Measurement of interscalene space volume in diagnosis of thoracic outlet syndrome: a cadaver study

Background/aim: The aim of this study was to measure the volume of interscalene space in thoracic outlet region on cadavers and radiological images and to analyze the potential value of these measurements in diagnosis and treatment of thoracic outlet syndrome (TOS). Materials and methods: The dimensions of the anterior interscalene space in 8 formalin-fixed human cadavers were studied by direct measurement and additionally evaluation of the volume of this space were done by using mold and volume calculation formula of square pyramid, due to resembling a pyramid. In the second phase of this study, interscalene space volume was calculated by formula and compared to calculations from computed tomography (CT) sections in 18 TOS and 16 control patients. Results: There was a strong correlation between the volume calculated by formula (4.79 ± 2.18 cm3) and by mold (4.84 ± 1.58 cm3), (R = 0.934, p = 0.001) in cadavers. The average volume measured in TOS patients (2.05 ± 0.32 cm3) was significantly smaller than control patients (4.30 ± 1.85 cm3, p < 0.0001). There were excellent or good results in 14 patients whereas in 4 patients who had neurogenic TOS achieved fair results after surgery. In these 4 patients the average volumes of abnormal sides were close to the healthy sides. Conclusion: In our study, volume of interscalene space in TOS patients was statistically smaller than control group. Also, the volume was even smaller in patients with excellent or good results after surgery. In this respect, volumetric measurements from CT sections could be used in diagnosis and treatment selection in TOS patients.

Long-term survival after R0 resection of thymoma.

Background The aim of this study was to evaluate the results of R0 resection of thymoma to identify prognostic factors for long-term outcomes. Methods Data of 62 patients (28 male, 34 female) with a mean age of 47.26 ± 14.42 years, who underwent R0 resection for thymoma and were followed-up between February 2004 and March 2016, were analyzed retrospectively. Results Eight patients had a video-assisted thoracoscopic thymectomy and 54 had a transsternal extended thymectomy. During a mean follow-up of 128.67 ± 7.95 months, regional recurrence of thymoma was observed in 9 (14.5%) patients. Overall 5- and 10-year survival rates were 85.36% and 78.20%, respectively. The 5- and 10-year survival rates in patients aged < 50 years were significantly better than in those aged ≥ 50 years (92% and 72% vs. 88% and 39%, p < 0.0001). The 10-year overall survival of patients in Masaoka stage I and II was better than those in stage III (88.9%, 78.4%, 69.8%, respectively, log-rank p < 0.001). The 10-year survival of patients with World Health Organization histological type A, AB, and B1 thymomas was better than those with type B2 and B3 (log-rank test p < 0.001). In multivariate analysis, age < 50 years ( p = 0.001), Masaoka stage ( p = 0.006), histological type ( p = 0.001), and recurrence ( p = 0.04) were independent prognostic factors for survival. Conclusion Our study indicates that age < 50 years, Masaoka stage, histological type, and recurrence are the determinants of survival in surgically resected cases of thymoma.

The importance of costoclavicular space on possible compression of the subclavian artery in the thoracic outlet region: a radio-anatomical study.

OBJECTIVES: The purposes of this study were to identify possible compression points along the transit route of the subclavian artery and to provide a detailed anatomical analysis of areas that are involved in the surgical management of the thoracic outlet syndrome (TOS). The results of the current study are based on measurements from cadavers, computed tomography (CT) scans and dry adult first ribs. METHODS: The width and length of the interscalene space and the width of the costoclavicular passage were measured on 18 cervical dissections in 9 cadavers, on 50 dry first ribs and on CT angiography sections from 15 patients whose conditions were not related to TOS. RESULTS: The average width and length of the interscalene space in cadavers were 15.28 ± 1.94 mm and 15.98 ± 2.13 mm, respectively. The widths of the costoclavicular passage (12.42 ± 1.43 mm) were significantly narrower than the widths and lengths of the interscalene space in cadavers (P < 0.05). The average width and length of the interscalene space (groove for the subclavian artery) in 50 dry ribs were 15.53 ± 2.12 mm and 16.12 ± 1.95 mm, respectively. In CT images, the widths of the costoclavicular passage were also significantly narrower than those of the interscalene space (P < 0.05). The measurements from cadavers, dry first ribs and CT images were not significantly different (P > 0.05). CONCLUSIONS: Our results showed that the costoclavicular width was the narrowest space along the passage route of the subclavian artery. When considering the surgical decompression of the subclavian artery for TOS, this narrowest area should always be kept in mind. Since measurements from CT images and cadavers were significantly similar, CT measurements may be used to evaluate the thoracic outlet region in patients with TOS.

Painful Chest Wall Swellings: Tietze Syndrome or Chest Wall Tumor?

BACKGROUND: Tietze syndrome (TS) is an inflammatory condition characterized by chest pain and swelling of costochondral junction. Primary chest wall tumors may mimic TS. In this article, we report our experience of approximately 121 patients initially diagnosed as TS and determined chest wall tumor in some cases at the follow-up. METHODS: This is a retrospective review of patients diagnosed as TS by clinical examination, chest X-ray, electrocardiogram, routine laboratory tests, and computed tomography (CT) of chest: all treated and followed up between March 2001 and July 2012. There were 121 cases (41 males and 80 females; mean age, 39.6 ± 3.2 years) of TS. RESULTS: In 27 patients with initial normal radiological findings, the size of swellings had doubled during the follow-up period (mean, 8.51 ± 2.15 months). These patients were reevaluated with chest CT and bone scintigraphy and then early diagnostic biopsy was performed. Pathologic examination revealed primary chest wall tumor in 13 patients (5 malignant, 8 benign). CT had a sensitivity of 92.3% and a specificity of 64.2% in detection of tumors (kappa: 0.56, p = 0.002), whereas the sensitivity and the specificity of bone scan were 84.6 and 35.7%, respectively (kappa: 0.199, p = 0.385). CONCLUSION: Primary chest wall tumors could mimic TS. Bone scintigraphy or CT is not specific enough to determine malignant and other benign disorders of costochondral junction. Therefore, clinicians should follow TS patients more closely, and in case of increasing size of swelling, early diagnostic biopsy should be considered.

Bilateral sympathicotomy for hyperhidrosis without using single-lung ventilation.

BACKGROUND/AIM: The goal of this retrospective study was to evaluate the outcomes and complications of bilateral videothoracoscopic sympathicotomy without using single-lung ventilation in the treatment of primary hyperhidrosis and facial blushing. MATERIALS AND METHODS: We retrospectively reviewed 154 consecutive patients (70 females and 84 males) who underwent bilateral sympathicotomy for palmar, axillary, and facial/scalp hyperhidrosis or facial blushing from February 2005 to June 2013. The patients were intubated with single-lumen endotracheal tube, and then sympathicotomies were performed via videothoracoscopy during controlled apnea periods. RESULTS: Sympathicotomies were performed at costal levels 2, 3, and 4. No perioperative mortality or conversion to open surgery was recorded. Mean operation time was 31.2 ± 2.4 min and mean hospital stay was 1.1 ± 0.6 days. One patient experienced a unilateral pneumothorax that required treatment. There were no abnormal hemodynamic parameters measured during the perioperative apnea periods. The long term follow-up period was 21.4 ± 5 months. Twenty-nine cases (18.8%) were complicated by compensatory sweating. No recurrence was observed during the follow-up period. CONCLUSION: Video-assisted thoracoscopic sympathicotomy without lung isolation provides effective cure of primary hyperhidrosis and facial blushing. This procedure can shorten the operative time without any aberrant hemodynamic shifts.

Quantative computerized tomography assessment of lung density as a predictor of postoperative pulmonary morbidity in patients with lung cancer.

BACKGROUND: The aim of this study was to evaluate the pulmonary reserve of the patients via preoperative quantitative computerized tomography (CT) and to determine if these preoperative quantitative measurements could predict the postoperative pulmonary morbidity. METHODS: Fifty patients with lung cancer who underwent lobectomy/segmentectomy were included in the study. Preoperative quantitative CT scans and pulmonary function tests data were evaluated retrospectively. We compare these measurements with postoperative morbidity. RESULTS: There were 32 males and 18 females with a mean age of 54.4±13.9 years. Mean total density was -790.6±73.4 HU. The volume of emphysematous lung was (<-900 HU) 885.2±1,378.4 cm(3). Forced expiratory volume in one second (FEV1) (r=-0.494, P=0.02) and diffusion capacity of carbon monoxide (DLCO) (r=-0.643, P<0.001) were found to be correlate with the volume of emphysematous lung. Furthermore FEV1 (r=0.59, P<0.001) and DLCO (r=0.48, P<0.001) were also found to be correlate with mean lung density. Postoperative pulmonary morbidity was significantly higher in patients with lower lung density (P<0.001), larger volume of emphysema (P<0.001) and lower DLCO (P=0.039). A cut-off point of -787.5 HU for lung density showed 86.96% sensitivity and 81.48% specificity for predicting the pulmonary morbidity (kappa =-0.68, P<0.001). Additionally a cut-off point of 5.41% for emphysematous volume showed 84.00% sensitivity and 80.00% specificity for predicting the pulmonary morbidity (kappa =0.64, P<0.001). According to logistic regression analyses emphysematous volume >5.41% (P=0.014) and lung density <-787.5 HU (P=0.009) were independent prognostic factors associated with postoperative pulmonary morbidity. CONCLUSIONS: In this study, the patients with a lower lung density than -787.5 HU and a higher volume of emphysema than 5.41% were found to be at increased risk for developing postoperative pulmonary morbidity. More stringent precautions should be taken in those patients that were found to be at high risk to avoid pulmonary complications.

[Cardiac and respiratory changes in the medium term after lung resection]. / Akciger rezeksiyonu sonrasi orta vadede kalp ve solunum fonksiyonlarinda degisiklikler.

OBJECTIVE: The aim of this study was to assess the cardiac and respiratory functions at the 6th postoperative month, in lung cancer patients undergoing segmentectomy/lobectomy or pneumonectomy. METHODS: Thirteen segmentectomy/lobectomy and 5 pneumonectomy patients with lung cancer were consecutively enrolled between April 2012 and February 2014. All patients underwent respiratory function tests and transthoracic echocardiography preoperatively and at 6 months postoperatively. RESULTS: Left ventricular functions were unchanged postoperatively. In the segmentectomy/lobectomy group, there were no changes in right ventricular fractional area change (RVFAC) or tricuspid annular plane systolic excursion (TAPSE). However, TAPSE decreased from 19 (17-21) to 15.5 (14-16) in pneumonectomy patients (p=0.04). RVFAC was 59.5 (58-61) preoperatively and 59 (58-61) at 6 months postoperatively (p=0.049). Neither group showed differences in pulmonary acceleration time or diastolic and systolic eccentricity indices after operation. Tissue Doppler imaging (TDI) revealed no deterioration in left ventricular functions, but right ventricular diastolic functions (tricuspid E'/A') were impaired in both groups. Right ventricular S', showing the systolic function, was slightly decreased in the pneumonectomy group, in addition to a decrease in isovolumic velocity and isovolumic acceleration (IVA). Only IVA was decreased, from 2.33 (1.79-3.14) to 2.17 (1.73-3.01) (p=0.001), in segmentectomy/lobectomy group. CONCLUSION: Segmentectomy/lobectomy should be preferred over pneumonectomy when possible. Tissue Doppler imaging may be routinely used as a part of echocardiographic evaluation in patients with a higher risk of right ventricular dysfunction in order for these patients to be candidates for a closer cardiovascular follow-up.

A Rare Entity: Bilateral First Rib Fractures Accompanying Bilateral Scapular Fractures.

First rib fractures are scarce due to their well-protected anatomic locations. Bilateral first rib fractures accompanying bilateral scapular fractures are very rare, although they may be together with scapular and clavicular fractures. According to our knowledge, no case of bilateral first rib fractures accompanying bilateral scapular fractures has been reported, so we herein discussed the diagnosis, treatment, and complications of bone fractures due to thoracic trauma in bias of this rare entity.

A Rare and Serious Syndrome That Requires Attention in Emergency Service: Traumatic Asphyxia.

Traumatic asphyxia is a rare syndrome caused by blunt thoracoabdominal trauma and characterized by cyanosis, edema, and subconjunctival and petechial hemorrhage on the face, neck, upper extremities, and the upper parts of the thorax. Traumatic asphyxia is usually diagnosed by history and inspection; however, the patient should be monitored more closely due to probable complications of thoracoabdominal injuries. Treatment is conservative, but the prognosis depends on the severity of the associated injuries. Herein we present a traumatic asphyxia due to an elevator accident in a 32-year-old male patient and discuss the diagnosis, treatment, and prognosis by reviewing the relevant literature.

Endobronchial intubation in thoracic surgery: Which side should be preferred?

AIM: This study was undertaken to compare the clinical performance of right versus left double-lumen endotracheal tubes placed without using fiberoptic bronchoscopy in thoracic surgery operations. METHODS: This was a retrospective review of patients who were operated on in our institution between January 2013 and February 2014. We analyzed clinical performance in terms of hypoxia, hypercapnia, and adequate deflation of the lungs with both left- and right-sided double-lumen endotracheal tubes. RESULTS: There were 80 patients with a mean age of 53.74 ± 15.59 years. Right-sided double-lumen tubes were used in 33 patients, and left-sided double-lumen tubes were used in 47. Perioperative hypoxi (p < 0.05), hypercapnia (p < 0.01), and inadequate deflation of the lung (p < 0.001) were found more frequently with the use of right-sided double-lumen endotracheal tubes. Arterial blood gas analyses in the post-anesthesia care unit showed that high pCO2 (>45 mm Hg), low pH (<7.36), and high lactate levels (>4 mmol L(-1)) were more frequent with right-sided double-lumen endotracheal tubes (p < 0.001). The incidence of atelectasis was greater (p < 0.001) and the duration of hospital stay was longer (p = 0.02) with the use of right-sided double-lumen endotracheal tubes. CONCLUSION: Right-sided double-lumen endotracheal tubes resulted in poorer clinical performance. Therefore, a left-sided double-lumen endotracheal tube should be preferred in thoracic surgery operations when an appropriate size of fiberoptic bronchoscope is not available.

Use of previously divided latissimus dorsi muscle for bronchopleural fistula.

Management of postpneumonectomy bronchopleural fistula remains a major challenge for thoracic surgeons. Successful closure of a postpneumonectomy bronchopleural fistula was performed in a 60-year-old man, using a flap made by a combination of serratus anterior and latissimus dorsi muscle which had been divided during the pneumonectomy operation. The flap was prepared on the presence of a dependable collateral serratus anterior branch to the lateral thoracic artery, which provides retrograde flow to the latissimus dorsi muscle.

Surgical correction of a fistula between left pulmonary artery and innominate vein.

A 48-year-old woman with chronic dyspnea complaints was referred to the thoracic surgery clinic for a surgical lung biopsy to make a definitive diagnosis of interstitial lung disease. Thoracic computed tomography imaging revealed a vascular structure located anterior to the aorta, between the left innominate vein and the pulmonary artery. Magnetic resonance angiography showed the abnormal vessel connection in detail. Pulmonary perfusion scintigraphy showed decreased perfusion of the left upper lobe and the superior lingular segment. A fistulectomy was performed through a mini thoracotomy. The patient no longer had any dyspnea symptoms after the operation.

An unexpected complication of titanium rib clips.

Surgical stabilization of the rib fractures has been successfully performed for the management of pain in multiple rib fractures, fixation of chronically painful nonunion, reduction of overriding ribs, and flail chest cases. Herein we report a patient who was treated with titanium rib clips after a motor vehicle accident leading to pulmonary parenchymal laceration and multiple painful rib fractures. Three of the rib clips were broken 4 months after the operation. The patient underwent the second operation for restabilization of the broken ribs. We review the relevant literature, with particular emphasis on the management of this complication.

Unusual coexistence of pulmonary sclerosing hemangioma and pericardial cyst.

Pulmonary sclerosing hemangioma is an uncommon tumor, thought to be a benign neoplasm. Pericardial cysts are also uncommon benign abnormalities, most often found incidentally on chest radiography. We describe the case of a 51-year-old woman in whom both lesions were incidentially detected on a routine chest radiograph. Enucleation of the pulmonary sclerosing hemangioma and simultaneous resection of the pericardial cyst were undertaken.

Thymoma type B1 arising in a giant supradiaphragmatic thymolipoma.

Thymolipomas are uncommon tumors of the anterior mediastinum. They may extend into, but rarely stem from, the chest cavity. Furthermore, thymoma arising in a thymolipoma is extremely rare. We report a unique case of thymoma type B1 that originated form a giant thymolipoma located in the chest cavity, which was resected by a lateral thoracotomy in a 23-year-old woman. To our knowledge, this is the first reported case of thymoma type B1 arising within a giant thymolipoma.

Could thoracoscopic sympathicotomy for hyperhidrosis also improve acne vulgaris?

INTRODUCTION: The aim of this study is to emphasize the therapeutic effect of thoracoscopic sympathicotomy performed at our clinic for facial/scalp hyperhidrosis or blushing on coincidental facial acne vulgaris based on previous reports indicating an association between the sympathetic nerve stimulus, epithelial melanocyte system and sebogenesis. MATERIAL AND METHODS: The possible therapeutic effects of sympathicotomy on facial acne vulgaris were analyzed in a study design of retrospective review with prospective collection of the data from March 2005 to March 2013. RESULTS: Forty-two patients were operated on at our clinic due to facial/scalp hyperhidrosis or blushing and 30 of these also had facial acne vulgaris. However, none harbored a systemic co-morbidity. The patients' medical history indicated that they had used several medical therapies including topical or systemic antibiotherapies to treat their acne for several years but this had met with limited success and the treatment was stopped in all patients an average of 8 ± 2.4 months prior to the operations. Furthermore, the patients with acne vulgaris also underwent a thoracoscopic sympathicotomy procedure at the second costal head (R2) for hyperhidrosis or blushing. All 30 patients showed marked improvement of their acne grade at the first postoperative month (p < 0.01). CONCLUSIONS: In this study, the patients' facial acne vulgaris grade significantly improved after undergoing a sympathicotomy. This can be explained by the possible effect the nervous system had on the epithelial melanocyte system and sebogenesis. However, prospective studies with an increased number of patients are needed to verify our findings.

Elastofibroma dorsi management and outcomes: review of 16 cases.

OBJECTIVES: Elastofibroma dorsi (ED) is a rare, benign lesion arising from connective tissue, usually found at the inferior pole of the scapula. To date, only a few small series have been reported in the English literature and there are few data about the long-term outcomes after surgery. Our goal is to contribute a better understanding of this tumour and to determine the long-term outcomes after surgery. METHODS: Sixteen patients with a diagnosis of ED were identified from the unit's database. The clinical presentation, diagnosis, pathological evidences and long-term outcomes were evaluated. RESULTS: There were 11 females and 5 males with a mean age of 61.1 years (range 38-78 years). The tumour was located on the right in 5 (31.2%) patients, on the left in 6 (37.5%) patients and bilaterally in 5 (31.2%). Six patients had painful scapular swelling resulting in restriction of movement of the shoulder whereas 10 reported only painful scapular mass. All 16 patients underwent complete resections. The tumour size ranged from 3 to 15 cm. The mean hospital stay was 3.1 ± 1.4 days with a morbidity of 18.75% (seroma observed in 3 patients). The mean follow-up was 58.4 ± 29.5 months (range 11-92 months). In 2 patients (12.5%) a new occurrence on the contralateral side was observed at the follow-up. CONCLUSIONS: Elastofibroma dorsi is a rare, ill-defined, pseudotumoural lesion of the soft tissues. Surgical treatment can be proposed if the lesion is symptomatic. Furthermore, at the follow-up, the possibility of new occurrences on the contralateral side should be kept in mind.