Spontaneous pneumothorax in the elderly: a sign of a malignancy?

BACKGROUND: Spontaneous pneumothorax usually occurs as a result of rupture of a subpleural bleb or emphysematous bulla. Spontaneous pneumothorax, which is more common in younger age groups, might be the first sign of pulmonary malignancy, especially when it manifests in older patients. METHODS: Data of all patients who were treated for spontaneous pneumothorax in our clinic between June 2013 and June 2017 were examined retrospectively. The demographic characteristics, diagnostic methods, pathologic subtypes, and treatment protocols applied in patients diagnosed with malignancy during the treatment period were investigated. RESULTS: Out of 1187 patients, 9 (0.8%) had incidental pulmonary malignancies. Metastatic lung cancer was detected in 2 of 9 patients, while primary lung cancer was detected in the other 7. Six patients were operated on and the other 3 were referred for oncologic treatment for various reasons. CONCLUSIONS: We suggest that cases of spontaneous pneumothorax in advanced age should be evaluated in a more detailed fashion, and further investigations should be carried out with suspicion of an underlying pulmonary malignancy.

Thoracoscopic Diagnosis of Follicular Lymphoma Relapsing after 13 Years.

Relapse in lymphoproliferative malignancies is not an exceptional entity and generally occurs within the first 2 or 3 years following the primary treatment. Lymph node biopsy is essential for the diagnosis of relapse and treatment. A 64-years-old woman was referred to our clinic for back pain and dyspnea. Chest X-ray and computed tomography (CT) showed pleural thickening in the right hemithorax and pleural effusion. Hereby, we report a patient with a history of follicular lymphoma treatment 13 years ago, presenting with unilateral pleural effusion and being diagnosed, unpredictably, with relapsing lymphoma by video-assisted thoracoscopic surgery pleural biopsy.

Results of surgical resection in lung cancer with synchronous brain metastasis.

BACKGROUND: This study aims to investigate the factors affecting the survival of operated non-small cell lung cancer patients with synchronous brain metastasis. METHODS: Clinical outcomes of a total of 16 patients (14 males, 2 females; mean age 60 years; range, 41 to 71 years) who were diagnosed with non-small cell lung cancer and concomitant solitary/oligo brain metastasis and who underwent an intervention primarily for cranium, followed by lung resection in our clinic between January 2012 and January 2016 were retrospectively analyzed. Cranial surgery or gamma-knife radiosurgery was performed in the treatment of brain metastases. RESULTS: Twelve patients with solitary brain metastasis underwent cranial surgery, while four patients with solitary/oligo metastases underwent gamma-knife radiosurgery prior to pulmonary resection. Definitive pathological examination revealed adenocarcinoma in 13 patients and squamous-cell lung carcinoma in three patients. Mean survival time was 15.3±8.6 months. One-year and two-year survival rates were 56.2% and 32%, respectively. The number of brain metastases, treatment type, tumor cell type, resection type, and status of lymph nodes were not statistically significantly associated with survival (p>0.05). CONCLUSION: Cranial surgery or gamma-knife radiosurgery followed by aggressive lung resection can be effectively applied in selected non-small cell lung cancer patients with synchronous brain metastasis. However, the suitability of the primary tumor and brain metastases for complete resection is of utmost importance in patient selection.

Factors affecting complication rates of pneumonectomy in destroyed lung.

BACKGROUND: This study aims to investigate the relationship between characteristics of patients who were performed pneumonectomy for destroyed lung and their surgical procedures with postoperative complications. METHODS: Thirty-nine patients (19 males, 20 females; mean age 35 years; range, 6 to 71 years) who were performed pneumonectomy with a diagnosis of destroyed lung between February 2007 and October 2014 were retrospectively evaluated. Patients were divided into two as those who did not develop any postoperative complication (group 1) and those who developed a postoperative complication (group 2). Patients' characteristics and details of the surgical procedures were compared between the two groups. RESULTS: Twenty-nine patients (74%) were performed left pneumonectomy. Mean duration of hospital stay was nine days. During the postoperative three-month follow-up period, morbidity and mortality were reported for 13 patients (33.3%) and one patient (2.6%), respectively. No significant difference was found between groups 1 and 2 in terms of age, gender, concomitant diseases, spirometric findings, blood transfusion status, surgical resection width or methods of bronchial stump closure. CONCLUSION: Low albumin levels increased the risk of developing postoperative complications in patients who were performed surgical resection for destroyed lung. Postpneumonectomy morbidity and mortality rates were at acceptable levels. Pneumonectomy should not be avoided as surgical treatment in eligible patients with destroyed lung.

The efficacy and economical benefits of blood patch pleurodesis in secondary spontaneous pneumothorax patients.

INTRODUCTION: Prolonged air leak in secondary spontaneous pneumothorax (SSP) patients remains one of the biggest challenges for thoracic surgeons. This study investigates the feasibility, effectiveness, clinical outcomes, and economical benefits of the autologous blood patch pleurodesis method in SSP. MATERIAL AND METHODS: First-episode SSP patients undergoing autologous blood patch pleurodesis for resistant air leak following underwater-seal thoracostomy, between January 2010 and June 2013 were taken into the study. Timing and success rate of pleurodesis, recurrence, additional intervention, hospital length of stay, and complications that occurred during follow-up were examined from medical records, retrospectively. RESULTS: Thirty-one (27 male, 4 female) SSP patients with expanded lungs on chest X-ray and resistant air leak on the 3(rd) post-interventional day were enrolled. Mean age was 53.7 ± 18.9 years (range: 23-81). Twenty-four patients were treated with tube thoracostomy, 2 with pezzer drain, and 5 with 8 F pleural catheter. 96.8% success was achieved; air leak in 29 of 31 patients (93.5%) ceased within the first 24 hours. No procedure-related complication such as fever, pain or empyema was seen. Late pneumothorax recurrence occurred in 4 (12.9%) patients; 1 treated with talc pleurodesis where the other 3 necessitated surgical intervention. CONCLUSIONS: Autologous blood patch pleurodesis is a safe, effective, and easily performed procedure with no need of any additional equipment or extra cost. This method can be applied to all patients with radiologically expanded lungs and continuous air leak after 48 hours following water-seal drainage thoracostomy, to reduce hospital stay duration, unnecessary surgical interventions, and the expenses.

Is single port enough in minimally surgery for pneumothorax?

BACKGROUND: Video-assisted thoracoscopic surgery is a widespread used procedure for treatment of primary spontaneous pneumothorax patients. In this study, the adaptation of single-port video-assisted thoracoscopic surgery approach to primary spontaneous pneumothorax patients necessitating surgical treatment, with its pros and cons over the traditional two- or three-port approaches are examined. METHODS: Between January 2011 and August 2013, 146 primary spontaneous pneumothorax patients suitable for surgical treatment are evaluated prospectively. Indications for surgery included prolonged air leak, recurrent pneumothorax, or abnormal findings on radiological examinations. Visual analog scale and patient satisfaction scale score were utilized. RESULTS: Forty triple-port, 69 double-port, and 37 single-port operations were performed. Mean age of 146 (126 male, 20 female) patients was 27.1 ± 16.4 (range 15-42). Mean operation duration was 63.59 ± 26 min; 61.7 for single, 64.2 for double, and 63.8 min for triple-port approaches. Total drainage was lower in the single-port group than the multi-port groups (P = 0.001). No conversion to open thoracotomy or 30-day hospital mortality was seen in our group. No recurrence was seen in single-port group on follow-up period. Visual analog scale scores on postoperative 24th, 48th, and 72nd hours were 3.42 ± 0.94, 2.46 ± 0.81, 1.96 ± 0.59 in the single-port group; significantly lower than the other groups (P = 0.011, P = 0.014, and P = 0.042, respectively). Patient satisfaction scale scores of patients in the single-port group on 24th and 48th hours were 1.90 ± 0.71 and 2.36 ± 0.62, respectively, indicating a significantly better score than the other two groups (P = 0.038 and P = 0.046). CONCLUSIONS: This study confirms the competency of single-port procedure in first-line surgical treatment of primary spontaneous pneumothorax.

Pulmonary resection in the treatment of life-threatening hemoptysis.

PURPOSE: Massive hemoptysis is a life threatening situation with high mortality rates. Surgery is effective, however generally an avoided treatment. We report our experience with patients undergoing lung resection for life-threatening hemoptysis. METHODS: Records of all surgically treated patients for hemoptysis between June 2009 and June 2012 were reviewed and analyzed retrospectively. RESULTS: Anatomical resection was performed on 31 (15.3%) patients out of 203 patients referred to our intensive care unit for life-threatening hemoptysis. 25 (80.6%) were male and six (19.4%) were female; with mean age of 46.4 ± 13.7 (21-77). Pneumonectomy was performed in four (12.9%), lobectomy in 24 (77.4%), segmentectomy in two (6.5%) and bilobectomy in one case. Postoperative complications developed in eight (25.8%), and mortality was observed in two (6.5%) patients. Etiology was bronchiectasis in 13 (42.0%), tuberculosis in eight (25.8%), carcinoma in four (12.9%), aspergilloma in four (12.9%), hydatid cyst in one (3.2%) and lung abscess in one (3.2%) of the cases. CONCLUSIONS: Although lung resection in the treatment of massive hemoptysis is accompanied with high morbidity and mortality rates, surgery is the only permanent curative modality. Acceptable results can be achived in the company of a multidisciplinary approach, through avoidance of pneumonectomy and urgent surgery.

One-port videothoracoscopic surgical intervention.

BACKGROUND: One-port video-assisted thoracic surgery (VATS) has recently been proposed as an alternative to conventional 3-port VATS. To reduce pain, chest wall paresthesia, and hospital stay, lesser ports are the current direction. MATERIALS AND METHODS: From 2007 to 2010, 98 patients underwent 1-port VATS procedure. The charts were retrospectively evaluated. A 2.5 cm long incision was made at the sixth intercostal space in the median axillary line. A single flexible port was used. Both the camera and the endoinstruments were introduced through the port. Patient characteristics, visual analog score, and postoperative paresthesia scores were evaluated. RESULTS: The study enrolled 38 women and 60 men with the mean age of 49.1±1.5 years (range, 19 to 75 y). Thirty-one patients (28.6%) were diagnosed with malignant pleural effusion. Perioperative pleurodesis with talc was performed in 81% of them. One-port VATS approach was used for pleura biopsies in 77 (78.6%), wedge resection in 4 (3.8%), pleurectomy in 13 (12.4%), and biopsy with talc chemical pleurodesis in 4 (3.8%) instances. The mean operation time was 24.4 minutes (range, 15 to 50 min). No major cardiorespiratory or surgical complications were noted. The median observation time was 60 months (range, 36±81 mo). Among benign pathology patients, 56 (82.3%) of them did not complain about any pain; however, 12 patients had prolonged discomfort (2 pinprick, 6 numbness, and 4 pruritus). CONCLUSIONS: One-port VATS in selected patients are feasible and seems to be safe in thoracic surgical interventions instead of conventional 3 ports that was presented in this series.

Are the 18F-FDG positron emission tomography/computed tomography findings in bronchopulmonary carcinoid tumors different than expected?

Bronchopulmonary carcinoid tumors (BPCT) are known as low malignity tumors. Different surgical methods are therapeutically used, ranging from simple excision of the mass to large regional resections. Also, the role of positron emission tomography in the diagnosis and staging of BPCT is controversial as false negative results has been reported in literature. Our aim was to study the diagnostic value of fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) and the therapeutic effect of specific surgical treatment on BPCT. We studied retrospectively from 2005 to 2011 75 cases of BPCT. Preoperative investigations included computerized tomography (CT), bronchoscopy and 18F-FDG PET. Statistical comparisons were performed based on tumor type, extent of the resection and the standardized uptake value (SUV). Fifty six cases were typical, 15 atypical and 4 oncocytic (a subtype of typical carcinoid). Of these patients, 27 (17 with typical, 8 with atypical and 2 with oncocytic carcinoid) had undergone a 18F-FDG PET scan. Operatory mortality was 0%, while the 7 years survival rate amounted to 97.5%. No recurrences were seen. Mean SUV was 5.28 for typical and 5.08 for atypical BPCT. The oncocytic type exhibited a particularly high SUV. In conclusion, our study, contrary to the findings of others, showed that the 18F-FDG uptake of BPCT was similar to that of malignant diseases. Aggressive surgical treatment resulted in a very good prognosis for these carcinoid tumors.

Video-assisted thoracoscopic removal of pulmonary hydatid cysts.

OBJECTIVES: Pulmonary hydatid disease is a parasitic disease with a high prevalence in low-middle income countries. We report four patients who were treated surgically using video-assisted thoracoscopy (VATS). METHODS: All patients were diagnosed with clinical and radiological findings on chest X-ray and computed tomography. Complete thoracoscopic removal by cystotomy and capitonnage was done in all four patients. The procedure included a standard thoracoscopy port incision and a 2-3 cm utility skin incision that was placed just superior to the cystic lesion. In the first case, a small-sized rib separator was used. The following three cases were operated without placing a rib separator on the utility incision. Conversion to open thoracotomy was not required. RESULTS: The average duration of the procedure was 90 min, and the average length of hospital stay was 4 days. No complications were observed after the thoracoscopic removal. At mean follow-up of 4 months, all patients were asymptomatic. CONCLUSIONS: VATS removal of the hydatid cysts can be done successfully in peripherally located cysts.

Pneumonectomy in children for destroyed lung: evaluation of 18 cases.

BACKGROUND: Destroyed lung is an uncommon condition; it describes a nonfunctional lung and is most often caused by inflammatory diseases. Surgical resection is used to resolve or prevent complications and improve quality of life. We reviewed our experience in surgery for destroyed lung in children. METHODS: The records of 18 children aged 16 years and younger who had undergone pneumonectomy for destroyed lung between 1991 and 2007 were analyzed retrospectively. RESULTS: Eighteen children, 10 males (55.5%) and 8 females, aged 5 to 16 years, with a mean age of 12.3 underwent pneumonectomy. Cough was the major presenting symptom (n = 18, 100%). The median preoperative period for symptoms was 6 years. Radiologic diagnostic methods included chest radiograph, computed tomography, bronchoscopy, and bronchography. Bronchiectasis (n = 13), tuberculosis (n = 4), and aspergillosis (n = 1) were the main pathologies. Five patients had tuberculosis history, and tuberculosis culture was positive in 2 patients. Pneumonectomy was applied to the left side in 14 and right side in 4 patients. There was no mortality. Complication occurred in 3 patients (atelectasis [n = 1], fistula and empyema [n = 1], and wound infection [n = 1]). Atelectasis was treated with bronchoscopy and stoma was needed for another patient for empyema. The mean follow-up was 64.9 months (range, 19 to 164 months). In their follow-up period, scoliosis was found in 1 patient. CONCLUSIONS: The morbidity and mortality rates of pneumonectomy are acceptable for selected and well prepared children. Antibiotics and antituberculosis treatment in certain cases and good timing in pneumonectomy are essential. Children grew and developed normally after pneumonectomy.

[Spontaneous pneumothorax: retrospective analysis of 348 cases]. / Spontan pnömotoraks: 348 olgunun geriye dönük olarak degerlendirilmesi.

BACKGROUND: In this study, spontaneous pneumothorax (SP) cases were divided into two groups and retrospectively evaluated according to age, sex, diagnostic methods, treatments, and results. METHODS: Between June 1997 and May 2005, 348 patients (320 males, 28 females; mean age 34.5; range 14 to 80 years) with SP were enrolled into our study. There were 274 (78.7%) primary SP and 74 (21.3%) secondary SP patients. Tuberculosis was the most common cause in secondary SP patients. Nasal oxygen and aspiration was the first-line therapeutic option in 10% of patients and tube thoracostomy was performed in 90%. RESULTS: Nasal oxygen and aspiration success ratio was 85.7% in primary SP patients and 66.7% in secondary SP patients. Tube thoracostomy success ratio was nearly the same in patients with primary and secondary SP (88.4% and 85.7%). Of the 29 patients (11.6%) with primary SP with unsuccessful result of tube thoracotomy, 15 underwent axillary thoracotomy and 14 underwent video-assisted thoracoscopic surgery (VATS). One patient among these 14 who underwent VATS (7.1%) had recurrence. CONCLUSION: Tube thoracostomy success ratio was high in both primary and secondary SP patients. Surgical procedures can be applied safely, with low recurrence rate, when the tube thoracostomy remains unsuccessful.

Bronchogenic cysts of the lung: report of 29 cases.

BACKGROUND: Intrapulmonary bronchogenic cysts are congenital anomalies of the tracheobronchial tree and foregut. The aim of this retrospective study was to review the diagnosis, clinical and histological features, operative techniques, outcomes and follow-up of intrapulmonary bronchogenic cysts treated in a single institute. METHODS: Twenty-nine patients with intrapulmonary bronchogenic cysts were treated surgically between 1990 and 2005. There were 17 female and 12 male patients and their ages ranged from 7 to 68 years. Patients were divided into two groups according to surgical procedure. Resection (lobectomy or wedge resection) was performed on Group I (n=18), and partial excision with de-epithelisation was performed on Group II (n=11). RESULTS: Twenty-five patients (86.2%) were symptomatic. Cough and sputum were the most common symptoms. Twenty-four of the 29 BCs were simple cysts (82.7%) whereas 5 (17.3%) were complicated cysts. Postoperative hospital stay was 4.55+/-0.86 days in group I and 6.54+/-3.34 days in group II (P=0.172). Complications in Group I were pneumonia in one case and wound infection in two cases; prolonged air leakage were observed in two cases of Group II. No statistical difference was determined between the complication rates of the two groups (P=0.91). However a significant difference was determined between the complication rates of simple and complicated cysts (P=0.026). Two cases in Group II showed recurrence, whereas no recurrence occurred in Group I. (P=0.065) No postoperative mortality was observed in any of the groups. CONCLUSIONS: All bronchogenic cysts should be treated surgically. We believe that partial excision with de-epithelisation may be an alternative to resection in symptomatic patients with limited respiratory capacity.

Clinicopathologic demonstration of complex bronchopulmonary foregut malformation.

Bronchopulmonary foregut malformations are rare and often prove to be extremely difficult to diagnose. The presented case is a 44-year-old man complaining about cough and hemoptysis. These symptoms continued despite medical treatment. A computed thorax tomographic scan depicted a paravertebral cystic lesion. The patient underwent surgical exploration, and communication between the cyst and the esophagus was found. A left lower lobectomy was performed. The pathologic result confirmed a duplication cyst of mixed bronchogenic and esophageal type with bronchiectasis of the lower lobe. We present this unusual malformation complex especially in an adult with the review of the literature.

[The role of video-assisted thoracoscopic surgery in the treatment of pleural empyema]. / Plevral ampiyemlerin tedavisinde videoyardimli torakoskopik cerrahinin rolü

Pleural empyema is a serious problem which affects any age group and still there is no standard approach. Our purpose in this study was to assess the safety, feasibility and efficacy of the video-assisted thoracoscopic surgery (VATS). Between 1997 and 2004 83 patients with empyema were enrolled in this study. Fifty-four patients were male, 29 females and the mean age was 39.4. The mean duration time of symptoms before VATS was 27.3 days. Twenty-two patients were in group-5, 44 in group-6 and 17 in group-7 according to Light's classification of parapneumonic effusions and empyema. Twenty-one patients underwent chest tube before VATS because of their conditions. VATS was converted to thoracotomy in 13 patients. All patients underwent debridement and irrigation during VATS. The cure was achieved in 58 (69.9%) patients with the mean 7.63 days drainage time. Twelve patients were underwent open decortication in the follow-up period. Ten of them were group-7 and 2 in group-6 (p= 0.006). The diagnosis was achieved in 60 (72.3%) patients as nonspecific pleuritis, tuberculosis in 19 and various diagnosis in 4. There was no mortality and minor complications occured in 14 patients. VATS is a safety and efficacy procedure in the treatment of early stage empyema. Use of VATS in early period of multiloculary empyema, prevents patients from unnecessary thoracotomies.

Effect of capitonnage and cystotomy on outcome of childhood pulmonary hydatid cysts.

OBJECTIVE: In this clinical retrospective study cystotomy and capitonnage were compared in patients with childhood pulmonary hydatid cysts with regard to postoperative period. METHODS: Between 1990 and 2004, 60 children with pulmonary hydatid cysts were treated surgically. There were 33 boys and 27 girls aged from 3 to 16 years. Cystotomy and closure of bronchial openings were performed in all patients. The patients were divided into 2 groups. While the residual cyst cavity was closed by means of capitonnage in group A (n = 37), cystotomy was applied in group B (n = 23). RESULTS: There was no mortality in either group. Chest tubes were removed after 3.59 +/- 1.04 days in group A and 5.83 +/- 2.84 days in group B. The hospital stay was 4.86 +/- 1.43 days for group A and 7.22 +/- 3.34 days for group B. Prolonged air leak was found in 2 children in group A and 7 children in group B. There was a significant difference between group A and group B with regard to chest tube removal time (P = .001), hospital stay (P = .003), development of prolonged air leak (P = .004), and all complications (P = .031). Follow-up information was available for 49 children, ranging from 13 to 86 months (mean, 56 months). Recurrence was seen in 2 children of group A and 1 child of group B during the follow-up period (P = .698). CONCLUSION: Capitonnage for pulmonary hydatid cysts is superior to cystotomy because it reduces morbidity (especially prolonged air leak) and hospital stay.

[Completion pneumonectomy: indications, complications, and results]. / Tamamlayici pnömonektomiler: endikasyonlari, komplikasyonlari ve sonuçlari.

Completion pneumonectomy is reported to be associated with high morbidity and mortality, especially when performed in patients with benign diseases. In our study we aimed to evaluate all patients underwent completion pneumonectomy in our clinic and to compare indications, complications and postoperative results with the literatures. Between January 1987 and December 2001, 27 consecutive patients who underwent completion pneumonectomy in our clinic were retrospectively reviewed. Postoperative morbidity and mortality rates were calculated according to indications and the results were compared to the standard pneumonectomies. There were 27 patients, 13 (48.1%) women and 14 (51.9%) men, with a median age of 26 (range, 10 to 62 years). Completion pneumonectomy was performed for benign diseases in 23 (85.2%) patients and for malign diseases in 4 (14.8%). Malign indications included 2 second primary tumors and 2 local recurrences. In the group with benign diseases; completion pneumonectomy was performed for tuberculosis in 5, bronchiectasis in 14, bronchopleural fistula in 2 and necrosis of lung in 2. Hospital mortality was 7.4% including 1 intraoperative and 1 postoperative deaths and both of them had undergone completion pneumonectomy for benign diseases. Complications occurred in 9 (33.3 %) patients, bronchopleural fistula + empyema were seen in 6 patients, cardiac rhythm disorders in 2 and wound infection in 1. All complications occurred in the patients operated for benign indications (39.1%). Completion pneumonectomy can be performed with an acceptable morbidity and mortality (similar to standard pneumonectomy) in selected cases. But the complication risk is higher in benign diseases, especially in tuberculosis. Surgical technique is important to avoid serious complications such as bronchopleural fistula and empyema.