Congenital diaphragmatic hernia.

Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the diaphragm, characterized by the herniation of abdominal contents into the chest, resulting in varying degrees of pulmonary hypoplasia and pulmonary hypertension. Significant advances in the prenatal diagnosis and identification of prognostic factors have resulted in the continued refinement of the approach to fetal therapies for CDH. In the postnatal period, protocolized approaches to lung-protective ventilation, nutrition, prevention of infection, and early aggressive management of pulmonary hypertension have led to improved outcomes in infants with CDH. Surgical repair of CDH is not urgent in most circumstances and can be delayed until the pulmonary status of the patient has stabilized. This article provides a comprehensive review of CDH, focusing on the complex pathophysiology, advances in prenatal diagnosis, fetal interventions, and optimal postnatal management of CDH.

Sleep-related breathing disorders in diaphragmatic pathologies.

OBJECTIVE: The diaphragm is the most significant muscle involved in breathing. There are very few studies and cases evaluating sleep-related breathing disorders in diaphragmatic pathologies. This study compares preoperative and postoperative polysomnography (PSG) and pulmonary function test (PFT) results in diaphragmatic pathologies. MATERIAL AND METHODS: The study included 28 patients who underwent video-assisted mini-thoracotomy (VATS) due to diaphragm eventration and paralysis between January 2014 and October 2019. Pulmonary function tests (PFT) and polysomnography (PSG) were performed preoperatively in all patients, and PSG and PFT were repeated 2 months after the surgery. RESULTS: Twenty-five of the 28 patients were found to have apnea-hypopnea index (AHI) ≥ 5 (89%). A significant decrease in the preoperative TST, stage 3, and REM periods was observed. Nineteen of these patients (76%) were supine isolated or supine dominant. There was a marked improvement in AHI and PFT values after the surgery. Only five patients required a PAP device. CONCLUSION: Doctors should perform PSG in patients with diaphragm pathologies, and these patients should be operated on after considering the comorbidities when OSA is detected.

Fibrin Glue and Partial Capitonnage in Giant Hydatid Cyst in a Pediatric Patient.

Surgical procedure is still used as the first choice in the treatment of pulmonary hydatid cysts. Video-assisted thoracoscopic surgery has started to be performed as a minimally invasive surgical option in recent years for lung hydatid cyst; however, few cases have been reported in the literature, especially in children. Thoracoscopic surgery experience is limited in pulmonary hydatid cyst for both adults and children. We present a pediatric case of giant lung hydatid cyst, in which we performed partial capitonnage with video-assisted thoracoscopic surgery and fibrin glue.

Infarct Volumes of Patients with Acute Ischemic Stroke Receiving Direct Oral Anticoagulants due to Non-Valvular Atrial Fibrillation.

Direct oral anticoagulants (DOACs) have been shown to decrease the risk of ischemic stroke in non-valvular atrial fibrillation (NVAF). This study aims to investigate whether DOACs result in a significant change in lesion volume and the severity of the subsequent disability in patients who have experienced a stroke. METHODS: The study included a total of 137 patients with NVAF and acute stroke. The cohort included 76 patients using DOACs, 21 patients using acetylsalicylic acid (ASA), and 40 patients with newly diagnosed atrial fibrillation (NDAF) who did not use antiaggregants or anticoagulants. Diffusion-weighted MRI was performed 6-12 hours after the first stroke symptoms and infarct volumes were measured by two independent observers. Baseline National Institutes of Health Stroke Scale (NIHSS) score, modified Rankin Scale (mRS) score at discharge and period of hospitalization were calculated. RESULTS: When patients using DOACs due to NVAF and patients with NDAF were compared, the volumes of patients using DOACs (median 7.8 vs 23.1 cm3; P ≤ 0.01) were statistically significantly smaller. However, there was no difference in volume between ASA users (median 16.9 cm3; P = 0.16) and patients with NDAF. The DOACs group was significantly different compared to the NDAF group in terms of NIHSS scores (median 4.4 vs 8.3; P ≤ 0.01) and mRS scores at discharge (median 1.7 vs 2.7; P ≤ 0.01), and period of hospitalization (median 6.4 vs 10.4 days; P ≤ 0.01). CONCLUSION: We observe, while using DOACs, the infarct volumes of patients who experience stroke are smaller than those with NDAF and using ASA, as well as mRS scores at discharge are low and length of hospital stay is short.

Clinical outcomes in the surgical treatment of esophageal leiomyoma: A retrospective evaluation of 13 cases.

BACKGROUND: In this study, we aimed to evaluate the surgical outcomes after enucleation of esophageal leiomyomas and present the feasibility of enucleation using video-assisted thoracoscopic surgery. METHODS: The medical records of 13 patients (8 males, 5 females; mean age 45.9 years; range, 30 to 69 years) who underwent open or thoracoscopic surgery for an esophageal leiomyoma between April 2007 and June 2019 were retrospectively reviewed. The patients were evaluated with regard to age, sex, presenting symptoms, duration of symptoms, size and localization of tumors, diagnostic methods, surgical methods, conversion to open surgery, morbidity and mortality, discharge time, and follow-up period. RESULTS: Of the patients, four were operated via thoracotomy and nine via video-assisted thoracoscopic surgery. Enucleation was successfully completed with thoracoscopy in five patients. Four patients required conversion to thoracotomy. In the early postoperative period, two of these four patients developed complications and underwent re-thoracotomy. A solitary leiomyoma was detected in all, but one patient (multiple). The mean size of the tumors was 68.4 mm. Complications were seen in only one patient during follow-up and no recurrence was observed in any patient. CONCLUSION: Our study results indicate that thoracoscopic enucleation of esophageal leiomyoma is a safe, feasible, and effective technique in selected patients and conversion to open surgery can be easily done for any reason during the procedure.

Prognostic significance of pathological complete response in non-small cell lung cancer following neoadjuvant treatment.

BACKGROUND: This study aims to investigate the factors associated with pathological complete response following neoadjuvant treatment and to examine the prognostic value of pathological complete response in patients with non-small cell lung cancer undergoing surgical resection. METHODS: Between February 2009 and January 2016, a total of 112 patients (96 males, 16 females; mean age 60±8 years; range, 37 to 85 years) with the diagnosis of non-small cell lung cancer who underwent anatomical pulmonary resection after neoadjuvant treatment were retrospectively analyzed. Demographic, clinical, radiological, and pathological characteristics of the patients were recorded. The patients were classified as pathological complete response and nonpathological complete response according to the presence of tumors in the pathology reports. Predictive factors for pathological complete response and its prognostic significance were analyzed. RESULTS: The mean follow-up was 35±20 (range, 0 to 110) months. Of the patients, 30 (27%) achieved a pathological complete response. Reduction rate in tumor size was significantly higher in the responsive group (32.5±21.6% vs. 19.2±18.8%, respectively) and was a predictor of pathological complete response independent from the T and N factors (p=0.004). Survival of the responsive patients was significantly longer than unresponsive patients (75±9 vs. 30±4 months, respectively; p<0.001). During follow-up, tumor recurrence was seen in 30 patients. Recurrence was observed in only one patient in the responsive group, while 29 patients in the unresponsive group had recurrence or metastasis. CONCLUSION: Tumor shrinkage rate after neoadjuvant treatment in non-small cell lung cancer is a predictive factor for pathological complete response. Survival of patients with a pathological complete response is also significantly longer than unresponsive patients.

Prognostic Importance of the Lymph Node Factor in Surgically Resected Non-Small Cell Lung Cancer.

BACKGROUND: Patients with N1 non-small cell lung cancer represent a heterogeneous population. The aim of this study is to determine the difference of survival rate between subtypes of N1 disease in surgically resected non-small cell lung cancer patients and to compare the survival in these patients with multi-N1 and single N2 (skip metastasis) disease. METHODS: Patients who underwent anatomical pulmonary resection in our institution between 2007 and 2014 with a pathological diagnosis of N1 and single N2 positive non-small cell lung cancer were included in the study. N1 positive patients were divided into three groups as single hilar; single interlobar, lobar, or segmental; and multiple N1 positive patients. These groups were compared among themselves as well as with incidentally found single N2 patients. RESULTS: A total of 1,742 patients who had non-small cell lung cancer underwent anatomical lung resection. The survival was better in single hilar lymph nodes than other subtypes of N1 disease (p = 0.015). There was no statistically significant difference in terms of survival between the other subtypes of N1 disease (p = 0.332). The difference in survival for single N2 disease compared with multi-N1 was not statistically significant (p = 0.054). Also, when we divided the groups as single and multi-N1, there was a significant difference in survival (p = 0.025). CONCLUSION: Single hilar lymph nodes with direct invasion have better survival rate than other subtypes of N1. Also, patients with multiple N1 positive lymph nodes have similar survival results compared with single N2 patients. Our results should be confirmed with larger series to better explain N1 disease.

Rare Lung Tumors: Alveolar Adenoma-Four Case Reports.

Alveolar adenoma is one of the rarely seen benign tumors of the lung, to date, one or two series have been reported. In this study, four rare alveolar adenoma cases were presented, thereby contributing to the existing scarce data.

Correlation between meteorological changes and primary spontaneous pneumothorax: Myth or fact?

BACKGROUND: This study aims to investigate the relationship between meteorological changes and the development of primary spontaneous pneumothorax. METHODS: Medical records of 1,097 patients ( 975 males, 122 females; mean age 23.5±4.2 years; range, 17 to 32 years) admitted to our hospital with a diagnosis of primary spontaneous pneumothorax between January 2010 and January 2014 were evaluated retrospectively. Daily mean values for air temperature, wind speed, humidity rate and atmospheric pressure values obtained from the local meteorological observatory were recorded. The four-year study period was separated into two groups as days with at least one primary spontaneous pneumothorax development (group 1) and days without any primary spontaneous pneumothorax development (group 2). RESULTS: Within the study period of a total of 1,461 days, 1,097 cases were recorded in 759 days during which primary spontaneous pneumothorax was observed. Eighty-nine percent of the patients were male. There was no significant difference between the groups in terms of mean air temperature, humidity rate, and wind speed. Atmospheric pressure was significantly lower in group 1 (p<0.001). Decrease in atmospheric pressure with respect to the previous day increased the risk of primary spontaneous pneumothorax development significantly (p<0.001). CONCLUSION: In our study, low atmospheric pressure and significant pressure decreases showed a strong correlation with primary spontaneous pneumothorax. Temperature, wind speed, and humidity values did not influence primary spontaneous pneumothorax development.

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.

Video-assisted minimally invasive diaphragmatic plication: feasibility of a recognized procedure through an uncharacteristic hybrid approach.

BACKGROUND: Diaphragmatic plication is an approved surgical procedure for treatment of symptomatic diaphragmatic paralysis and eventration. We aim to define our minimally invasive technique of plication and objectively assess our surgical outcomes of the largest series reported in the literature so far, using pulmonary function tests. METHODS: Symptomatic patients whom were planned to undergo plication using video-assisted mini-thoracotomy between December 2009 and December 2015 were the cohort of this retrospective study. Single camera port and a utility incision (3-4 cm) were used for access. Data of patient demographics with preoperative and postoperative spirometric results were collected for statistical comparison. RESULTS: Procedure (30 left, 7 right) was completed in 37 (27 male, 10 female) patients. One patient was excluded because of insufficient objective postoperative comparison criteria due to previous permanent tracheostomy. Mean length of surgery was 48.8 ± 19.7 (range: 30-70) min. Postoperative overall morbidity was 8.3 %, with no mortality. The mean length of hospital stay was 3.1 ± 1.7 days. All patients except one (97.3 %) were asymptomatic on discharge and on follow-ups. Significant improvement in measurements of forced expiratory volume in 1st second was observed on postoperative measurements (P < 0.001), with a mean overall increase of 13 % in whole cohort. No recurrence was detected throughout a mean follow-up of 19 months. CONCLUSIONS: Diaphragmatic plication via video-assisted mini-thoracotomy is an effective and curative surgical procedure which can be performed successfully with low morbidity rates. As it combines the rapidity and economical benefits of open thoracotomy with the advantages of video thoracoscopic procedures such as fast recovery and short postoperative hospital stay, it can be preferred as a safe and effective alternative hybrid method compared to standard open or closed techniques, for symptomatic patients with non-functional hemidiaphragm.

Is polysomnographic examination necessary for subjects with diaphragm pathologies?

OBJECTIVES: While respiratory distress is accepted as the only indication for diaphragmatic plication surgery, sleep disorders have been underestimated. In this study, we aimed to detect the sleep disorders that accompany diaphragm pathologies. Specifically, the association of obstructive sleep apnea syndrome with diaphragm eventration and diaphragm paralysis was evaluated. METHODS: This study was performed in Süreyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital between 2014-2016. All patients had symptoms of obstructive sleep apnea (snoring and/or cessation of breath during sleep and/or daytime sleepiness) and underwent diaphragmatic plication via video-assisted mini-thoracotomy. Additionally, all patients underwent pre- and postoperative full-night polysomnography. Pre- and postoperative clinical findings, polysomnography results, Epworth sleepiness scale scores and pulmonary function test results were compared. RESULTS: Twelve patients (7 males) with a mean age of 48 (range, 27-60) years and a mean body mass index of 25 (range, 20-30) kg/m2 were included in the study. Preoperative polysomnography showed obstructive sleep apnea syndrome in 9 of the 12 patients (75%), while 3 of the patients (25%) were regarded as normal. Postoperatively, patient complaints, apnea hypopnea indices, Epworth sleepiness scale scores and pulmonary function test results all demonstrated remarkable improvement. CONCLUSION: All patients suffering from diaphragm pathologies with symptoms should undergo polysomnography, and patients diagnosed with obstructive sleep apnea syndrome should be operated on. In this way, long-term comorbidities of sleep disorders may be prevented.

Is polysomnographic examination necessary for subjects with diaphragm pathologies?

OBJECTIVES: While respiratory distress is accepted as the only indication for diaphragmatic plication surgery, sleep disorders have been underestimated. In this study, we aimed to detect the sleep disorders that accompany diaphragm pathologies. Specifically, the association of obstructive sleep apnea syndrome with diaphragm eventration and diaphragm paralysis was evaluated. METHODS: This study was performed in Süreyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital between 2014-2016. All patients had symptoms of obstructive sleep apnea (snoring and/or cessation of breath during sleep and/or daytime sleepiness) and underwent diaphragmatic plication via video-assisted mini-thoracotomy. Additionally, all patients underwent pre- and postoperative full-night polysomnography. Pre- and postoperative clinical findings, polysomnography results, Epworth sleepiness scale scores and pulmonary function test results were compared. RESULTS: Twelve patients (7 males) with a mean age of 48 (range, 27-60) years and a mean body mass index of 25 (range, 20-30) kg/m2 were included in the study. Preoperative polysomnography showed obstructive sleep apnea syndrome in 9 of the 12 patients (75%), while 3 of the patients (25%) were regarded as normal. Postoperatively, patient complaints, apnea hypopnea indices, Epworth sleepiness scale scores and pulmonary function test results all demonstrated remarkable improvement. CONCLUSION: All patients suffering from diaphragm pathologies with symptoms should undergo polysomnography, and patients diagnosed with obstructive sleep apnea syndrome should be operated on. In this way, long-term comorbidities of sleep disorders may be prevented.

The Most Minimally Invasive Lobectomy: Videomediastinoscopic Lobectomy.

Transcervical approaches are well-described procedures. However, they are performed in a limited number of experienced centers. Transcervical lobectomies are even rarer. However, these lobectomy cases defined in the literature are performed through a collar incision with the aid of a sternal retractor. The case presented here describes the first right upper lobectomy through videomediastinoscopy without sternal elevation.

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.

Comparison of Mid-Term Clinical Outcomes of Different Surgical Approaches in Symptomatic Diaphragmatic Eventration.

PURPOSE: There is no data comparing different surgical techniques for diaphragmatic re-positioning for hemi-diaphragmatic eventration in adults. Our aim was to verify the potential pros and cons of two major surgical techniques in symptomatic eventration patients. METHODS: Patients undergoing thoracotomy for diaphragmatic elevation repair either by un-opened (accordion placation) or by opened (double-breasted placation) diaphragmatic technique between January 2007 and August 2013 were analyzed retrospectively, and compared in terms of operative outcomes on 12th and 24th months. RESULTS: Forty-two patients underwent accordion (n = 23) or double-breasted (n = 19) plication. Postoperative drainage was significantly increased (215 ± 66 ml vs. 114 ± 48 ml; P = 0.0082) in double-breasted group. Although the corrected diaphragm was radiologically better preserved in this group, this divergence showed no additional effect on postoperative pulmonary functions or the dyspnea score on 12th or 24th months. No complication particularly related to both techniques or recurrence was noted during follow-up of 28 ± 12 months. CONCLUSIONS: Radiological prospect of corrected diaphragm is better preserved with double-breasted plication, but the significant and permanent improvement of respiratory functions was similar. Since the clinical outcome is equivalent, incision of the diaphragm is not essential.

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.

A Bronchopleurocutaneous Fistula Caused by Unexpected Foreign Body Aspiration: False Barley (Hordeum murinum).

A 13-year-old boy with no previous history of foreign body aspiration, presenting with side pain, was referred to our clinic with a pneumonia diagnosis by an external medical facility where he had been started on antibiotic treatment. Consolidation in the right inferior lobe and minimal pleural effusion were found on the lung radiograph and computed tomography scan. Skin hyperemia and abscess formation in the right chest were observed subsequently. A drain was placed; bronchoscopy, sampling for cultures, and a biopsy were performed. Four months after this first episode ended with inconclusive results, the patient returned, reporting that a spike of grass was protruding from the continued abscess drainage. The skin lesion closed after emptying of the abscess cavity; a check-up bronchoscopy was unremarkable. The extrusion from the skin of the foreign body, a rare event in the published literature, was our first such case.