Endoscopic Thoracic Sympathectomy in the Treatment of Vasospastic Angina Resistant to Medical Therapy.

BACKGROUND: In this study, we aimed to investigate the clinical follow-up results of endoscopic thoracic sympathectomy (ETS) in the treatment of vasospastic angina (VSA) resistant to maximal medical therapy. METHODS: A total of 80 patients with VSA who presented to our hospital between 2010 and 2022 were included in our study. Among them, 6 patients who did not respond to medical therapy underwent ETS. In-hospital and long-term clinical outcomes of patients who underwent ETS were recorded. RESULTS: The median age of the patients with VSA was 57 [48-66] years, and 70% of the group were males. In the ETS group, compared to the non-ETS group, higher numbers of hospital admissions and coronary angiographies were observed before ETS (median 6 [5-6] versus 2 [1-3], P <.001; median 5 [3-6] versus 2 [1-3], P =.004, respectively). Additionally, while 2 patients (33.3%) in the ETS group had implantable cardioverter defib-rillator (ICD), only 2 patients (2.7%) in the non-ETS group had ICD (P =.027). Out of the 6 patients who underwent ETS, 2 were females, with a median age of 56 [45-63] years. Four patients underwent successful bilateral ETS, while 2 patients underwent unilateral ETS. During the follow-up period after ETS, only 3 patients experienced sporadic attacks (once in 28 months, twice in 41 months, and once in 9 years, respectively), while no attacks were observed in 3 patients during their median follow-up of 7 years. CONCLUSION: It appears that ETS is effective in preventing VSA attacks without any major complications.

Could cytology supplant frozen section for intraoperative evaluation of thoracic lesions? A single institutional experience in a developing country.

BACKGROUND: The diagnostic performance of cytology was compared with the frozen results and its usability was evaluated as a rapid diagnosis method in intraoperative thoracic surgery in a single institution (Istanbul, Turkey). METHODS: All 197 subsequent patient specimens (cases) from 158 patients who were sent to our department from the thoracic surgery clinic for an intraoperative diagnosis request between the years 2016 and 2021 were evaluated. Obtained results from frozen and cytology were compared with final paraffin section diagnoses. Lesions were grouped into three different groups as nonneoplastic, benign, and malignant neoplasms. RESULTS: Diagnostic accuracy values of cytology and frozen sections in intraoperative consultation were 98.8% and 99.4%, respectively. Sensitivity values of cytology and frozen sections in intraoperative consultation were 96.3% and 98.7%, respectively. Specificity values of cytology and frozen sections in intraoperative consultation were 100% and 100%, respectively. Negative predictive values of cytology and frozen sections in intraoperative consultation were 96.7% and 98.9%, respectively. Positive predictive values of cytology and frozen sections in intraoperative consultation were 100% and 100%, respectively. Kappa statistics between cytology and frozen revealed a very high interrater reliability (Cohen's Kappa value: 0.911; p = .001; p < .01). The difficulty in distinguishing primary and metastatic carcinoma, which is mostly undecided in frozen sections and the definitive diagnosis is left to paraffin sections, seems also be a problem in the cytological examination. CONCLUSIONS: Cytological diagnosis can be used in the evaluation of small biopsy specimens that require tissue preservation in intraoperative consultation, especially for immunohistochemical and advanced genetic studies.

Role of thymus on prognosis of myasthenia gravis in Turkish population.

OBJECTIVE: Myasthenia gravis (MG) is an autoimmune disease that may cause a disorder in transmission at the neuromuscular junction. Antibodies directed against acetylcholine receptors are responsible. The thymus is the place that that production of these antibodies mainly occurs. The thymus gland abnormalities and abnormal production of these antibodies are associated with MG. Consequently, thymectomy is a common treatment for MG. The nature of the disease makes it difficult to plan prospective, controlled trials; therefore, there is no current consensus among clinicians on a single algorithm of treatment, and the approach is frequently based on the observations and experiences of experts. The contributions to the literature largely consist of retrospective studies examining an approach to treatment and the effects of thymectomy on prognosis. In this retrospective study, evaluation of Turkish patients with myasthenia gravis was carried out for the importance of thymectomy and effects on prognosis. METHODS: In this study, 93 patients with myasthenia gravis whose followed up at Neuromuscular outpatient clinic between 1998-2018 were evaluated retrospectively. Type of disease, antibody status, treatment, thymectomy, thymus pathology and prognosis were assessed. RESULTS: Thymectomy had been a positive effect on the prognosis of the disease independent of the duration of disease and thymic pathology. The best results had been obtained with early thymectomy with short disease duration, younger age and patients with thymic hyperplasia. Success of therapy was limited with thymoma. With advanced age need for thymectomy was decreased. CONCLUSION: In the present study, evaluation of 93 patients with myasthenia gravis was done retrospectively and it was concluded that thymectomy had a positive effect on prognosis, especially in young patients when performed as early as possible. The most successful results were obtained in cases with thymic hyperplasia.

Effectiveness of Video-Assisted Thoracoscopic Surgery in Undiagnosed Exudative Pleural Effusions.

OBJECTIVES: Undiagnosed pleural effusions mostly require histologic studies for a definite diagnosis. In addition, malignant pleural effusions responsible for a significant part of exudative pleurisy need palliative therapy The purpose of our study is to research the effectiveness of video-assisted thoracoscopic surgery in definitive diagnosis and palliative treatment of unexplained non-parapneumonic exudative pleural effusions. MATERIALS AND METHODS: The study included 263 patients with non-parapneumonic exudative pleurisy, which could not be diagnosed by an initial clinical, radiological, biochemical, microbiological, and cytological investigation in three centers. All patients underwent video-assisted thoracoscopic surgery for definitive diagnosis between January 2002 and January 2018. Patients' data were retrospectively analyzed in terms of age, gender, symptoms, previously diagnosed cancers, computerized tomography of chest findings, histopathological diagnosis, cytological diagnosis, morbidity, mortality, and success rates of the procedure. Patient groups from the three centers were divided into three groups according to the center of the patient. The groups were compared statistically in terms of cytologic diagnosis rates. RESULTS: The most common complaint was dysnea (66.5%). Of the 263 cases, 83 were previously diagnosed with cancer. The simple pleural effusion (66.5%) was the most frequent radiological finding. The success rate for definitive diagnosis was detected as 97%. Of all the cases, the rate of specific cytological diagnosis was detected to be 34%. The cytologic diagnosis rate was meaningfully lower in Group 1than in Groups2 and 3. The postoperative morbidity rate was detected as 9%. CONCLUSION: Video-assisted thoracic surgery is not only a rapid and effective diagnostic method, but also a palliative therapeutic method. We think that it should be used immediately after initial diagnostic thoracentesis in undiagnosed exudative PEin the less experienced centers.

Extended left pneumonectomy and left atrial reconstruction with autogenous graft in patient with T4 lung cancer.

In selective patients with T4 non-small cell lung cancer with the primary tumor invading the mediastinal organs, extended lung resection may contribute to long-term survival. Adequate patients should be given a chance for surgery if complete resection and required reconstruction can be achieved. In this article, we report a 63-year-old male patient with T4 non-small cell lung cancer invading the left atrium. In the patient, we performed an extended left pneumonectomy with en bloc partial resection of the left atrium wall (4×2.5 cm) where the defect was repaired with pericardial patch via cardiopulmonary bypass. No severe complication developed postoperatively. The patient who was given adjuvant chemotherapy has been living for more than 10 years without disease.

The Diagnostic Value of Pericardial Fluid and Pericardial Biopsy: Single Center Experiences.

BACKGROUND: Patients with recurrent pericardial effusion and pericardial tamponade are usually treated in thoracic surgery clinics by VATS (video-assisted thoracoscopic surgery) or open pericardial window operation. The diagnostic importance of pathological evaluation of the pericardial fluid and tissue in the same patients has been reported in few studies. We reviewed pathological examination of the pericardial tissue and fluid specimens and the effect on the clinical treatment in our clinic, and compared the results with the literature. METHODS: We retrospectively analyzed 174 patients who underwent pericardial window operation due to pericardial tamponade or recurrent pericardial effusion. For all patients both the results of the pericardial fluid and pericardial biopsy specimen were evaluated. Clinicopathological factors were analyzed by using descriptive analysis. RESULTS: Median age was 61 (range, 20-94 years). The most common benign diagnosis was chronic inflammation (94 patients) by pericardial biopsy. History of malignancy was present in 28 patients (16.1%) and the most common disease was lung cancer (14 patients). A total of 24 patients (13.8%) could be diagnosed as having malignancy by pericardial fluid or pericardial biopsy examination. The malignancy was recognized for 12 patients who had a history of cancer; 9 of 12 with pericardial biopsy, 7 diagnosed by pericardial fluid. Twelve of 156 patients were recognized as having underlying malignancy by pericardial biopsy (n = 9) or fluid examination (n = 10), without known malignancy previously. CONCLUSION: Recurrent pericardial effusion/pericardial tamponade are entities frequently diagnosed, and surgical interventions may be needed either for diagnosis and/or treatment, but specific etiology can rarely be obtained in spite of pathological examination of either pericardial tissue or fluid. For increasing the probability of a specific diagnosis both the pericardial fluid and the pericardial tissues have to be sent for pathologic examination.

Sympathectomy versus Sympathicotomy in Palmar Hyperhidrosis Comparing T3 Ablation.

OBJECTIVE: The objective of this study was to evaluate and compare thoracoscopic sympathectomy and sympathicotomy at the third ganglia (T3) level for the treatment of primary palmar hyperhidrosis in terms of initial surgery results, complications, and patient satisfaction. MATERIALS AND METHODS: Two groups of patient underwent T3 thoracoscopic sympathectomy and thoracoscopic sympathicotomy under general anesthesia using single-lung ventilation via a double-lumen endotracheal tube by the same surgical team for the treatment of severe primary palmar hyperhidrosis or a combination of levels for multiarea between 2008 and 2013. The groups were homogeneous for relevant demographic, physiological, and clinical data. All patients were examined preoperatively and were followed up at 6 months postoperatively. In both groups, patient's satisfaction was evaluated 6 months after surgery by a detailed interview and scored into three grades (1 = very satisfied, 2 = satisfied, and 3 = dissatisfied). RESULTS: No operative mortality, major intraoperative complication, infections, and Horner syndrome were recorded. There was no treatment failure. The average time of operation was 50 minutes for Group A (sympathectomy) and 36 minutes for Group B (sympathicotomy). Compensatory sweating occurred in 40 patients (89% for Group A and 85.11% for Group B) with a different accumulation of the severity degree. The satisfaction rate was 91.11% for Group A and 93.61% for Group B. CONCLUSION: There was no significant difference between thoracoscopic sympathectomy and sympathicotomy at the third ganglia (T3) level for the treatment of primary palmar hyperhidrosis in terms of initial surgery results, complications, and patient satisfaction. Neither surgical technique is better than the other one for palmar hyperhidrosis treatment. Development of severe compensatory sweating and postoperative pain are major determinant factors of patient dissatisfaction. Sympathicotomy should be preferred for palmar hyperhidrosis treatment, as it is much technically shorter, simpler to implement, and also easier to learn.

Thoracic Traumas: A Single-Center Experience.

OBJECTIVES: Trauma is currently among the most important health problems resulting in mortality. Approximately 25% of trauma-related deaths are associated with thoracic trauma. In the present study, morbidity and mortality rates and interventions performed in patients who had been treated as inpatients in Dr. Siyami Ersek Thoracic and Cardiovascular Surgery hospital after trauma were aimed to be evaluated. MATERIAL AND METHODS: In our study, 404 patients who were treated as inpatients because of thoracic trauma between January 2005 and December 2008 were retrospectively evaluated. RESULTS: The rates of blunt and penetrating trauma were 39.6% and 60.4%, respectively. In the study, 115 (28.4%) patients were noted to have pneumothorax, 99 (24.5%) had hemothorax, and 57 (14.1%) had hemopneumothorax. While tube thoracostomy was sufficient for treatment in approximately 80% of the patients, major surgical interventions were performed in 12.6% of the patients. Mortality rate was found to be 2.2%. CONCLUSION: In patients with chest trauma, necessary interventions should be started at the time of the event, and the time from trauma to arriving at the emergency department should be made the best of. Mortality and morbidity rates in thoracic trauma cases may be reduced by timely interventions and effective intensive care monitoring.

Intrathoracic giant solitary fibrous tumor.

BACKGROUND: Solitary fibrous tumor of the pleura is a rare, usually benign, and slow-growing neoplasm. Complete surgical resection for giant tumor of the pleura is challenging because of poor exposure and a large blood supply. We report the case of a giant hypervascular fibrous tumor that filled nearly the entire left hemithorax and anterior mediastinum, and its preoperative management. CASE REPORT: A 59-year-old woman presented to us with exertional dyspnea and chest pain. A chest radiograph showed the right hemithorax completely opaque and a mediastinal shift to the left hemithorax. A tomography scan of the thorax showed a giant mass that almost completely filled the right hemithorax and compressed the mediastinum to the left. Because of excessive bleeding during dissection, the operation was terminated after a biopsy specimen was obtained. The biopsy was diagnosed as a benign fibrous tumour. A thoracic computed tomography angiogram showed that the mass was supplied by multiple intercostal arteries as well as an aberrant artery that branches off the celiac trunk in the subdiaphragmatic region. Due to the many arteries that needed to be embolized, the final decision was to control the bleeding following resection by inducing total circulatory arrest with the help of cardiopulmonary bypass. The bleeding could not be controlled under cardiopulmonary bypass and the patient's death was confirmed. CONCLUSIONS: We report this case to emphasize the necessity of preoperative embolization; the use of cardiopulmonary bypass and total circulatory arrest is not a valid alternative method to control the bleeding.

[Esophageal foreign bodies in children and adults: 20 years experience]. / Çocuklarda ve eriskinlerde özofagus yabanci cisimleri: 20 yillik deneyim.

BACKGROUND: Esophageal foreign object ingestion is frequently seen in all ages. Failure to treat can cause serious complications such as esophageal perforation. The aims of this study were to characterize the clinical features related to foreign objects in the esophagus and to analyze the results of commonly used methods for their removal. METHODS: We analyzed 20 years of records from Siyami Ersek Hospital, Istanbul and identified 512 cases of foreign objects enlodged in the esophagus. RESULTS: In pediatric patients, the majority were aged between 2-5 years (34.4%), while in adult patients, the majority were above 55 years (38.7%). Coins were the most common foreign object detected in children (68.8%), whereas meat impaction was most common in adults (87.4%). The most common location of the foreign object was the cervical esophagus in children (78.2%), and the thoracic esophagus in adults (66.4%). In 30.8% of adults, there was esophageal or systemic disease. Objects were removed with a Magill clamp in 48.3% of children. Rigid endoscopy was the main treatment in adult patients. Perforation due to endoscopy developed in three patients. Surgical repair was performed on these patients but all died due to mediastinitis. CONCLUSION: Underlying esophageal or systemic diseases may predispose adults to foreign object ingestion in the esophagus. Improved endoscopic experience and clinical management of thoracic surgeons led to reduced morbidity and mortality in recent years.

Surgical properties and survival of a pericardial window via left minithoracotomy for benign and malignant pericardial tamponade in cancer patients.

BACKGROUND: Surgical drainage is a rapid and effective treatment for pericardial tamponade in cancer patients. We aimed to investigate the effectiveness of pericardial window formation via mini-thoracotomy for treating pericardial tamponade in cancer patients, and to evaluate clinical factors affecting long-term survival. METHODS: Records of 53 cancer patients with pericardial tamponade treated by pericardial window formation between 2002 and 2008 were examined. Five patients were excluded due to insufficient data. Kaplan-Meier and Cox regression analysis were used for analysis. RESULTS: Forty-eight patients (64.7% male), with a mean age of 55.20 ± 12.97 years were included. Patients were followed up until the last control visit or death. There was no surgery-related mortality and the 30-day mortality rate was 8.33%; all died during postoperative hospitalization. Morbidity rate was 18.75%. Symptomatic recurrence rate was 2.08%. Cancer type and nature of the pericardial effusion were the major factors determining long-term survival (P <0.001 and P <0.004, respectively).Overall median survival was 10.41 ± 1.79 months. One- and 2-year survival rates were 45 ± 7% and 18 ± 5%, respectively. CONCLUSION: Pericardial window creation via minithoracotomy was proven to be a safe and effective approach in surgical treatment of pericardial tamponade in cancer patients. Cancer type and nature of pericardial effusion were the main factors affecting long-term survival.

Long-term results of lung decortication in patients with trapped lung secondary to coronary artery bypass grafting.

PURPOSE: To evaluate long-term results of decortications in patients with symptomatic restrictive pleurisy and trapped lung after coronary bypass grafting. METHODS: Twenty consecutive patients undergoing lung decortications for trapped lung after coronary bypass grafting were prospectively evaluated. Pulmonary function tests were used as objective criteria, and quality of life was assessed by the Medical Research Council dyspnea scale. A p value <0.05 was considered significant. RESULTS: Twenty patients, 3 women and 17 men, with a median age of 59 years were evaluated. The median time interval between coronary bypass grafting and decortications was 9.3 months. The mean preoperative forced expiratory volume in one second and forced vital capacity were 63.8% ± 7.4% and 50.5% ± 6.6% of the predicted value, respectively, and the improvement rates after decortications were 14.97% ± 6.3% and 17.62% ± 6.38%, respectively. Dyspnea scores improved after decortications (p <0.05). The median follow-up was 25 months. After surgery, 3 patients developed superficial wound infections, and out of 7 patients with prolonged air leaks, 2 underwent re-operation. After surgery, one patient died on day 34 and another, after 3 years. CONCLUSION: Lung decortications, re-expanding the affected lung, ensures symptom remission and improves quality of life of patients with trapped lung after coronary bypass grafting in the long-term.

[Tracheobronchial injuries]. / Trakeobronsiyal yaralanmalar.

BACKGROUND: We aimed in this study to investigate and compare the diagnostic and therapeutic methods in tracheobronchial injuries. METHODS: Nine cases (7 male, 2 female) operated between 2003 and 2008 because of tracheobronchial injury were included in the study. The cause of tracheobronchial injury was trauma in 7 cases and postintubation laceration in 2 cases. The cases were evaluated in terms of age, sex, type of trauma, clinical findings, localization of injury, performed diagnostic and therapeutic methods, and results. RESULTS: The causes of tracheobronchial laceration were blunt trauma in 6 cases, penetrating trauma in 1 case and iatrogenic (postintubation) in 2 cases. Lacerations were in the trachea in 5 cases and at the bronchial level in 4 cases. Operations included right upper bilobectomy in 1 case, tracheal resection and end to end anastomosis in 1 case, end to end anastomosis in 3 cases, and primary repair in 4 cases. One case died during the operation and 1 case died postoperatively. CONCLUSION: In tracheobronchial injuries, early diagnosis and treatment are very important. The most useful method is bronchoscopy for determining the type and localization of the injury. In treatment, primary repair should be preferred over anatomical resections whenever possible.

Long-term results of diaphragmatic plication in adults with unilateral diaphragm paralysis.

BACKGROUND: In this study we aimed to evaluate the long-term outcome of diaphragmatic plication for symptomatic unilateral diaphragm paralysis. METHODS: Thirteen patients who underwent unilateral diaphragmatic plication (2 patients had right, 11 left plication) between January 2003 and December 2006 were evaluated. One patient died postoperatively due to sepsis. The remaining 12 patients [9 males, 3 females; mean age 60 (36-66) years] were reevaluated with chest radiography, flouroscopy or ultrasonography, pulmonary function tests, computed tomography (CT) or magnetic resonance imaging (MRI), and the MRC/ATS dyspnea score at an average of 5.4 (4-7) years after diaphragmatic plication. RESULTS: The etiology of paralysis was trauma (9 patients), cardiac by pass surgery (3 patients), and idiopathic (1 patient). The principle symptom was progressive dyspnea with a mean duration of 32.9 (22-60) months before surgery. All patients had an elevated hemidiaphragm and paradoxical movement radiologically prior to surgery. There were partial atelectasis and reccurent infection of the lower lobe in the affected side on CT in 9 patients. Atelectasis was completely improved in 9 patients after plication. Preoperative spirometry showed a clear restrictive pattern. Mean preoperative FVC was 56.7 ± 11.6% and FEV1 65.3 ± 8.7%. FVC and FEV1 improved by 43.6 ± 30.6% (p < 0.001) and 27.3 ± 10.9% (p < 0.001) at late follow-up. MRC/ATS dyspnea scores improved 3 points in 11 patients and 1 point in 1 patient at long-term (p < 0.0001). Eight patients had returned to work at 3 months after surgery. CONCLUSIONS: Diaphragmatic plication for unilateral diaphragm paralysis decreases lung compression, ensures remission of symptoms, and improves quality of life in long-term period.

Simultaneous open-heart surgery and pectus deformity correction.

PURPOSE: Pectus deformities and cardiac problems sometimes require simultaneous surgery. We report our experience of performing this surgery and review the relevant literature. METHODS: We performed simultaneous pectus deformity correction and open-heart surgery in six patients between 1999 and 2006. The pectus deformities were pectus carinatum in one patient and pectus excavatum in five patients. The cardiac problems were coronary artery disease in one patient, an atrioseptal defect (ASD) with a ventricular septal defect (VSD) in one, a VSD in one, mitral valve insufficiency with left atrial dilatation in one, and an ascending aortic aneurysm with aortic valve insufficiency caused by Marfan's syndrome in two. We corrected the pectus deformities using the modified Ravitch's sternoplasty in all patients. First, while the patient was supine, we resected the costal cartilage; then, after completing the cardiac surgery, the sternum was closed and the additional time required for the pectus operation was calculated for each patient. Patients were examined 1, 4, and 6 months postoperatively. RESULTS: The average operation time was 102 min, and there were no major complications. The pectus bars were removed 4-6 months postoperatively. Good cardiac and cosmetic results were achieved in all patients, who were followed up for 5 years. CONCLUSIONS: Concomitant pectus deformity correction and open-heart surgery can be performed safely, eliminating the risks of a second operation in a staged procedure.

Hydatid cyst in the wall of the ascending aorta.

Hydatid disease rarely involves the aortic wall. We report a case of hydatidosis involving the ascending aorta and the left atrium. The patient underwent replacement of the ascending aorta with a prosthetic Dacron graft and left atrial cystectomy. At the 6-month follow-up, she was leading a normal life.

A new approach to pectus deformity in females.

One of the most preferred procedures for correction of pectus deformities is the modified Ravitch procedure. The main aim is cosmetic for many patients, especially in females. Two types of skin incisions have been described for this operation in the literature: midsternal and transversal. Both incisions leave a skin scar on the sternum and result in unacceptable cosmetic results. As a way of concealing the ugly skin incision scar under the breasts after puberty, we describe and discuss the use of bilateral inframammarian separated skin incisions. We have used our method for correction of pectus deformity in 12 female cases in our clinic since 1991. Two 4-5 cm incisions were localized as 1/3 medially and 2/3 laterally below both breasts. With this incision we performed the modified Ravitch technique. In spite of technical difficulties of exposure, correction of the deformity was satisfactory in all patients. Only one patient had seroma and one had perioperative pneumothorax. The patients were followed up for from 3 months to 9 years. No recurrence was observed. Breast development and sensitivity was found to benormal at follow-up. The new approach was found to be effective and more cosmetically acceptable than the other approaches for correction of pectus excavatum in female patients.