Tracheal length in adult human: the results of 100 autopsies / Longitud de la tráquea en humanos adultos: los resultados de 100 autopsias

The purpose of this study was to investigate the average tracheal length and number of the tracheal cartilages in Turkish people, with emphasis on the relationships to body height and sex. A hundred fresh human cadaver tracheas were harvested from 75 males and 25 females. Age, sex and body height of cadavers were recorded. All the neck and intrathoracic structures were removed. The tracheal length was measured between the subcricoid level to the carina in resting and maximally stretched positions. Average tracheal length and number of the tracheal cartilages were compared in different body height groups in both sexes. We found that average body height was 160±6.4 cm and average tracheal length in resting position was 8.5±1 cm (range 6.5­11 cm) in females and average body height was 168.6±5.6 cm, average tracheal length was 8.7±1.1 cm (range 7­11.6 cm) in males, average number of tracheal cartilages was 13.6±1.7 (range 10­16) in females and 13.3±1.6 (range 10­19) in males and average number of the tracheal cartilages per centimeter was 1.6±0.2 in female and 1.5± 0.2 in male cadavers in resting position. Average tracheal length in male group was found to be significantly different in cadavers with body height equal or taller than 170 cm in comparison to cadavers with body height shorter than 170 cm (p <0.05). This study revealed that the average tracheal length in Turkish people is shorter than the reported length in literature. It is worth commenting that there is a considerable difference between the different races with regard to tracheal length. Tracheal length may vary with body height.

El objetivo de este estudio fue investigar la longitud traqueal promedio y el número de los cartílagos traqueales en pueblo turco, con énfasis en las relaciones a la altura del cuerpo y el sexo. Cien tráqueas frescas de cadáveres humanos fueron extraidas de 75 hombres y 25 mujeres. Se registraron la edad, sexo y altura del cuerpo en cada caso. Se disecaron el cuello y las estructuras intratorácicas. La longitud de la tráquea fue medida entre el nivel subcricoides y la carina en reposo, y en posición de máximo estiramineto. Se comparó la longitud promedio traqueal y el número de los cartílagos traqueales ente grupos con diferente de la altura del cuerpo en ambos sexos. En las mujeres, la altura del cuerpo promedio fue 160±6,4 cm y la longitud traqueal promedio en posición de reposo 8,5±1 cm (rango 6,5­11 cm). En hombres, la altura del cuerpo promedio fue 168,6±5,6 cm y la longitud traqueal promedio 8,7±1,1 cm (rango 7­11,6 cm). El número promedio de cartílagos traqueales fue 13,6±1,7 (rango 10­16) en las mujeres y 13,3±1,6 (rango 10­19) en los hombres, y el número promedio de cartílagos traqueales por centímetro fue 1,6±0,2 en mujeres y 1,5±0,2 en los hombres, en posición de reposo. La longitud traqueal promedio en el grupo de hombres fue significativamente diferente en cadáveres con una altura del cuerpo igual o mayor que 170 cm, en comparación con cadáveres con la altura del cuerpo menor a 170 cm (p<0,05). Este estudio reveló que la longitud traqueal promedio en pueblo turco es menor que la longitud reportada en la literatura. Por otra parte, existe una diferencia considerable entre las diferentes razas con respecto a la longitud traqueal. La longitud traqueal puede variar con la altura del cuerpo.

Single-Incision Video-Assisted Thoracic Surgery for an Extralobar Sequestration in a Child.

Uniportal or single-incision video-assisted thoracic surgery (VATS) has been performed successfully in adult patients with different intrathoracic pathologies for years. However, no report in uniportal/single-incision VATS in pediatric patients in the English literature has been published up to date. This may be explained by the limited number of patients and the difficulties in working in very narrow thoracic cavity of babies and children. For these reasons, all the published cases of VATS for extralobar sequestration in infants or children were performed through the three-port approach. We report herein a case of single-incision VATS in a child for the resection of an extralobar sequestration.

A comparative cost analysis study of lobectomy performed via video-assisted thoracic surgery versus thoracotomy in Turkey.

INTRODUCTION: Cost analysis studies performed in western countries report that the overall cost of lobectomies performed via video-assisted thoracic surgery is similar to or less than those performed via thoracotomy. The situation may be different in a developing country. AIM: We evaluated the cost differences of these two surgical methods. MATERIAL AND METHODS: We retrospectively reviewed the hospital records of 81 patients who underwent lobectomy either via video-assisted thoracic surgery (n = 32) or via thoracotomy (n = 49). Patient characteristics, pathology, perioperative complications, additional surgical procedures, length of hospital and intensive care unit stay, and outcomes of both groups were recorded. Detailed cost data for medications, anesthesia, laboratory, surgical instruments, disposable instruments and surgery cost itself were also documented. Statistical analyses were performed to compare the groups. RESULTS: The two groups were homogeneous in regard to age, sex, pathology and perioperative morbidity. The mean duration of hospitalization in the video-assisted thoracic surgery group was significantly shorter than that of the thoracotomy group (7.78 ±5.11 days vs. 10.65 ±6.57 days, p < 0.05). Overall final mean cost in the video-assisted thoracic surgery group was significantly higher than that of the thoracotomy group ($3970 ±1873 vs. $3083 ±1013, p = 0.002). This significant difference relies mostly on the cost of disposable surgical instruments, which were used much more in the video-assisted thoracic surgery group than the thoracotomy group ($2252 ±1856 vs. $427 ±47, p < 0.05). CONCLUSIONS: In contrast to western countries, a video-assisted thoracic surgical lobectomy may cost more than a lobectomy via thoracotomy in a developing country. More expensive disposable surgical instruments and cheaper hospital stay charges lead to higher overall costs in video-assisted thoracic surgical lobectomy patients.

Thoracic surgery for haemoptysis in the context of tuberculosis: what is the best management approach?

Haemoptysis is not an unusual finding in patients with old or active pulmonary tuberculosis. Because of bronchial artery or a branch of pulmonary artery erosion due to cavitary infiltration, bronchiectasis, fungus ball, broncholithiasis or destroyed lung, the bleeding can sometimes be a life-threatening situation. Assessment of the patient and finding the exact site of bleeding can be difficult especially in a patient with disseminated lung disease. Chest computerized tomography and bronchoscopy remain the methods of choice for lateralization of the disease. Some patients can be treated successfully with endobronchial interventions. Bronchial artery embolization can be rewarding in some patients but the recurrence rate is higher in tuberculosis than other etiologies of haemoptysis. Surgical resection of the lung, mainly lobectomy, remains a life-saving procedure but it should be performed very selectively to avoid higher postoperative morbidity and mortality. Different management options of haemoptysis in patients with pulmonary tuberculosis are discussed in this manuscript.

Detection of reactive oxygen metabolites in malignant and adjacent normal tissues of patients with lung cancer.

BACKGROUND: Different types of reactive oxygen metabolites (ROMs) are known to be involved in carcinogenesis. Several studies have emphasized the formation of ROMs in ischemic tissues and in cases of inflammation. The increased amounts of ROMs in tumor tissues can either be because of their causative effects or because they are produced by the tumor itself. Our study aimed to investigate and compare the levels of ROMs in tumor tissue and adjacent lung parenchyma obtained from patients with lung cancer. METHODS: Fifteen patients (all male, mean age 63.6 ± 9 years) with non-small cell lung cancer were enrolled in the study. All patients were smokers. Of the patients with lung cancer, twelve had epidermoid carcinoma and three had adenocarcinoma. During anatomical resection of the lung, tumor tissue and macroscopically adjacent healthy lung parenchyma (control) that was 5 cm away from the tumor were obtained. The tissues were freshly frozen and stored at -20°C. The generation of ROMs was monitored using luminol- and lucigenin-enhanced chemiluminescence (CL) techniques. RESULTS: Both luminol (specific for (.)OH, H(2)O(2), and HOCl(-)) and lucigenin (selective for O(2)(.)(-)) CL measurements were significantly higher in tumor tissues than in control tissues (P <0.001). Luminol and lucigenin CL measurements were 1.93 ± 0.71 and 2.5 ± 0.84 times brighter, respectively, in tumor tissues than in the adjacent parenchyma (P = 0.07). CONCLUSION: In patients with lung cancer, all ROM levels were increased in tumor tissues when compared with the adjacent lung tissue. Because the increase in lucigenin concentration, which is due to tissue ischemia, is higher than the increase in luminol, which is directly related to the presence and severity of inflammation, ischemia may be more important than inflammation for tumor development in patients with lung cancer.

Surgical management for hydatid disease.

Hydatid disease is caused by the parasite Echinococcus granulosus. The liver and the lungs are common sites. When a cystic lesion is seen on CT scan, diagnosis is made based on the patient having lived in an endemic area. Serologic tests are used for differential diagnosis. Medical treatment is centered on albendazole. Surgery is recommended either by open or endoscopic technique depending on the characteristics of the cysts and the patient. Complications of surgery are rare except for prolonged air leaks. Mortality occurs when the cyst is located in the central nervous system or occludes major vessels.

Video-assisted thoracoscopic removal of pulmonary hydatid cysts.

OBJECTIVES: Pulmonary hydatid disease is a parasitic disease with a high prevalence in low-middle income countries. We report four patients who were treated surgically using video-assisted thoracoscopy (VATS). METHODS: All patients were diagnosed with clinical and radiological findings on chest X-ray and computed tomography. Complete thoracoscopic removal by cystotomy and capitonnage was done in all four patients. The procedure included a standard thoracoscopy port incision and a 2-3 cm utility skin incision that was placed just superior to the cystic lesion. In the first case, a small-sized rib separator was used. The following three cases were operated without placing a rib separator on the utility incision. Conversion to open thoracotomy was not required. RESULTS: The average duration of the procedure was 90 min, and the average length of hospital stay was 4 days. No complications were observed after the thoracoscopic removal. At mean follow-up of 4 months, all patients were asymptomatic. CONCLUSIONS: VATS removal of the hydatid cysts can be done successfully in peripherally located cysts.

Superiority of video-assisted to standard mediastinoscopy in non-small-cell lung cancer staging.

BACKGROUND: We compared the efficiency of videomediastinoscopy (VM) and standard mediastinoscopy (SM) in detecting mediastinal lymph node (MLN) metastasis in non-small-cell lung cancer (NSCLC) patients. METHODS: By SM method a surgeon sampled bilateral paratracheal and subcarinal lymph node stations and then by VM method, another surgeon resampled all lymph node stations once more through the same incision in the same operative setting. Results of the pathologic examinations of two methods were compared. RESULTS: Twenty-seven consecutive mediastinoscopies were included. The numbers of nodal stations biopsied in SM and VM were 97 and 103, respectively. Lymph node metastasis was found in six patients with SM and nine patients with VM. Lymph node dissection by thoracotomy revealed metastases, which were not found by mediastinoscopy, in two patients. Our study showed an accuracy of 92.3% for VM versus 80.7% for SM and corresponding negative predictive values of 88.2% and 75%, respectively (p = 0.002; Fig. 1). CONCLUSION: This study showed that VM is superior to SM in detecting MLN metastasis in patients with NSCLC.

[A rare cause of hemopneumothorax: an aberrant systemic artery]. / Nadir görülen bir hemopnömotoraks nedeni: Aberan sistemik arter.

Spontaneous hemopneumothorax is a rare situation that can be life-threatening in young patients presenting hemodynamic instability due to hypovolemic shock. One of the extraordinary causes of hemopneumothorax is rupture of an apically located aberrant artery after pneumothorax, which is noticed as a third etiological factor in the literature. This case is presented in order to highlight this uncommon etiological factor together with the literature.

Spontaneous pneumomediastinum: report of two cases.

Spontaneous pneumomediastinum (SPM) is an uncommon, benign, self-limited disorder that usually occurs in young adult males without any apparent precipitating factor or disease. SPM responds extremely well to conservative treatment, without recurrence in the great majority of cases. In this report, two patients who were admitted for SPM are discussed together with the associated literature.

Streptokinase for malignant pleural effusions: a randomized controlled study.

Effective palliative treatment in malignant pleural effusion can only be carried out when the lung is fully expanded after drainage of effusion. We investigated the efficacy of intrapleural fibrinolytics for lysing fibrin deposits and improving lung reexpansion in patients with malignant pleural effusion. We randomly allocated 47 patients with malignant pleural effusion into 2 groups: a fibrinolytic group of 24 were given 3 cycles of 250,000 U intrapleural streptokinase; the control group of 23 received pleural drainage only. Pleurodesis with 5 mg of talc slurry was performed in all patients who had lung reexpansion after drainage. Patient characteristics, pleural drainage, lung expansion assessed by chest radiography, and pleurodesis outcomes were compared between the 2 groups. Patient characteristics were similar in both groups. Lung reexpansion was adequate for performing talc pleurodesis in 96% of patients in the fibrinolytic group and 74% in the control group. In the fibrinolytic group, the mean volume of daily pleural drainage before streptokinase administration was 425 mL, and it increased significantly to 737 mL after streptokinase infusion. Intrapleural administration of streptokinase is advisable for patients with malignant pleural effusion.

Recurrent pneumothorax diagnosed as catamenial after videothoracoscopic examination of the pleural cavity.

We describe a case of catamenial pneumothorax due to a diaphragmatic defect that was confirmed and treated through the thoracoscopic approach. The patient was a 34-year-old woman who had 3 episodes of right chest pain and shortness of breath, each time starting on the day preceding her menstruation. During thoracoscopy, pathologic changes in the central tendon were apparent, as a 2-mm defect in the diaphragm was discovered. The defect was sutured. Apical pleurectomy and chemical pleurodesis were applied. According to the literature, suspicion of catamenial pneumothorax requires detailed examination of the diaphragm. Every effort, such as pleurectomy and pleurodesis, with postoperative hormonal therapy, should be added to treatment, owing to the high probability of recurrence.

An unusual presentation of Castleman's disease.

Castleman's disease is one of the heterogeneous group of lymphoproliferative disorders of unknown aetiology. It commonly presents as a mediastinal mass. It can be unicentric involving only a single site, or multicentric involving multiple sites. We report a patient with unicentric Castleman's disease, in which the mass was located in the posterior mediastinum and accompanied by a massive pleural effusion, which is extremely rare in unicentric disease. This case report highlights the imaging techniques used in the differential diagnosis and surgical considerations due to the hypervascular nature of the tumour.

The autologous pleural buttressing of staple lines in surgery for bullous lung disease.

OBJECTIVE: Prolonged air leak remains as one of the most common complications after surgery for bullous lung disease. Reinforcement of the staple line with either prosthetic material or bovine pericardial strips has been advocated to avoid this problem. We used the patients' own parietal pleural layer to cover the staple lines to prevent air leak and subsequently assessed the comparative results. METHODS: A total of 22 patients underwent thoracotomy for bullous lung disease, mainly due to lobe-dominance bullae combined with emphysema, between November 2006 and November 2008. A case-control study was set from the surgical data of patients who were operated on using stapling devices without any buttressing material (group I=12) and were compared with the group of patients who were operated on using staplers buttressed with an autologous pleural layer (group II=10). Patient characteristics, chest-tube removal time and length of hospital stay were prospectively recorded in group II. The outcomes of the two groups were analysed based on postoperative complications, chest-tube removal time and postoperative length of hospital stay. RESULTS: There was no statistically significant difference between both the groups in preoperative characteristics including age, sex, co-morbid factors, and respiratory functions, heterogeneity of emphysema, intra-operative adhesion density and length of staple line. However, the chest tube was removed significantly earlier in patients whose bullae were resected by stapling devices buttressed with autologous-parietal pleura (p=0.04). CONCLUSIONS: Autologous pleural reinforcement of the staple line in surgery for bullous lung disease is a safe, effective and cost-free procedure that precipitates the early removal of the chest tube.

Lung decortication for chronic empyaema: effects on pulmonary function and thoracic asymmetry in the late period.

OBJECTIVE: Chronic empyaema deteriorates lung function and causes thoracic asymmetry due to intercostal narrowing in the diseased hemithorax. This study aims to investigate the rates of improvement in the pulmonary function tests (PFTs) and the thoracic deformity in late postoperative period of lung decortication, performed for chronic empyaema. METHODS: A total of 50 patients who underwent standard open decortication for empyaema were included. The PFTs and computed tomographic (CT) scans of the chest were analysed in all patients after 6-58 months postoperatively. The measurements of antero-posterior and transverse diameters of both hemithoraxes were performed on both preoperative and postoperative chest CTs. The thoracic asymmetry was calculated as the ratio of the measurements of the diseased side to the normal side. The pre- and postoperative parameters were compared statistically. RESULTS: The mean preoperative forced expiratory volume in first second (FEV(1)) and forced vital capacity (FVC) increased from 61.40% and 60.89% to 78.92% and 77.48%, respectively, in the late postoperative period (p<0.001). The mean preoperative transverse diameter of affected hemithorax increased from 11.22 cm to 11.98 cm (p<0.001) and, the transverse asymmetry improved from 11.52% to 5.94%, postoperatively (p<0.001). The mean preoperative antero-posterior chest diameter improved from 15.58 cm to 16.67 cm (p<0.001), and the antero-posterior asymmetry improved from 11.42% to 5.42% (p<0.001) in the late postoperative period. CONCLUSIONS: The open decortication for chronic pleural empyaema significantly increases FEV(1) and FVC. Due to the re-expansion of the lung and enlargement of the intercostal spaces, the chest wall deformity also improves considerably after the operation.

Sequential right upper sleeve lobectomy and left pneumonectomy for bilateral synchronous lung cancer.

Bilateral pulmonary resections can be performed in patients with synchronous non-small cell lung cancers. However, pneumonectomy and lobectomy in the same patient is still an arguable approach. We report a successful sequential right upper sleeve lobectomy and left pneumonectomy performed in a 47-year-old male patient who had bilateral synchronous primary lung cancer.

Comparison of the single or double chest tube applications after pulmonary lobectomies.

OBJECTIVE: Draining of the chest cavity with two chest tubes after pulmonary lobectomy is a common practice. This study aimed to investigate whether using two tubes after a pulmonary lobectomy is more effective than using a single tube. METHOD: This prospective randomised study included 100 consecutive patients who underwent lobectomy or bilobectomy for any pathological condition between May 2006 and November 2007. In the 50 patients in the 'single-tube group', only one 32F chest tube was inserted, and in the 50 patients in the 'double-tube group', two 32F chest tubes were inserted. Pre-, intra- and postoperative variables in both the groups were compared. RESULTS: The pre- and intraoperative characteristics of the patients were similar in both groups. The mean amount of drainage from chest tubes was 600+/-43.2cc in the single-tube group and 896+/-56.2cc in the double-tube group (p<0.001). The mean values of postoperative pain assessed on the visual analogue scale (VAS) in the early (second day) period were 4.28+/-0.21 in the single-tube group and 5.10+/-0.23 in the double-tube group (p=0.014). The VAS scores in the late (second week) period were 1.48+/-0.13 in the single-tube group and 2.00+/-0.17 in the double-tube group (p=0.01). All other related parameters were similar in both groups. CONCLUSIONS: Insertion of two chest tubes is not more effective than the insertion of a single chest tube after pulmonary lobectomy. Moreover, using a single tube is in fact more effective than using two tubes in that it causes less postoperative pain and less pleural fluid loss.

Delays in the diagnosis and treatment of primary lung cancer: are longer delays associated with advanced pathological stage?

We aimed to investigate the delays from the first symptom to thoracotomy and to examine whether the delays cause the stage advancement in lung cancer. This prospective study included 138 patients with non-small cell lung carcinoma who underwent thoracotomy. Clinical files of the patients were analyzed and a questionnaire was created to obtain information from the patients. The mean duration values were 81.3 days for the application interval, 61.3 days for the referral interval, 20.3 days for the diagnostic interval, and 21.9 days for the treatment interval. The application interval was longer than 30 days (patient delay) in 50 patients (37.9 %). The mean interval from the first visit to doctor to thoracotomy was 97.2 days. There was a doctor delay in 102 (73.9 %) patients; a referral delay in 83 patients (60.1 %), a diagnostic delay in 47 patients (36.4 %), and a treatment delay in 96 patients (69.6 %). The mean total duration was 176.2 days. Ninety-four patients (71.2 %) had a total delay. Mean total delay was 184.5 days in pathologic stage I, 187.3 days in stage II, 167.7 days in stage IIIA, 142.6 days in stage IIIB, and 150.3 days in stage IV (p>0.05). Delays during the course between the first symptom and thoracotomy in lung cancer patients were a common problem among our patients. Prolonged durations in the application and referral of patients are the most significant cause of delays. Presence of delay or length of delay did not correlate with pathologic tumour stage in this study.

Recurrent pulmonary hydatid disease: analysis of ten cases.

PURPOSE: To investigate the incidence and define the importance of recurrent pulmonary hydatid cysts in developing countries. METHODS: We analyzed the records of 312 patients with pulmonary hydatid cyst disease diagnosed in our center between 1999 and 2005. RESULTS: A recurrent pulmonary hydatid cyst was diagnosed in 10 (3.2%) of the 312 patients [8 men and 2 women, mean age 36.9 (range 20-60) years]. The diagnosis was based on radiographic, clinical, or serological findings, established intraoperatively. The most frequent symptom of recurrent pulmonary hydatid cyst was hemoptysis (60%). The mean interval between diagnosis of the initial hydatid cyst and detection of recurrence was 8.75 (range 3-15) years. Bronchoscopy was performed in all patients, but proved diagnostic in only one. The localization of the initial and recurrent cysts differed in seven patients. A median follow-up period of 5 years revealed second recurrences in only two patients; manifesting as an intrapleural rupture of the cyst in one and as empyema in one. The recurrence was treated by resection in all patients; as cystectomy in eight patients, lobectomy in one patient, and pneumonectomy in one patient. CONCLUSION: Pulmonary hydatid cyst may recur in the same or a different location in the lung. Patients with a pleural lesion must be followed up regularly for any signs of recurrence.