A case of acute fibrinous and organizing pneumonia during early postoperative period after lung transplantation.

Acute fibrinous and organizing pneumonia (AFOP) is a distinct histologic pattern usually classified under the term chronic lung allograft dysfunction. We present a 48-year-old female patient who experienced AFOP during the 2nd week of double lung transplantation for pulmonary Langerhans cell histiocytosis and secondary pulmonary hypertension. During the 8th day after transplantation, fever and neutrophilia developed together with bilateral consolidation. Infection markers were elevated. Despite coverage of a full antimicrobial spectrum, the situation progressed. The patient was diagnosed with AFOP with transbronchial biopsy. The infiltration resolved and the patient improved dramatically with the initiation of pulse corticosteroid treatment. AFOP should be suspected when there is a pulmonary consolidation after lung transplantation, even in the very early post-transplantation period. Several causes, such as alveolar damage and drug reactions, should be considered in the differential diagnosis.

Clinical and characteristic features of surgically treated endobronchial hamartoma cases: analysis of twenty-two cases.

PURPOSE: Endobronchial hamartomas are tumors originating from peribronchial mesenchymal tissues. Generally, endobronchial methods are used in the treatment of these tumors, which are usually benign. Surgery is used in cases of endobronchial hamartoma that cannot be fully treated with endobronchial methods, or that developed parenchyma destruction due to bronchial obstruction. The objective of this study is to assess clinical and characteristic features of surgically treated cases of endobronchial hamartoma. MATERIALS AND METHODS: Twenty-two patients who underwent anatomic resection between 1988 and 2011 in our clinic were diagnosed with hamartoma. Clinical and characteristic features of these patients (17 males and 5 females) were assessed retrospectively via patient records. RESULTS: Patients were aged between 43 and 72 (average 54.4). Fifteen patients underwent lobectomy (lobectomy for 13 patients, bilobectomy for 1), 6 patients underwent bronchotomy, 1 patient underwent tracheotomy and 1 underwent pneumonectomy. Pathologic diagnosis was chondromatosis hamartoma for 9 patients and lipomatosis hamartoma for 6 patients; dominant cell type was not detected for 7 patients. No surgery-related mortality was observed. No recurrence was observed for patients after the surgery. CONCLUSIONS: Endoscopic treatment methods yield successful results in endobronchial hamartomas. However, surgery is required in cases that develop irreversible parenchymal destruction due to chronic obstruction and suppuration, or those that cannot be treated via endobronchial methods.

Intrathoracic hibernoma: an uncommon tumour / Hibernoma intratorácico: un tumor poco frecuente

Hibernomas are uncommon benign tumours that arise from the remnants of fetal brown adipose tissue. They are usually asymptomatic and have a slow growth pattern. Intrathoracic and pleural locations are exceptional for localization of hibernoma. A review of the English language medical literature revealed more than 110 cases, 20 of which were intrathoracic. In the article below, we discuss a 40-year old male patient who had pleural involvement and was treated by surgical resection. Following resection, the patient has remained problem-free for nine years.

Los hibernomas son tumores benignos poco frecuentes que surgen de restos del tejido adiposo marrón fetal. Son generalmente asintomáticos y tienen un patrón de crecimiento lento. Las localizaciones intratorácicas y pleurales son excepcionales para la localización del hibernoma. Una revisión de la literatura médica en lengua inglesa reveló más de 110 casos, 20 de los cuales se trataban de hibernomas intratorácicos. En el siguiente artículo, discutimos el caso de un paciente de 40 años de edad, que tenía una afección pleural y fue tratado con una resección quirúrgica. Después de la resección, el paciente ha permanecido sin problemas durante nueve años.

Radiation therapy for resistant sternal hydatid disease.

Hydatid disease is a zoonotic infectious disease for which there are known treatment procedures and effective antibiotics; however, there are resistant cases that do not respond to medication or surgery. We report a case diagnosed as hydatid disease of the chest wall and treated with radiation therapy (RT) after medical and surgical therapy had failed. In conclusion, RT represents an alternative treatment modality in resistant cases.

Intrathoracic hibernoma: an uncommon tumour.

Hibernomas are uncommon benign tumours that arise from the remnants of fetal brown adipose tissue. They are usually asymptomatic and have a slow growth pattern. Intrathoracic and pleural locations are exceptional for localization of hibernoma. A review of the English language medical literature revealed more than 110 cases, 20 of which were intrathoracic. In the article below, we discuss a 40-year old male patient who had pleural involvement and was treated by surgical resection. Following resection, the patient has remained problem-free for nine years.

A new risk factor in oesophageal cancer aetiology: hyperthyroidism.

PURPOSE: In individuals with malignant disease, many qualitative and quantitative hormonal changes have been detected. Although there are many studies showing that there is a relationship between thyroid hormone disorders and certain tumours, no study investigating the association between oesophageal cancer and thyroid diseases has been reported. The present study was designed to evaluate whether there is a relationship between oesophageal cancer and thyroid hormones. METHODS: In a prospective study conducted between December 2006 and February 2008, thyroid functions were studied in a group of 102 sequential patients with oesophageal cancer and a control group of 160 sequential patients without oesophageal cancer, presenting to the Thoracic Surgery Department of Ataturk University. Age, gender, tumour location and histological type in patients with oesophageal cancer were recorded. RESULTS: Of 102 patients with oesophageal cancer, 21 (20.58%) had hyperthyroidism, 2 (1.96%) had hypothyroidism and 6 (5.88%) exhibited nodular/multinodular goitre on ultrasonography and computed tomography. In the control group, 8 patients (5.0%) had hyperthyroidism, 4 (2.5%) had hypothyroidism and 7 (4.38%) showed nodular/multinodular goitre. In patients with oesophageal cancer, the incidence of hyperthyroidism was found to be significantly higher compared to the control group (p < 0.001). CONCLUSION: Data show that there may be an important relationship between oesophageal cancer and hyperthyroidism. We believe that thyroid hormone levels should be measured in all cases of oesophageal cancer. In further prospective and experimental studies, the physiopathology of this relationship can be fully explained.

Effect of intrapleural povidone-iodine lavage on thyroid hormones in thoracic surgery.

OBJECTIVE: Povidone-iodine (PI) is an effective disinfectant used in many surgical operations. It is known that PI is absorbed by the skin after application. Absorption is even greater in infants, as their skin is thinner and more permeable. Iodine absorption in the orbita, neck and during abdominal surgery has been previously investigated, but such a study has not been performed for the pleura, which has a greater area and capacity for absorption. In this study, we investigated the effect of intraoperative povidone-iodine lavage on thyroid hormones during thoracic surgery. MATERIAL AND METHOD: Fifty patients without any thyroid pathology scheduled for thoracotomy were divided into 2 groups. Group A (n = 25) was given intraoperative saline lavage, while group B (n = 25) had povidone-iodine lavage. Levels of free T3 (FT3), free T4 (FT4) and thyroid-stimulating hormone (TSH) measured 1 day preoperatively and 1 day postoperatively were analyzed. RESULTS: There was a statistically meaningful change in FT3 levels ( P = 0.033) between groups, but the measured changes in FT4 and TSH levels were not statistically significant ( P = 0.98 and P = 0.71, respectively). FT3 scores for group A were decreased postoperatively compared to the scores for group B, but all results were in normal ranges. In group A, the changes between preoperative and postoperative levels of FT3 and FT4 were statistically significant, while changes in TSH levels were not. In group B, changes in FT4 levels were statistically significant and changes in FT3 and TSH levels were not. CONCLUSIONS: The scores show that the iodine absorbed by the pleura during intraoperative povidone-iodine lavage has an effect on thyroid function. Intrapleural PI lavage results in changes to some thyroid hormone levels due to pleural absorption. Thus, intrapleural PI lavage should be used with care.

The use of self-expandable metallic stents for palliative treatment of inoperable esophageal cancer.

Most patients with esophageal carcinoma present in the advanced stage die from tumor invasion and widespread metastases. Because radical regimens are not appropriate for the majority of patients, and their expected survivals are as short as to be measured by months, the main aim of therapy is palliation with minimum morbidity and mortality. Among the palliative modalities are surgery, external radiotherapy or brachytherapy, dilatation, laser, photodynamic therapy, bipolar electrocoagulation tumor probe, and chemical ablation. The placement of self-expandable metallic stents is another method that improves dysphagia for these patients. In this study, the aim was to evaluate retrospectively the effectiveness of metallic stents deployed because of inoperable malignant esophageal stenosis and esophagotracheal fistulas. The results of 170 patients with 202 stents administered because of inoperable malignant esophageal stenosis and esophagorespiratory fistula between January 2000 and October 2008 at the Ataturk University, Department of Thoracic Surgery, were investigated. Despite epidemiological and clinical data, information regarding relief of dysphagia and quality of life were also examined. One hundred seventy patients with stents were between 28 and 91 years old (mean age 63.7 years+/-11.4 years). Ninety-seven were male and 73 were female. Stent indications were advanced tumors with distant metastasis (82 cases, 48.2%), unresectable tumors (51 cases, 30%), patients who cannot tolerate surgery or chemoradiotherapy (18 cases, 10.5%), local recurrence after primary therapy (1 case, 0.5%), esophagorespiratory fistulas from tumor or therapy (14 cases, 8.2%), and refusal of surgery (4 cases, 2.3%). Dysphagia scores evaluated by a modified Takita's grading system improved from 3.4 before the procedure to 2.6 afterward. The overall complication rate without chest pain was 31.7% (occurring in 64 cases). Mean survival was 177.7 days+/-59.3 days (2-993 days). Quality-of-life scores (The European Organization of Research and Treatment of Cancer QLQ C30) improved from 73+/-10.3 (57-85) to 112+/-12.6 (90-125). In therapy of malignant esophageal obstructions, metallic stents provide a significant improvement in dysphagia and require less frequent re-intervention according to other methods of dysphagia palliation such as dilatation, laser, and photodynamic therapy, nearly completely relieve esophagotracheal fistulas and improve quality of life to an important degree.

Current management of esophageal perforation: 20 years experience.

Esophageal perforations are surgical emergencies associated with high morbidity and mortality rates. No single strategy has been sufficient to deal with the majority of situations. We aim to postulate a therapeutic algorithm for this complication based on 20 years of experience and also on data from published literature. We performed a retrospective clinical review of 44 patients treated for esophageal perforation at our hospital between January 1989 and May 2008. We reviewed the characteristics of these patients, including age, gender, accompanying diseases, etiology of perforation, diagnosis, location, time interval between perforation and diagnosis, treatment of the perforation, morbidity, hospital mortality, and duration of hospitalization. Perforation occurred in the cervical esophagus in 14 patients (31.8%), thoracic esophagus in 18 patients (40.9%), and abdominal esophagus in 12 patients (27.3%). Management of the esophageal perforation included primary closure in 23 patients (52.3%), resection in 7 patients (15.9%), and nonsurgical therapy in 14 patients (31.8%). In the surgically treated group, the mortality rate was 3 of 30 patients (10%), and 2 of 14 patients (14.3%) in the conservatively managed group. Four of the 14 nonsurgical patients were inserted with covered self-expandable stents. The specific treatment of an esophageal perforation should be selected according to each individual patient. To date, the most effective treatment would appear to be operative management. With improvements in endoscopic procedures, the morbidity and mortality rates of esophageal perforations are significantly decreased. We suggest that minimally invasive techniques for the repair of esophageal perforations will be very important in the future treatment of this condition.

The management of esophagogastric anastomotic leak after esophagectomy for esophageal carcinoma.

Esophagogastric anastomotic leaks are the most feared surgical complications following resection of esophageal cancers. We aimed to develop a therapeutic algorithm for this complication characterized by high morbidity and mortality using our 20 years of experience and the published literature. A total of 354 patients who had undergone an esophagectomy and esophagogastric anastomosis due to esophageal carcinoma were evaluated retrospectively. The incidence for anastomotic leak was 15.5% (n = 90) in the cervical region and 4.2% (n = 264) in the thoracic region (mean: 7.1%). Cervical anastomotic leaks were detected after a mean period of 7.2 days following the procedure. Fourteen patients with cervical leaks were treated conservatively. Four out of 14 patients (28.6%) died due to sepsis and multi-organ failure related to fistula. Thoracic anastomotic leaks were detected after a mean period of 4.7 days following the procedure. Emergency reoperation, resection and reconstruction procedures were performed in one patient. Self-expanding metallic coated stents were placed at the anastomosis region in two patients. A more conservative approach was employed in other patients with thoracic anastomotic leaks. Six of them (46.2%) died due to fistula. General mortality rate was 37.0%, and the duration of hospitalization was 40.0 days for patients with anastomotic leaks. Cervical anastomotic leaks are more common than thoracic anastomotic leaks, but most of them are successfully treated with conservative approaches. Thoracic anastomotic leaks that in the past were related to high mortality rates despite conservative or surgical procedures might be successfully treated nowadays with the use of self-expanding metallic coated stents.

Completion pneumonectomy for bronchiectasis: morbidity, mortality and management.

BACKGROUND: Completion pneumonectomy performed for benign causes is associated with a high morbidity and mortality. We analyzed the patients who underwent completion pneumonectomy procedure for bronchiectasis, which constitutes a specific benign condition, together with the indications for surgery, the difficulties encountered during operations and the postoperative results. METHODS: Records of all patients who underwent completion pneumonectomy for the diagnosis of brochiectasis between January 1991 and April 2006 at the thoracic surgery clinic of a training and research hospital specializing in chest diseases and chest surgery were retrospectively evaluated. The age and the gender of the patients, etiologic factors, symptoms, characteristics of the first operation, the time between the first operation and completion pneumonectomy, and postoperative follow-up are examined. RESULTS: During the evaluation period of more than 15 years, 23 patients underwent completion pneumonectomy. The median age of these 23 patients was 28 (range: 9 - 53); 17 of the patients were male and 6 were female. The most common indication for surgery was recurrent lung infections (n = 15). The most common symptoms were cough (n = 21), expectoration (n = 19), and hemoptysis (n = 15). The mean time between the first operation and the completion pneumonectomy was 4.9 years (range: 5 months - 11 years). Left completion pneumonectomy was performed in 14 and right completion pneumonectomy was performed in 9 cases. The mean duration of hospital stay was 16.7 days (range: 12 - 42 days). The course after surgery was uneventful in all patients. The mortality rate was 0 % and morbidity was 43.5 %. CONCLUSION: Although completion pneumonectomy for benign causes is a high risk procedure, it can be performed in selected patients with an acceptable morbidity and mortality after an effective preoperative medical therapy for inflammation of the lungs and with careful dissection at the operation.

Follicular thyroid carcinoma: metastasis to the sternum, 13 years after total thyroidectomy.

Primary and metastatic malignancies of the sternum are uncommon. Secondary lesions to the sternum occur more commonly in patients with lung and breast cancer, and only a few cases of sternal metastasis arising from a follicular thyroid carcinoma have been reported in the literature. Rarely, metastases to the sternum present in the guise of primary sternal tumours may be treated surgically with that diagnosis in mind. We describe a case of a sternal mass treated by radical surgery, which ultimately proved to be a solitary metastasis from a follicular carcinoma of the thyroid, appearing 13 years after total thyroidectomy and radioactive iodine therapy. Late metastatic thyroid carcinoma to the sternum should be kept in mind in the differential diagnosis of sternal lesions. For patients with thyroid carcinoma and sternal metastasis, we recommend surgical resection of the metastasis, not only as a curative or palliative measure but also to maximise the effect of subsequent radioiodine treatment.

Serum levels of IGF-I and IGFBP-III and their relation with carcinoembryonic antigen and carbohydrate antigen 19-9 in cases of esophageal cancer.

Tumour markers are used for diagnosis, staging, evaluation of response to treatment, prognosis and detection of recurrences in clinical oncology. In this study, we aim to investigate the levels of insulin-like growth factor (IGF)-I and IGF-binding protein (IGFBP)-III in cases with oesophageal carcinoma. We investigated their possible use as tumour markers and their relation to other tumour markers. Forty patients who were diagnosed as having oesophageal carcinoma by histopathological evaluation of endoscopic biopsies between January 2003 and July 2004 and 40 healthy people as the control group were included in the study. The serum levels of tumour markers including IGF-I, IGFBP-III, carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 were measured in both groups. Data were compared statistically, and the importance of IGF-I and IGFBP-III levels were investigated in cases with oesophageal carcinoma. IGF-I levels were significantly higher in patients with oesophageal carcinoma when compared with the control group (p < 0.05), whereas IGFBP-III levels were significantly lower (p < 0.05). The increase in CEA levels was not statistically significant when compared with the control group. The increase in CA 19-9 levels was statistically significant when compared with the control group (p < 0.05). No correlation was detected between levels of IGF-I and IGFBP-III and levels of CEA and CA 19-9. We suggest that the serum IGF-I level may be used as a tumour marker in oesophageal carcinoma. A low level of serum IGFBP-III is also significant in cases with oesophageal carcinoma. We believe that drugs which inhibit IGF-I function or which stimulate the function of IGFBP-III may open new horizons in extra-surgical modalities for the treatment of oesophageal cancer.

Oesophageal adenoid cystic carcinoma and its management options.

Adenoid cystic carcinoma (ACC) commonly originates in the major salivary glands and respiratory tract, but extremely rarely in the oesophagus. We report the surgical and pathologic findings of a primary ACC of the oesophagus in a 59-year-old woman, and review the management options of this tumour.

Surgical approach of pulmonary hydatidosis in childhood.

To review the results of different surgical treatment in hydatid disease of the lung in paediatric patients. A total of 102 children with pulmonary hydatid cysts were treated at the our clinic in the period from 1990 to 2001. There were 59 boys and 43 girls and their age ranged from 4 to 16 years (mean 10.2). Chest radiography, computed tomography and abdominal ultrasonography were the most commonly used diagnostic techniques. The cysts were located in the right lung in 68 patients (66.6%), in the left lung in 30 patients (29.4%), in both lungs in four patients (3.9%). Concomitant liver cyst hydatid was also detected in 12 patients that were located at right lung, and two patients with bilateral lung involvement. All cases were managed surgically. Of 14 cases with concomitant liver and intrathoracic hydatid cysts, right thoracophrenotomy was performed in 12, median sternotomy in one, and phrenotomy in other. Partial cystectomy and capitonnage were the most commonly used surgical methods. Post-operative complication was seen in 10 (9.8%) patients. Infection at the incision site occurred in four patients and air leakage in three. Complications of capitonnage were seen in three patients. One patient (1%) died at fourth post-operative day due to sepsis. Parenchyma protective operations should be performed especially in children living in endemic areas because of the possibility of recurrence of the disease in the future. Single stage operations in suitable cases decrease the cost of treatment and make surgical therapy suitable in both children and young adults, by reducing the hospital in-patient time and morbidity.

Combination of paraesophageal hernia and Morgagni hernia in an old patient.

Paraesophageal hiatal hernia is an uncommon condition that requires urgent correction to prevent life-threatening complications. It is present in 14% of all hiatal hernias. The incidence of Morgagni hernia among all diaphragmatic defects is 3-4% and about 90% of the hernias occur on the right, 8% are bilateral and 2% are on the left. The combination of a Morgagni hernia and paraesophageal hernia is very rare and only four cases have been reported in the literature. All of them occurred in the right. This report describes an old case admitted to our clinic with dyspnea, chest pain and chronic gastrointestinal symptoms, found to have combined left Morgagni and paraesophageal hernia. Surgical repair was performed via transabdominal approach. This unusual case and surgical approaches are discussed in light of the data presented in the literature.

Mediastinal bronchogenic cyst treated by mediastinoscopic drainage.

Bronchogenic cysts are rare congenital anomalies located in the mediastinum and lung parenchyma. We present the clinical findings and describe the mediastinoscopic treatment of a bronchogenic cyst at the subcarinal space in a 50-year-old man. CT revealed a lesion at the subcarinal space with soft tissue density. Initially, mediastinoscopy was performed for diagnostic purposes. Histopathological evaluation of biopsy material taken from the cyst wall confirmed that the lesion was a bronchogenic cyst. The cyst contents were drained and a sclerosant agent was applied to the cyst lumen via the drainage tube. Mediastinoscopy not only provides diagnostic information but can also be used safely in the treatment of anterior bronchogenic cysts in patients not amenable to a second operation.

Esophageal tuberculosis abscess: an unusual cause of dysphagia.

Primary esophageal tuberculosis is extremely rare. It is almost always secondary to tuberculosis of other organs. Abscess formation of the tuberculosis in the esophageal wall has not been reported in the literature previously. In this report, we present a case of esophageal tuberculosis abscess, with presented dysphagia, diagnosed by histologic evaluation of surgery specimen, without any other organ involvement. The unusual cause and the interesting clinical course of dysphagia are described.