Management of chylothorax with octreotide after congenital heart surgery.

OBJECTIVE: Chylothorax is a rare complication of congenital cardiac surgery that can seriously impair the postoperative course unless treated properly. We present our treatment protocol and results with octreotide, a somatostatin analogue, in cases of chylothorax following congenital heart surgery. MATERIAL AND METHODS: Between March 2006 and December 2009, 12 patients were treated for chylothorax following congenital cardiac surgery. Patients consisted of five females and seven males, with a mean age of 16.6 months (7 days - 36 months). Octreotide was administrated as a continuous intravenous infusion with a dosage of 4-10 µg/kg/h. RESULTS: Chylothorax was successfully resolved in an average of 10.3 days (7-14 days) with octreotide infusion and a strict oral diet containing medium-chain triglycerides. At a mean follow-up of 9.4 months (1-35), all patients are doing well, without any recurrence of chylothorax. CONCLUSION: Octreotide, a long-acting somatostatin analog, is an effective and safe agent for the treatment of postoperative chylothorax and warrants further investigation in a larger series with a greater number of patients.

Factors affecting morbidity and mortality in flail chest: comparison of anterior and lateral location.

OBJECTIVE: Flail chest is most often accompanied by significant underlying pulmonary parenchymal injuries and may constitute a life-threatening thoracic injury. In this study we evaluated the treatment modalities for flail chest depending on the effect of trauma localization on mortality and morbidity. METHODS: Between 2003 and 2008, 23 patients (20 males/3 females) were treated for flail chest. Location of the trauma in the chest wall, mechanical ventilation support, prognosis and injury severity score (ISS) were recorded for all patients. Mechanical ventilation support was given in 14 patients (60.8 %), and 12 of these 14 patients required subsequent tracheostomy. Internal fixation was used in 3 patients. RESULTS: The major cause of flail chest was a car crash in 18 of 23 patients (76 %). Median ISS was 62.8 for all patients. The patients with flail chest who had bilateral costochondral separation (anterior chest location) (group I, n = 10) had a significantly higher ISS than those with single-side posterolateral flail chest (group II, n = 13; ISS: 70/55; P = 0.02). The need for mechanical ventilation support was also higher in the group with bilateral costochondral separation. Morbidity was higher in group I than in group II ( P = 0.198), and mortality was also significantly higher in group I ( P = 0.08). Patients with a cranial trauma and flail chest had a higher mortality (19 %) than patients with only flail chest (no mortality). The mean ISS was 75 for patients with cranial trauma and flail chest and 55.7 ( P = 0.001) for patients with only flail chest. Sepsis and subarachnoid bleeding were the major causes of mortality. The mean ISS was 54.5 for patients under the age of 55 (n = 14) whereas it was 69.4 in those aged 55 and over (n = 9; P = 0.034). Mortality in the older group was also higher (33 % versus 7 %; P = 0.02). CONCLUSION: Early intubation and mechanical ventilation is of paramount importance in patients with flail chest. However, prolonged mechanical ventilation is associated with a poor outcome. Tracheotomy and frequent flexible bronchoscopy are an effective pulmonary toilet. Advanced age was a major risk factor for flail chest trauma mortality, together with the severity of the injury. When cranial trauma was accompanied by flail chest, mortality and morbidity rates increased. Bilateral costochondral separation also increased the risk of morbidity and the need for mechanical ventilation in patients with flail chest.

Bilateral trapped lung with concomitant Wermer's syndrome and cutis laxa.

We report a rare occurrence of trapped lung associated with Wermer's syndrome and cutis laxa. A 25-year-old man with bilateral trapped lung presented with respiratory distress. Additional investigation revealed adenoma of the parathyroid and hypophysis, a neuroendocrine abdominal tumor, and cutis laxa. Successful treatment of the respiratory symptoms was achieved through a median sternotomy with bilateral decortication, and excision of the bilateral fibrous pleural bands and bullae on the right upper lobe. Octreotide therapy was initiated and a percutaneous ultrasound-guided alcohol injection to the parathyroid adenoma was done. The patient has gynecomastia, acromegaly, and kyphoscoliosis. The patient remains well at 19 months after treatment.

Unusual manifestation of bronchiolitis obliterans organizing pneumonia.

Bronchiolitis obliterans organizing pneumonia (BOOP) is an uncommon fibrotic lung disease characterized by involvement of the small conducting airways. BOOP has a wide spectrum of radiologic and clinical features. Usually, it appears radiologically as multiple alveolar patchy areas of consolidation. However, different presentations have also been described. We report two cases of solitary masses of the lung that preoperatively presented as malignant lesions but were subsequently diagnosed as bronchiolitis obliterans organizing pneumonia. One of the cases of BOOP was probably secondary to suppuration of a hydatid cyst. Complicated hydatid cyst may give rise to various clinical manifestations and may present radiologically as a solid lung mass. The radiologic findings of pulmonary ruptured or complicated hydatid cyst may resemble primary lung tumor. Open surgery can be required for not only for diagnosis but also for treatment of solitary BOOP. A review of the literature is also presented.

Descending necrotizing mediastinitis: treatment of a delayed case.

Descending necrotizing mediastinitis (DNM) is a severe and rare infection that can spread to the mediastinum through the anatomic cervical spaces, secondary to cervical or odontogenical infections. Delay of diagnosis and insufficient drainage always result in high mortality. We present a case of DNM with bilaterally pulmonary infiltration in a 45-year old woman. The cause of DNM was postextraction odontogenic abscess and delay of diagnosis which resulted in sepsis. Surgical treatment was performed as soon as possible in following sequence: cervical mediastinotomy, right thoracotomy, and pleural and mediastinal irrigation with saline. Although the diagnosis was delayed, invasive surgical interventions allowed successful eradication of the injection.

Sunflower seed mimicking complicated hydatid cyst.

We present a case of a foreign body in lung parenchyma, found incidentally during surgery in an adult woman. The clinical and radiological findings were consistent with a pulmonary hydatid cyst. Owing to the similar clinical and radiological appearances, a thoracotomy was required for the correct diagnosis of a sunflower seed mimicking hydatid disease.

Pedunculated solitary fibrous tumours arising from the pleura.

Solitary fibrous tumour (SFT) is one of the rare tumours which arise from visceral pleura. Klemperer and Rabin first described SFT as a distinct clinical entity among primary pleural tumoUrs in 1931. Approximately 820 cases have been reported in literature to date. The management of patients with SFT is complete resection of the tumour and follow up of the patient to detect any possible late recurrence. In the present paper, we report two cases of pedunculated solitary fibrous tumours of the pleura that appeared as a wandering chest nodule to which surgical resection undertaken at our hospital. The aim is to summarise our experience in the management of solitary fibrous tumour.

Extrapleural hematoma: when is surgery indicated?

Extrapleural haematoma (EH) is a rare clinical condition of which four cases are presented. Different etiologies were encountered. Identical findings were found on the chest X-ray. Two cases were secondary to spontaneous rib fracture and the other two were iatrogenic. Surgical exploration was necessary in one patient following pleural biopsy. Medical treatment and clinical observation were the treatment of choice in the remaining three stable patients.

[Nine years of trauma cases]. / Dokuz yillik travma olgularimiz.

Trauma is one of the major cause of death in the young population. The patients treated due to trauma were evaluated retrospectively during the last nine years. 212 cases with trauma were hospitalised in our clinic, between 1.7.1990-11.4.1999. 190 (89.6%) of them were operated and 22 (10.4%) of them were observed selectively. 36 (17%) of the cases were female and 176 (83%) of them were male. The mean age was 32.4 (16-81). 93 (43%) of them were hospitalized following traffic accidents; 56 (26.4%) of them stab wounds, 33 (15.6%) of them gunshots and 30 (14.1%) of them blunt trauma. The diagnosis was done through the diagnostic peritoneal lavage 95.1% of the traffic accident cases. The diagnosis was performed through diagnostic peritoneal lavage 76.9% of the after blunt trauma cases. After gunshots the diagnosis was done by 59.4% of the cases with physical examination. Local lesion exploration helped us to establish the diagnosis 51.4% of the stab wound cases. The most frequent organ injury following traffic accidents is splenic injury and injury of small intestine following penetrating trauma. The amount of our negative laparotomy was more than in literature and 47 (24.7%) cases were accepted as negative exploration. Negative laparotomy was seen mostly by stab wounds (49%). 17 (77.3%) of the 22 cases observed selectively were the cases of the last two years. In the recent two years the amount our negative laparotomy was six and our negative laparotomy ratio is 14%. Our mortality and the morbidity rates were at the acceptable level.

A rare cause of acute abdomen: splenic infarction.

Splenic infarction is a rare disorder. We have treated 4 patients during the last year. Abdominal pain in the left upper quadrant was the common complaint. Other complaints were fever, nausea and vomiting. Computed tomography showed infarcted areas in the spleen in all of the patients. Splenectomy was applied to three of the patients with recurring symptoms. The other patient had the first episode treated medically. Pulmonary embolism in one and surgical wound infection occurred in another patient during postoperative follow-up for nine (range: 4-14) months.

Retroperitoneal localization of hydatid cyst disease.

In this study we discuss a rare case; hydatid cyst disease that is located in the retroperitoneum. Two cases were treated in our department with hydatid cyst disease located in the retroperitoneum; one of the cysts was in the minor pelvis and the other was on the left psoas muscle. Diagnosis was confirmed with blood tests, and radiological examinations. The cyst wall was excised partially and was oversewn. Following the operation both of the patients were given albendasole tablets for 10 weeks with blood count and liver enzyme monitorization. Hydatic cysts located in retroperitoneum were treated successfully. Especially in the endemic areas hydatid cyst should be remembered when evaluating cystic masses in the retroperitoneum. It can be treated successfully with surgery.

The comparison of electron microscopy and scintigraphy in determining the protective effect of dimethylsulphoxide (DMSO) on ischemia/reperfusion injury through Pringle maneuver.

BACKGROUND/AIMS: We investigated the role of the electron microscopy and hepatobiliary scintigraphy in determining the effect of DMSO (dimethysulphoxide) and ischemia/reperfusion injury in the liver after the Pringle maneuver. METHODOLOGY: Twenty-four rabbits were divided into the following groups; A: Control group, B: Pringle, C: 10 mg/kg DMSO, D: 1 g/kg DMSO + Pringle. Group A was considered as a control group and only laparotomy was applied. Group B was exposed to Pringle maneuver only. Group C was given 10 mg/kg of DMSO via the vena cava inferior. Group D was given 1 g/kg of DMSO. A clamp was fastened for the groups of B, C and D in the 30th minute of the Pringle maneuver and a biopsy was applied five minutes later. Fifteen minutes later a dynamic hepatobiliary scintigraphy was applied. From dynamic images, liver peak time and activity half time of the liver were obtained. RESULTS: It was found that liver peak time and liver activity half time values of the group B, C and D were significantly longer than group A. Liver peak time and liver activity half time values of group B was not different from group C. However, some values of group D were found to be significantly shorter than groups B and C. In the electron microscopy examination, only in group B were some specific degenerative changes observed in the sinusoids. We observed less irreversible changes in group C than in group B. On the other hand, the least irreversible changes were in group D. CONCLUSIONS: As a conclusion, while electron microscopy is regarded as the "gold standard", hepatobiliary scintigraphy may be thought of as an easily applicable method in determining the ischemic reperfusion injury in the clinical comparison of the protective agents.

Bilateral chylothorax caused by pleuropulmonary lymphangiomyomatosis: a challenging problem in thoracic surgery.

Massive left-sided pleural effusion in a 35-year-old man was initially diagnosed as idiopathic spontaneous chylothorax and treated with serial thoracenteses and left thoracotomy. Six weeks later, a right thoracotomy was performed for contralateral chylothorax, and histologic examination revealed lymphangiomyomatosis. The patient survived this rare and potentially fatal disease. We have found no previously published case of bilateral lymphangiomyomatosis treated with separate thoracotomies because of bilateral chylothorax.

The role of hepatobiliary scintigraphy in the evaluation of the protective effects of dimethylsulphoxide in ischaemic/reperfusion injury of liver.

Liver ischaemia may lead to parenchymal damage depending on the duration of the ischaemia. Dimethylsulphoxide (DMSO), a well-known radical oxygen scavenger, is a protective agent against ischaemia/reperfusion injury. In this study we aimed to investigate the role of hepatobiliary scintigraphy (HBSc) in detecting the protective effect of DMSO. Eighteen rabbits, in three groups of six, were injected with 37 MBq technetium-99m-mebrofenin via the ear veins. Dynamic scintigrams were taken for 60 min (1 frame/min). In group A, HBSc was performed without any surgery. In groups B and C the Pringle manoeuvre (PM) was applied for 30 min, and tissue specimens for electron microscopy were taken from the liver parenchyma 5 min after the end of the PM. In addition, in group C 1 g/kg DMSO was injected into each rabbit 5 min before application of the PM. HBSc was then performed in groups B and C. From the dynamic images time-activity curves (TACs) were obtained for each group, and the time of peak uptake (TPU) and time for half of the activity to clear from the liver (T1/2) were calculated. The TPU and T1/2 of group B were significantly longer than those of groups A and C (P<0.0005 and P<0.005 for TPU, and P<0.0005 and P<0.02 for T1/2, respectively). The TPU and T1/2 of group C were significantly longer than those of group A (P < 0.005 and P < 0.02, respectively). While the electron microscopic images in group C showed reversible changes, those in group B showed both irreversible and reversible changes. The electron microscopic findings of groups B and C confirmed the scintigraphic findings. In conclusion, HBSc might be used as a practical quantitative method for detecting the protective effects of DMSO. However, its clinical value should be evaluated by further studies with human subjects.

Laparoscopic versus open cholecystectomy: effect on pulmonary function tests.

BACKGROUND/AIMS: Operations often cause impairment in respiration due to pain. This study was designed to compare the changes in pulmonary function tests after open and laparoscopic cholecystectomy. METHODOLOGY: Two groups of 35 patients were randomly set up. Each patient had 3 pulmonary function tests performed and 2 postero-anterior grid chest roentgenograms taken. All of these data were evaluated by the same group of investigators. RESULTS: After taking into consideration the difference between pulmonary function tests, values were not significant (P < or = 0.05). All pulmonary function test values decreased significantly on the 1st postoperative day (P < or = 0.05). When postero-anterior chest roentgenograms were compared no clinically evident atelectasis except 3 lineary was seen in the laparoscopic cholecystectomy group, whereas 5 lineary, 7 focal, and 3 segmentary atelectasia were encountered in the open cholecystectomy group (P < or = 0.05). CONCLUSIONS: We believe that laparoscopic cholecystectomy has more advantages when speaking of postoperative pulmonary function tests and atelectasia.

Bronchoscopic removal of foreign bodies in children: retrospective analysis of 822 cases.

At the Department of Thoracic and Cardiovascular Surgery of Hacettepe University, a total number of 822 pediatric bronchoscopies were performed from 1984 through 1990 for suspected foreign body aspiration. Of the children 65.3% were boys and 34.7% were girls ranging in age from one month to 14 years. Definitive statement of foreign-body aspiration was obtained from 394 patients. Unilateral hyperaeration, atelectasis, and unilateral parenchymal infiltration were the most common radiological findings. In all endoscopic procedures, a pediatric rigid bronchoscope was used under general anesthesia and controlled ventilation. Foreign bodies were found in 77.7% of the 822 patients. In the rest of the children inflammatory disorders were confirmed. The foreign bodies most commonly found in 639 patients were sun-flower seeds (21.1%), beans (10.4%), water-melon seeds (10%), and hazelnuts (9.8%). In our presented series, the incidence of non-fatal complication was 1.8%, apart from these patients 5 of them (0.6%) died after the bronchoscopic procedures.

Detection of right-sided endocarditis in children with congenital heart disease by two-dimensional echocardiography.

Right-sided endocarditis is rare in children. Since the clinical picture is nonspecific and the frequency of sterile blood cultures is high, the clinical and laboratory diagnosis is difficult. Recent reports suggest that echocardiography is a useful method to detect the presence of right-sided endocarditis. We studied 8 patients with congenital heart disease and right-sided endocarditis detected by two-dimensional echocardiography. All the patients were shown to have one or more vegetations in the two-dimensional echocardiographic examination. The 4 patients who did not respond to antibiotic therapy underwent elective cardiac surgery. One of these patients additionally had recurrent emboli to the lungs. Another of these 4 patients died during surgery due to myocardial failure. Apart from these 4 cases, urgent surgical intervention had to be carried out in 2 cases because of very large vegetative masses. Surgical confirmation of the diagnosis was available in all 6 cases. According to these results, we can conclude that two-dimensional echocardiography assumes a specific diagnostic role in cases with right-sided endocarditis.