Post bar removal results of pectus deformity patients who underwent minimally invasive correction.

Introduction: The most common chest wall deformities are pectus excavatum and pectus carinatum. Surgical repair of these deformities via minimally invasive technique using pectus bars is commonly preferred by numerous thoracic surgeons. Despite this common choice for treatment, the duration of the bar stay, the bar removal process, the possible complications and ways to prevent them have been debated over the years and still there is no single decision. Aim: To determine the decision making, surgical outcomes and negative factors in the bar removal process. Material and methods: There were 1032 patients underwent bar removal between 2006-2020 and their data was recorded prospectively. We analyzed patients' demographics, family history, Haller index, bar count, body mass index, stabilizer and wire usage, length of hospital stay, time until bar removal, incision side and complications retrospectively. Results: There was no significant correlation between BMI and surgery time (p = 0.748). There was no statistically significant correlation between the age groups and the number of pectus bars removed. The other factors showed no significant difference. The surgery time was found to be significantly longer in those with callus tissue (p = 0.002). Conclusions: These findings suggest that pectus bars can be left in place for a shorter time than the standard 3-year interval without any additional recurrence risk and without compromising quality of life. As a result, patients with persistent pain after pectus repair should be well evaluated for the possibility of life-threatening complications during bar removal.

Comparative study of video-assisted thoracoscopic surgery versus open thymectomy for thymoma and myasthenia gravis.

INTRODUCTION: Thymectomy is the preferred standard treatment in younger non-thymoma patients with myasthenia gravis as well as in patients with early stage thymoma. Total thymectomy by median sternotomy has been the surgical approach since resection of the thymus with video-assisted thoracoscopic surgery (VATS). AIM: To compare the clinical outcomes of VATS thymectomy with conventional open thymectomy for neoplastic and non-neoplastic thymic diseases. MATERIAL AND METHODS: Forty patients underwent thymectomy between October 2012 and January 2016. Fifteen patients were male and 25 patients were female. The mean age was 40.3 ±17.7 years. Seventeen (55%) patients underwent VATS thymectomy and 23 (45%) patients underwent an open procedure. We retrospectively reviewed the data of the patients and compared these two techniques. RESULTS: The mean tumor size was 5.17 ±3.2 cm in the thymoma group (VATS 2.5 ±2.4 cm vs. open access 4.7 ±3.7 cm). None of the patients experienced a myasthenic crisis. Conversion to thoracotomy was required in 1 patient in the VATS group due to bleeding from the right internal mammary artery; therefore, the conversion rate was 2.5% among all the patients. No mortality occurred in either group. No significant difference was found in the perioperative blood loss, operative time or pain visual analogue scale scores. On the other hand, regarding postoperative drainage, duration of chest tube drainage and length of hospital stay, VATS thymectomy yielded better results and the differences were significant. CONCLUSIONS: Video-assisted thoracoscopic surgery thymectomy can be performed for both neoplastic and non-neoplastic thymic diseases with minimal morbidity and mortality.

Uniportal versus multiport video-assisted thoracoscopic surgery for anatomical lung resections: a glance at a dilemma.

INTRODUCTION: As the number of operations performed by videothoracoscopy is increasing, there is also a tendency to decrease the number of port incisions. Apart from the reduced number of surgical incisions, there are a few reports and systematic reviews that demonstrate some potential advantages of the uniportal video-assisted thoracoscopic surgery, but the impact of the reduced incisions in the clinical setting still remains uncertain. AIM: To compare uniportal video-assisted thoracoscopic surgery to multiport video-assisted thoracoscopic surgery for anatomical lung resections in patients with malignant and benign lung diseases. MATERIAL AND METHODS: From August 2010 to April 2016, a total of 102 patients with malignant and benign lung diseases underwent videothoracoscopic lobar and sublobar lung resections in our department. Comorbidities, tumor stage, tumor localization, mortality, operative time, pain visual analogue scale, length of hospital stay, perioperative blood loss, duration and amount of postoperative drainage and air leak, number of harvested lymph nodes and complication rates were analyzed. RESULTS: No significant difference was found in the duration of chest tube drainage, pain visual analogue scale score, length of hospital stay, perioperative blood loss, amount of postoperative drainage, number of harvested lymph nodes or complication rate. There was no surgical mortality in either of the two groups. However, operative time was shorter (189 min vs. 256 min, p < 0.005) in the multiport group than in the uniportal group. CONCLUSIONS: Compared with the uniportal approach, the multiport approach is associated with a significantly shorter operative time in our study.

Validity of the updated European Society of Thoracic Surgeons staging guideline in lung cancer patients.

OBJECTIVE: The European Society of Thoracic Surgeons (ESTS) has proposed a revised preoperative lymph node staging guideline for patients with potentially resectable non-small cell lung cancer (NSCLC). We aimed to assess the validity of this revised ESTS guideline and survival results in our patient cohort. METHODS: A total of 571 patients with potentially resectable NSCLC seen between January 2004 and November 2013 were included in the study. The preoperative mediastinal staging was performed by video-assisted cervical mediastinoscopy or video-assisted mediastinoscopic lymphadenectomy in all patients except those with peripheral cT1N0 nonadenocarcinoma tumors. Resection via thoracotomy or video-assisted thoracoscopic surgery was done in patients with no mediastinal lymph node metastasis. Surgical pathological results were compared with the ESTS staging guideline, and the validity of the guideline was tested. RESULTS: In this series, mediastinal lymph node metastasis was revealed preoperatively in 266 patients (46.6%). A total of 305 patients underwent anatomic lung resection. The sensitivity, specificity, positive and negative predictive values, and accuracy of the guidelines were calculated as 95.0%, 100%, 100%, 94.6%, and 97.2%, respectively. CONCLUSIONS: The ESTS revised preoperative lymph node staging guidelines for patients with NSCLC seem to be effective and valid, and may provide high survival following resectional surgery.

A prospective randomized trial comparing homologous and autologous fibrin sealants for the control of alveolar air leak.

BACKGROUND: Postoperative air leak is a common complication seen after pulmonary resection. It is a significant reason of morbidity and also leads to greater hospital cost owing to prolonged length of stay. The purpose of this study is to compare homologous sealant with autologous one to prevent air leak following pulmonary resection. METHODS: A total of 57 patients aged between 20 and 79 (mean age: 54.36) who underwent pulmonary resection other than pneumonectomy (lobar or sublobar resections) were analyzed. There were 47 males (83%) and 10 females (17%). Patients who intraoperatively had air leaks were randomized to receive homologous (Tisseel; n=28) or autologous (Vivostat; n=29) fibrin sealant. Differences among groups in terms of air leak, prolonged air leak, hospital stay, amount of air leak were analyzed. RESULTS: Indications for surgery were primary lung cancer in 42 patients (71.9%), secondary malignancy in 5 patients (8.8%), and benign disease in 10 patients (17.5%). Lobectomy was performed in 40 patients (70.2%), whereas 17 patients (29.8%) had wedge resection. Thirteen (46.4%) patients developed complications in patients receiving homologous sealant while 11 (38.0%) patients had complication in autologous sealant group (P=0.711). Median duration of air leak was 3 days in two groups. Time to intercostal drain removal was 3.39 and 3.38 days in homologous and autologous sealant group respectively (P=0.978). Mean hospital stay was 5.5 days in patients receiving homologous sealant whereas it was 5.0 days in patients who had autologous agent (P=0.140). There were no significant differences between groups in terms of measured maximum air leak (P=0.823) and mean air leak (P=0.186). There was no significant difference in the incidence of complications between two groups (P=0.711). CONCLUSIONS: Autologous and heterologous fibrin sealants are safe and acts similarly in terms of air leak and hospital stay in patients who had resectional surgery.

Single port thoracoscopic treatment of thoracic duct injury after thyroidectomy with neck dissection.

Chylous leakage is a complication of thyroidectomy accompanied by bilateral neck dissection with incidence of 0.5-6.2%. A 51-year-old female patient underwent total thyroidectomy, bilateral and central neck dissection for papillary thyroid carcinoma. In post-operative 4th day, left sided chylous leakage was observed as 1,500 cc/day through neck drain. Leakage did not cease after 1-month conservative treatment so single port thoracoscopic intervention was performed. Under general anesthesia, patient was placed in left lateral decubitus position. An Alexis® retractor was placed through sixth intercostal space. Thoracic cavity was visualized with 30º scope. Posteroinferior edge of lower lobe was retracted superior posteriorly with a Foerster clamp to display inferior pulmonary ligament, which was then divided with electrocautery. Posterior mediastinal pleura between azygous vein and chest wall was incised to mobilize the vein. After that, mediastinal pleura between azygous vein and esophagus was cut longitudinally and esophagus was retracted anteriorly to dissect towards aorta. By dissection, thoracic duct was revealed as a thin tubular structure with occasional peristalsis. After isolation of the duct, it was clipped using Hem-o-lok®. Finally, fibrin sealant was applied to decrease risk of recurrence. One chest tube was placed to ensure adequate drainage of thoracic cavity and complete re-expansion of lung. Neck drain and chest tube was extracted in postoperative second and fourth day respectively and patient was discharged at 8th day. Single port thoracoscopy is a safe choice for treatment of chylous leakages due to cervical ductus thoracicus injury with faster recovery.

The EMSY Gene Collaborates with CCND1 in Non-Small Cell Lung Carcinogenesis.

Background: Lung cancer is the leading cause of cancer deaths. The main risk factor is smoking but the risk is also associated with various genetic and epigenetic components in addition to environmental factors. Increases in the gene copy numbers due to chromosomal amplifications constitute a common mechanism for oncogene activation. A gene-dense region on chromosome 11q13 which harbors four core regions that are frequently amplified, has been associated with various types of cancer. The important cell cycle regulatory protein cyclin D1 (CCND1) is an essential driver of the first core region of the Chr11q13 amplicon. Deregulation of CCND1 has been associated with different kinds of human malignancies including lung cancer. The EMSY (c11orf30) gene has been proposed as the possible driver of the fourth core of the 11q13 amplicon and its amplification has been associated with breast and ovarian cancers. There is no report in the literature investigating the EMSY gene in lung cancer. Methods: In this study, expression levels of the EMSY and CCND1 genes were investigated in 85 patients with non small cell lung cancer by Real Time PCR. Results: Expression of the EMSY and CCND1 genes were increased in 56 (65.8%) and 50 (58.8%) of the patients, respectively. Both genes showed a higher expression in the tumors when compared to normal tissues. A strong correlation was present between the expression rates of both genes (p<0.001). Patients with adenocarcinoma had higher expression levels of both genes (p=0.02). Conclusion: We conclude that EMSY and CCND1 work in collaboration and contribute to the pathogenesis of lung cancer.

Rectosigmoidoscopy complicated by bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and pneumoderma.

Rectosigmoidoscopy is a common procedure for diagnosis and follow-up of diseases of the lower gastrointestinal system. Although the procedure is proven to be safe in experienced hands, there is always risk of complications. We report a case of bilateral pneumothoraces, pneumoperitonium, pneumoretroperitoneum, pneumomediastinum, and pneumoderma due to perforation during a rectosigmoidoscopy. Co-occurrence of all these in 1 patient is a very rare clinical condition. This report underlines the possibility of even the rarest and unexpected complications related to rectosigmoidoscopy. Endoscopist should be careful to avoid perforation, be aware of the potential complications, and be able to manage them.

ZNF703 Overexpression may act as an oncogene in non-small cell lung cancer.

Despite therapeutic advances, lung cancer remains one of the most common causes of cancer-related deaths worldwide. The ZNF703 gene has been identified as the driver of the 8p11-12 region and its amplification or overexpression has been associated with several types of cancers. It has also been shown that ZNF703 overexpression can activate the Akt/mTOR signaling pathway. The aim of our study was to investigate the role of the ZNF703 gene in association with Akt/mTOR activation in non-small cell lung cancer (NSCLC). Expression levels in tumors and matched noncancerous tissue samples from 47 patients were analyzed by qRT-PCR and the Akt phosphorylation levels were investigated by Western blotting. Our results show that ZNF703 is up-regulated in 63.4% of NSCLC tumor samples. Althogh the correlation did not reach a statistically significant level Akt phosphorylation was increased in tumor tissues expressing high levels of ZNF703. The role of the ZNF703 gene has not been investigated in NSCLC. Our data show that ZNF703 may contribute to tumor development in NSCLC by activating the Akt/mTOR pathway.

Single stage bilateral uniportal videothoracoscopic sympathicotomy for hyperhidrosis: can it be managed as an outpatient procedure?

INTRODUCTION: The videothoracoscopic approach is minimally invasive with benefits that include less postoperative pain and shorter hospital stay. It is also a safe procedure which can be performed on an outpatient basis. AIM: To determine whether videothoracoscopic sympathicotomy can be performed safely in most patients as an outpatient procedure. MATERIAL AND METHODS: Between July 2005 and October 2015, a total of 92 patients underwent bilateral and single port thoracoscopic sympathicotomy in our department on an outpatient basis. The level of sympathicotomy was T2 in 2 (2.2%) patients, T2 to T3 in 31 (33%) patients, T2 to T4 in 46 (50%) patients and T3 to T4 in 12 (13%) patients. Demographic data, length of postoperative stay, substitution index (SI), admission rate (AR) and readmission rate (RR), complications and patient satisfaction were reviewed retrospectively. RESULTS: Two (2.2%) patients suffered from chest pain, while 4 (4.3%) patients complained about pain at the port site. Mean discharge time after surgery was 5.1 h (range: 4-6 h), mean duration of hospital stay was 0.15 days (0-3 days) postoperatively and the mean operation time was 43.6 min (15-130 min). In 8 (8.6%) patients, pneumothorax was detected on postoperative chest X-ray, while 5 (5.4%) patients required chest tube drainage. Mild or moderate compensatory sweating developed in 32 (34.7%) patients. No recurrence was observed, and the satisfaction rate was 96.7%. Substitution index and admission rate were 91.3% and 11% respectively, while RR was 0%. CONCLUSIONS: Bilateral video-assisted thoracoscopic sympathicotomy can be performed safely in most patients as an outpatient procedure.

Minimally invasive repair of pectus excavatum (MIRPE) in adults: is it a proper choice?

INTRODUCTION: The Nuss procedure is suitable for prepubertal and early pubertal patients but can also be used in adult patients. AIM: To determine whether the minimally invasive technique (MIRPE) can also be performed successfully in adults. MATERIAL AND METHODS: Between July 2006 and January 2016, 836 patients (744 male, 92 female) underwent correction of pectus excavatum with the MIRPE technique at our institution. The mean age was 16.8 years (2-45 years). There were 236 adult patients (28.2%) (> 18 years) - 20 female, 216 male. The mean age among the adult patients was 23.2 years (18-45 years). The recorded data included length of hospital stay, postoperative complications, number of bars used, duration of the surgical procedure and signs of pneumothorax on the postoperative chest X-ray. RESULTS: The MIRPE was performed in 236 adult patients. The average operative time was 44.4 min (25-90 min). The median postoperative stay was 4.92 ±2.81 days (3-21 days) in adults and 4.64 ±1.58 (2-13) in younger patients. The difference was not statistically significant (p = 0.637). Two or more bars were used in 36 (15.8%) adult patients and in 44 (7.5%) younger patients. The difference was not statistically significant either (p = 0.068). Regarding the overall complications, complication rates among the adult patients and younger patients were 26.2% and 11.8% respectively. The difference was statistically significant (p = 0.007). CONCLUSIONS: MIRPE is a feasible procedure that produces good long-term results in the treatment of pectus excavatum in adults.

Amplification of chromosome 8 genes in lung cancer.

Chromosomal alterations are frequent events in lung carcinogenesis and usually display regions of focal amplification containing several overexpressed oncogenes. Although gains and losses of chromosomal loci have been reported copy number changes of the individual genes have not been analyzed in lung cancer. In this study 22 genes were analyzed by MLPA in tumors and matched normal tissue samples from 82 patients with non-small cell lung cancer. Gene amplifications were observed in 84% of the samples. Chromosome 8 was found to harbor the most frequent copy number alterations. The most frequently amplified genes were ZNF703, PRDM14 and MYC on chromosome 8 and the BIRC5 gene on chromosome 17. The frequency of deletions were much lower and the most frequently deleted gene was ADAM9. Amplification of the ZNF703, PRDM14 and MYC genes were highly correlated suggesting that the genes displaying high copy number changes on chromosome 8 collaborate during lung carcinogenesis.

Rapid pleurodesis is an outpatient alternative in patients with malignant pleural effusions: a prospective randomized controlled trial.

BACKGROUND: Chemical pleurodesis can be palliative for recurrent, symptomatic pleural effusions in patients who are not candidate for a thoracic surgical procedure. We hypothesized that effective pleurodesis could be accomplished with a rapid method of pleurodesis as effective as the standard method. METHODS: A prospective randomized 'non-inferiority' trial was conducted in 96 patients with malignant pleural effusion (MPE) who are not potentially curable and/or not amenable to any other surgical intervention. They were randomly allocated to group 1 (rapid pleurodesis) and to group 2 (standard protocol). In group 1, following complete fluid evacuation, talc slurry was instilled into the pleural space. This was accomplished within 2 h of thoracic catheter insertion, unless the drained fluid was more than 1,500 mL. After clamping the tube for 30 min, the pleural space was drained for 1 h, after which the thoracic catheter was removed. In group 2, talc-slurry was administered when the daily drainage was lower than 300 mL/day. RESULTS: No-complication developed due to talc-slurry in two groups. Complete or partial response was achieved in 35 (87.5%) and 33 (84.6%) patients in group 1 and group 2 respectively (P=0.670). The mean drainage time was 40.7 and 165.2 h in group 1 and group 2 respectively (P<0.001). CONCLUSIONS: Rapid pleurodesis with talc slurry is safe and effective and it can be performed in an outpatient basis.

Video-assisted mediastinoscopic lymphadenectomy is associated with better survival than mediastinoscopy in patients with resected non-small cell lung cancer.

OBJECTIVES: We aimed to analyze the accuracy of video-assisted mediastinoscopic lymphadenectomy (VAMLA) as a tool for preoperative staging and the impact of the technique on survival in patients with non-small cell lung cancer (NSCLC) undergoing pulmonary resection. METHODS: Between May 2006 and December 2010, 433 patients underwent pulmonary resection for NSCLC, 89 (21%) had VAMLA before resection and 344 (79%) had standard mediastinoscopy. The patients who had negative VAMLA/mediastinoscopy results underwent anatomic pulmonary resection and systematic lymph node dissection. RESULTS: The median and mean numbers of resected lymph node stations were 5 and 4.9 in the VAMLA group and 4 and 4.2 in the mediastinoscopy group (P = .9). The mean number of lymph nodes per biopsy specimen using standard mediastinoscopy was 10.1, whereas it was 30.4 using VAMLA (P < .001). VAMLA unveiled N2 or N3 disease in 30 (33.7%) and in 6 (6.7%) of patients, respectively. The negative predictive value, sensitivity, false-negative value, and accuracy of VAMLA were statistically higher in the VAMLA groups compared with those of standard mediastinoscopy. The 5-year survival was 90% for VAMLA patients and 66% for mediastinoscopy patients (P = .01). By multivariable analysis, VAMLA was associated with better survival (odds ratio, 1.34; 95% confidence interval, 1.1-3.2; P = .02). CONCLUSIONS: VAMLA was associated with improved survival in NSCLC patients who had resectional surgery.

Vascular thoracic outlet syndrome developed after minimally invasive repair of pectus excavatum.

The Nuss procedure is a minimally invasive surgical repair technique for pectus excavatum with fewer delayed complications compared to open procedures. We report the case of a 22-year-old man with deep pectus excavatum who developed vascular thoracic outlet syndrome after the Nuss procedure. Further evaluation demonstrated that the first rib was causing severe obstruction of the right subclavian artery. The patient showed clinical features of subclavian artery compression. A first rib resection, division of the anterior scalene muscle and fibrous bands provided complete relief of the complaints. The forced structural and spatial changes produced by the elevation of the depressed upper chest might have caused this complication. Vascular thoracic outlet syndrome should be kept in mind as a possible complication in patients who have undergone minimally invasive repair of pectus excavatum, and this complication can be treated by first rib resection.

Association of epidermal growth factor receptor and K-Ras mutations with smoking history in non-small cell lung cancer patients.

Lung cancer, a major health problem affecting the epithelial lining of the lower respiratory tract, is considered to be one of the deadliest types of cancer in males and females and it is well-known that smoking is the chief cause of lung cancer. In addition to smoking and environmental factors, genetic susceptibility may also contribute to the development of lung cancer. Previous studies have shown that certain non-small cell lung cancer (NSCLC) patients harbor gain-of-function mutations in the epidermal growth factor receptor gene (EGFR). Phosphorylated EGFR triggers the activation of intracellular signal transduction pathways, including the RAS-MAPK, PI3K-Akt and STAT pathways. However, K-Ras gene point mutations in codons 12, 13 or 61 cause the inactivation of GTPase activity which results in overstimulation of cellular growth and gives rise to neoplastic development. Our aim was to investigate the presence and association of EGFR and K-Ras mutations in 50 primary NSCLC patients with a smoking history by using real-time PCR and sequencing. EGFR mutations were detected in four patients (8%). Two of these mutations were L858R mutations and the remaining two were deletion mutations spanning between codons 746 and 750. The L858R mutation was significantly associated with smoking status (P=0.003). K-Ras codon 12 and 61 mutations were also observed in four patients. However, no association was observed between K-Ras mutations and the tumor staging, gender, histology and smoking status of the patients.

A rare benign tumor of the lung: Inflammatory myofibroblastic tumor - Case report.

A fifty year old lady who was operated for thyroid cancer two years ago and completed adjuvant therapy, underwent a computer tomography (CT) of the chest during her follow up. The CT showed a mass lesion in the right lung, located to the lateral segment of the middle lobe. There were no intrabronchial lesions on bronchoscopy. Positron emission CT (PET CT) showed a dense hypermetabolic mass located in the right middle lobe lateral segment and having malignant characteristics. A videothorascopic wedge resection was performed and the specimen was sent for frozen section, which showed no evidence of malignancy. Pathology report revealed an inflammatory myofibroblastic tumor (IMT). Since IMT is a rare benign tumor of the lung, we herein report this patient along with a discussion of the relevant literature.

Primary pulmonary non-Hodgkin's lymphoma: ten cases with a review of the literature.

INTRODUCTION: Primary pulmonary non-Hodgkin's lymphoma (PPNHL) of the lung occurs very rarely. To clarify clinical features, treatment alternatives and outcomes, we evaluated our surgically diagnosed PPNHL cases. MATERIALS AND METHODS: A retrospective review of PPNHL cases from January 2004 to December 2009 was performed. Demographic and clinical data are presented as means or medians. Overall survival was estimated using the Kaplan-Meier method. Survival rates were compared using the log-rank test. A p value < 0.05 was considered significant. RESULTS: Patients were eight males and two females with a median age of 50 years (range, 29-76 years). In 40% of the patients, antigenic stimulation, immune-suppression or auto-immune disease could not been found. All patients were symptomatic at presentation. Surgical procedures were needed to obtain a diagnosis (nine wedge resections and one pneumonectomy). Eight patients had an extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma), and two had diffuse large B-cell lymphomas. The patients were treated with observation (pneumonectomy case), chemotherapy (n= 7), and chemotherapy and radiotherapy (n= 1). Five-year survival was 76%. Difference in survival rates of patients with bilateral vs. unilateral disease were not statistically different. CONCLUSIONS: On contrary of the literature, PPNHL can occur with absence of antigenic stimulation, and patients generally have some symptoms. Chemotherapy or surgery can be used to treat PPNHL. Patient survival is good.