemithorax in 4 (33%) patients. The cysts were resected by thoracotomy in 4 (33%) patients and by video-assisted thoracic surgery in 8 (67%) patients. There was an excellent long-term follow-up with no morbidity or mortality. CONCLUSION: Videothoracoscopic surgical removal of pericardial cysts is an excellent surgical intervention without serious morbidity and mortality.

Rib approximation without intercostal nerve compression reduces post-thoracotomy pain: a prospective randomized study.

OBJECTIVE: One of the most important considerations in the care of thoracic surgery patients is the control of pain, which leads to increased morbidity and relevant mortality. METHODS: Between February and May 2009, 60 patients undergoing full muscle-sparing posterior minithoracotomy were prospectively randomized into two groups, according to the thoracotomy closure techniques. In the first group (group A), two holes were drilled into the sixth rib using a hand perforator, and sutures were passed through the holes in the sixth rib and were circled from the upper edge of the fifth rib, thereby compressing the intercostal nerve underneath the fifth rib. In the second group (group B), the intercostal muscle underneath the fifth rib was partially dissected along with the intercostal nerve, corresponding to the holes on the sixth rib. Two 1/0 polyglactin (Vicyrl) sutures were passed through the holes in the sixth rib and above the intercostal nerve. RESULTS: There were 30 patients in each group. The visual analog score, observer verbal ranking scale (OVRS) scores for pain, and Ramsay sedation scores were used to follow-up on postoperative analgesia and sedation. The von Frey hair test was used to evaluate hyperalgesia of the patients. The patients in group B had lower visual analog scores at rest and during coughing. The patients in group B had lower OVRS scores than group A patients. The groups were not statistically different in terms of the Ramsay sedation scores and von Frey hair tests. CONCLUSIONS: Thoracotomy closure by a technique that avoids intercostal nerve compression significantly decreases post-thoracotomy pain.

[Therapeutic approach in hemodynamically stable transmediastinal gunshot wounds]. / Hemodinamisi stabil transmediastinal atesli silah yaralanmalarinda tedavi yaklasimi.

Transmediastinal gunshot wounds may result in damage to the heart, large blood vessels, esophagus or lung. In hemodynamically stable patients, diagnostic examinations have critical importance and the preferred therapies still have unresolved points. In this paper, we present our experience with five patients, three of whom were operated for transmediastinal gunshot wounds after diagnostic tests; all were hemodynamically stable. Before deciding on operation, diagnostic tests should be performed in hemodynamically stable patients with transmediastinal gunshot wounds.

[Thoracoscopic bullectomy and pleural abrasion in the treatment of primary spontaneous pneumothorax]. / Primer spontan pnömotoraks tedavisinde torakoskopik büllektomi ve plevral abrazyon.

Although spontaneous pneumothorax is the most common problem seen by the thoracic surgeon, there is no universal agreement in its management. Thoracoscopic bullectomy is preferred to open bullectomy because of minimal trauma, less pain, early recovery and discharge with comparable results. Seventy thoracoscopic bullectomy and apical pleural abrasion in 65 patients with spontaneous pneumothorax were retrospectively reviewed. All but 8 (13%) patients were male with a mean age of 24 years (range 17-55). Only the patients who had a prolonged air leak (> 4 days), reccurence/bilateral pneumothorax occupational reasons and bilateral pneumothorax were the indications for surgical treatment. The patients who had conversion to open thoracotomy were not included in the study. Computerized tomography was performed in all cases prior to the surgery. Endo-GIA 45-60 mm (4.8) staplers (Auto Suture, Tyco, USA) were used for bullectomy using three port access. The apical pleural abrasion following thoracoscopic bullectomy was performed in all cases. One patient developed haematoma on the first postoperative day and underwent open thoracotomy and evacuation of the haematoma. The median hospital stay was 3 (1-11) days. Recurrent pneumothorax was observed in 5 (7.1%) patients. Although thoracoscopic bullectomy is an expensive procedure that requires experience, however reduced pain, shorter hospital stay and early recovery makes it preferred method in such cases.

Pleurovenous shunt for treating refractory benign pleural effusion.

We report the case of a 63-year-old female with hepatic cirrhosis due to chronic hepatitis C, successfully treated for refractory nonmalignant hepatic hydrothorax by using a long-term pleurovenous shunt (PVS). After failure of conventional treatment by mechanical pleurodesis, a PVS was inserted to drain the pleural fluid into the right subclavian vein. After 8 months of follow-up, the effusion is well controlled, and the shunt remains patent.