Approach to patients with chylothorax complicating pulmonary resection.

Mediastinal lymph node dissection, an important part of surgery for non-small cell lung cancer, is associated with a risk of chylothorax. Although mortality has significantly decreased in recent years, it still worries thoracic surgeons. In this report we reviewed our experience on chylothorax with 26 cases and assessed the outcomes after conservative and surgical approaches. Between January 2000 and June 2010, twenty-six patients developed chylothorax after pulmonary resection performed for non-small cell lung cancer. Initially, all cases were treated conservatively with cessation of oral intake and the application of talc poudrage. If the conservative method failed, a surgical approach was used, which consisted either of suturing the leak or of mass ligation. The mean age of patients was 56 ± 9.05 years, and 3 were female. Chylothorax was more common on the right side, in lobectomy cases, in cases with adenocarcinoma, and in patients with advanced stage lung cancer, but the difference did not reach statistical significance. Conservative treatment was successful in 19 of 26 (73 %) patients, four of whom had undergone pneumonectomy. Seven out of 26 cases (27%) required thoracotomy to control the chylous leak. Though thoracotomy was required mostly for the right side (6 right vs. 1 left, p = 0.15), and in patients who had had pneumonectomy as their first operation (4 patients vs. 3, p = 0.18), this did not reach statistical significance. No patient died as a result of surgical intervention. In conclusion, chylothorax is not rare after pulmonary resection performed for lung cancer. But it is not as dangerous as it used to be. Talc pleurodesis has increased the success of conservative management and minimized the need for surgical intervention. In cases of high output leak the surgeon should not hesitate to perform surgery. VATS can be performed instead of open surgery in suitable cases.

Surgical treatment of superior sulcus tumors: results and prognostic factors.

BACKGROUND: This study aims to investigate the treatment modalities and factors influencing survival in surgically treated superior sulcus tumors. PATIENTS AND METHOD: Sixty-five cases of surgically treated non-small cell carcinoma of the lung occurring as superior sulcus tumors between 1994 and 2007 were retrospectively reviewed. Twenty-five patients underwent induction radiotherapy (RT), 10 had induction chemoradiotherapy (CT/RT). In thirty patients surgery was performed directly. The mortality rate was 6.2 %. Pathological stage was T3 in 55, T4 in 10, N0 in 52, and N1 in 5 and N2 in 8 patients. RESULTS: Overall 5- and 10-year survival rates were 31 % and 28 %, respectively. Complete resection rate was 90 % for patients who received induction CT/RT and 80 % for patients who either received induction RT alone or patients in whom surgery was performed directly. In patients who received neoadjuvant therapy with complete tumor resection, the median survival time was 33 months (28 months for patients who received induction RT alone and 36 months for patients who received induction CT/RT), and the 5-year survival rate was 41 %. Median survival time and 5-year survival rate of patients treated by direct surgery with complete resection was 24 months and 37 %, respectively ( P = 0.87). Five-year survival and 10-year survival rates were significantly higher after complete resection than after incomplete resection (38 % and 34 % vs. 0 %, P = 0.0001). In multivariate analysis, only N2 disease ( P = 0.04) and incomplete resection ( P = 0.03) were found to be poor prognostic factors. CONCLUSION: The presence of N2 disease and incomplete resection are the two most important factors affecting survival. Induction CT/RT may increase the ability to achieve complete surgical resection.

Characteristics and prognosis of resected T3 non-small cell lung cancer.

AIM: The aim this study is to determine the characteristics, survival, and factors affecting the survival of resected T3 non-small cell lung cancer. METHODS: The records of 97 cases were retrospectively reviewed with T3 non-small cell lung cancer patients that were operated between 1996-2001. Complete resection was achieved in 71 (73.2%) patient. The distribution of N status was 47.4%, 28.9%, and 23.7% for N0, N1 and N2 respectively. The evaluated prognostic factors in univariate and multivariate analyses were, histologic type, type of resection, N status, subgroups of pT3, resection margins and effect of adjuvant therapy. RESULTS: Overall 5-year survival rate was 24.3%. Median survival and 5-year survival of the patients whose tumors resected completely was 33 months and 31.5%, whereas 18 months and 7.3% for the patients resected incompletely (P=0.03). Median survival being not significantly different among the three subgroups: 25, 23, and 32 months (P=0.7) in the bronchial pT3, mediastinal pT3, and peripheral pT3 subgroups, respectively. Histology (P=0.57), type of surgical resection (lobectomy versus pneumonectomy) (P=0.25), and use of adjuvant therapy (P=0.054) did not influence the survival significantly. However N status influenced the survival significantly (P=0.01). According to the multivariate analyses, two factors were selected as prognostic indicators: N2 status (P=0.03) and incomplete resection (P=0.03). CONCLUSION: Three pT3 subgroups did not show survival differences. Complete resection and N2 status are the two most influencing factors in survival of the patients. Adjuvant therapy effected the survival and the quality of life reversely.

Elective pneumonectomy for non-small cell lung cancer: factors affecting early operative mortality and morbidity.

BACKGROUND: The aim of this study was to investigate the factors influencing the morbidity and mortality of the non-small cell lung cancer (NSCLC) cases where pneumonectomy was performed. MATERIAL & METHODS: All 101 patients who had underwent a pneumonectomy for NSCLC between 1994-2001 in our hospital were included in the retrospective study. There were 97 males and 4 females with a mean age of 56+/-9.6. Factors affecting morbidity and mortality were analysed by univariate and multivariate analysis. RESULTS: The morbidity rate was 53% and the mortality rate was 9%. Morbidity was related to cardiopulmonary complications in 40% of the cases. The risk factors for cardiopulmonary morbidity with univariate analysis were age > 60 years (p = 0.004), FEV1 < 2 lt (p = 0.016), early bronchopleural fistula (p = 0.0001), tumour size > 4 cm (p = 0.033), vital capacity < 3.7 lt (p = 0.016), forced vital capacity < 3.5 lt (p = 0.033).. With multivariate analysis the risk factors cardiopulmonary morbidity were age (60 >) (p = 0.012) and tumour size > 4 cm (p = 0.043). The risk factors mortality with univariate analysis were right pneumonectomy (p = 0.025), respiratory morbidity (p = 0.0001), cardiac morbidity (p = 0.002), cell type (Epidermoid CA) (0.047), tumour size > 6 cm (p = 0.036), fluid infusion (p = 0.009), forced vital capacity < 78% (p = 0.039), forced expiratory volume in 1 second < 75% (p = 0.039), PO2 (p = 0.037), PCO2 > 42 mmHg (p = 0.023). CONCLUSION: Among the pneumonectomies performed for NSCLC, the causes of postoperative morbidity were multifactorial, however, multivariate analysis did not show any significant factor affecting the mortality, related to this procedure.

Delayed diagnosis of a complete bronchial rupture after blunt thoracic trauma.

Bronchial ruptures due to blunt chest traumas are rarely encountered injuries. They can be missed in the emergency room depending on the clinical findings. We present a case report of a previously healthy 32-year-old woman who received multiple rib and clavicula fractures on the right side in a traffic accident. The plain radiograms taken on the first and fifth day showed no other pathological findings than the above-mentioned fractures. Her control chest radiography, which was taken 7 weeks later, showed a totally opaque left hemithorax but no findings of pneumothorax were present. Fiberoptic bronchoscopy and virtual bronchoscopy showed a left main bronchial rupture. The patient was treated with an end-to-end anastomosis via left posterolateral thoracotomy.

Chylothorax: a complication following lung resection in patients with NSCLC - chylothorax following lung resection.

BACKGROUND: Chylothorax following lung resection is not as rare as a postoperative complication as previously reported due to systematic lymph node dissection in patients undergoing lung resection for NSCLC. METHODS: We retrospectively reviewed our cases that had undergone lung resection for NSCLC and investigated the frequency and outcome of chylothorax in these patients. The factors investigated were the site and type resection, technique of systematic lymph node dissection, tumour histology and disease stage. RESULTS: Seven of 673 patients that had undergone lung resection were complicated by chylothorax (1.04 %), following lobectomy in 5 (1.28 %) and pneumonectomy in 2 (0.7 %) (p = 0.36). The fistula closed spontaneously in 5 patients between 4 - 17 days postoperatively (71 %). One of the patients in the conservative management group died on the 28th day postoperatively due to pneumonia (14 %). The remaining 2 patients underwent rethoracotomy on the 5th and 6th days. CONCLUSIONS: These results suggest that the site of operation, type resection, and technique of systematic nodal dissection, tumour histology and disease stage do not influence the development of chylothorax in patients with NSCLC. The chylous fistula following lung resection for NSCLC tends to close spontaneously.

Shoulder-girdle strength after standard and lateral muscle-sparing thoracotomy.

BACKGROUND: There is no objective data in the literature to support the statement that shoulder-girdle strength can be preserved better after muscle-sparing thoracotomy compared with standard thoracotomy. The aim of this study is to determine the decrease on muscle strength with objective criteria by measuring the peak torque value produced by the shoulder girdle. METHOD: Peak torque values on abduction and adduction of entire shoulder range at the velocity of 60 and 120 degree per second were measured with an isokinetik dynomometer which was attached to a computer. The measurements were performed in 20 cases, all candidates for thoracotomy. Patients were randomised into 2 groups; muscle sparing thoracotomy was undertaken in group A, and standard thoracotomy in group B. The same measurements were repeated 3 months after the surgery. RESULTS: The decrease in postoperative PT values between group A and B was statistically significant (p<0.003). The decrease on shoulder abduction and adduction was insignificant in group A (p = 0.33 and p=0.13) and statistically significant in group B (p<0.0001 and p<0.001). CONCLUSION: These results confirm the statement that shoulder girdle strength is better preserved with muscle-sparing thoracotomy.