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.

Cavernous hemangioma of the rib: a rare tumour.

Hemangioma is exceedingly rare in the ribs. A case of rib hemangioma in a 54-year-old woman is presented. Chest roentgenogram and computed tomography revealed a mass in the left lateral costaphrenic sinus with bone destruction. She underwent resection of the 7th and 8th rib. The pathologic diagnosis was cavernous hemangioma. Hemangiomas of the rib are rare tumours but should be kept in mind in the differential diagnosis of rib tumours.

Acquired pulmonary arteriovenous malformation secondary to hydatid cyst operation.

Pulmonary arteriovenous malformations are abnormal communications between pulmonary arteries and pulmonary veins. The majority of the cases are congenital in origin, and acquired pulmonary arteriovenous malformations are very rare. We present a case here, which - to the best of our knowledge - is the first acquired pulmonary arteriovenous malformation secondary to a hydatid cyst operation in the literature, and we discuss the etiology, clinical presentation, diagnostic modalities and treatment of acquired pulmonary arteriovenous malformations.

Utility of intraoperative frozen section examination in thoracic surgery. A review of 721 cases.

AIM: Intraoperative frozen section examination (FSE) is an important tool for determining how extensive a surgical procedure needs to be. In this study we reviewed the indications for FSE, the correlation between FSE and postoperative histopathology, and the contribution of intraoperative FSE in determining the extent of the surgical procedure. METHODS: A total of 744 FSE performed in 721 patients between January 1995 and January 2004 were reviewed retrospectively. The FSE were divided into 7 groups according to the indications of the request for frozen section. False positivity and false negativity were evaluated. RESULTS: The indications for FSE included intraoperative diagnosis of pulmonary masses (311, 41.8%), determination of N2 status with mediastinoscopy and mediastinotomy (153, 20.6%), staging of pulmonary carcinomas during the operation (86, 11.6%), assessment of the margin of bronchial surgical resection following pulmonary resection (54, 7.2%), presence of solitary pulmonary nodules (75, 10.1%), presence of mediastinal masses (39, 5.2%), and pleural thickening (26, 3.5%). When compared to postoperative paraffin sections, FSE was found to have a 1.9% (8) rate of false negatives and a 0.2% (1) rate of false positives (P < 0.001). CONCLUSIONS: Intraoperative FSE in thoracic surgery is a rather reliable method. When FSE indicates malignancy, it is a valuable guide in directing the extent of the ongoing surgical procedure. However, when FSE indicates a benign lesion, surgeons should interpret this in the light of the patient's clinical and radiological features and the lesion's macroscopic nature when deciding how extensive an operation needs to be.

The relationship between time of admittance and complications in paediatric tracheobronchial foreign body aspiration.

PURPOSE: Majority of tracheobronchial foreign body aspirations occur in paediatric age group and may constitute a life hazard. We examined the relationship between the time of admittance and complications in children with tracheobronchial foreign body aspiration. MATERIAL AND METHODS: Sex, age, time of admittance, presenting symptoms, radiological findings, and the nature of the foreign body were reviewed retrospectively in patients aged 16 and under follow-up for tracheobronchial foreign body aspiration between January 1990 and January 2005. Cases were randomly assigned into 6 groups based on admittance times. RESULTS: Within 15-year period, 263 children under the age of 16 were followed-up for tracheobronchial aspiration of foreign body. The most commonly aspirated foreign bodies included sunflower seed, peanut, hazelnut, walnut. While the pathology could be detected radiographically in 80.3% (n : 211) of the cases, in 19.7% (n : 52) radiology was normal. All cases had rigid bronchoscopy under general anaesthesia. In 220 cases foreign body was detected and could successfully be removed in 209 cases. The remaining 11 cases required bronchotomy or pneumotomy to remove the foreign body. Among 679 cases operated for bronchiectasis during the same period, 22 cases (3.2%) had foreign body as the aetiology. No complications were observed when the patients presented to the hospital within the first 24 hours after the aspiration while fever, purulent sputum, haemoptysis and bronchiectasis were noted in those presented later. Most of the complications were medically treated. CONCLUSION: Paying medical attention within the first 24 hours after the aspiration of foreign bodies is critical in order to accomplish a complication-free course. Organic foreign bodies and retention period of 30 days and over, constitute major risk factors in the development of bronchiectasis. It is advisable to perform bronchoscopy in the early stages of all suspected cases to avoid serious complications such as bronchiectasis.

Surgical treatment of pulmonary hydatid cysts in children.

OBJECTIVE: Hydatid disease is a parasitosis and endemic in many sheepraising areas; it is still an important health problem in Turkey. We report our experience with childhood hydatid cyst and discuss the concepts of treatment. METHODS: The clinical courses of 128 children with thoracic and liver hydatid cyst operated on from 1994 to 2000 were reviewed. The group consisted of 71 boys and 57 girls aged from 8 months to 16 years. Intact cysts were found in 144 patients and ruptured cysts in 68. RESULTS: In the postoperative course we have encountered 20 perioperative complications in 16 patients. The most common complication was residual pleural space and delayed air leakage, which occurred in 9 patients. There was no early death. CONCLUSION: Surgery is the treatment of choice for most patients with pulmonary hydatid disease. The aim of surgery is evacuation of the cyst, removal of the endocyst, and management of the residual cavity. Conservative surgical methods that preserve lung parenchyma should be preferred.

A case of multiple synchronous localized fibrous tumor of the pleura.

We report a patient with two synchronous distinct masses in the same hemithorax both of which got the diagnosis of benign localized fibrous tumor of the pleura. The plain chest X-ray was rather obscured due to a large left-sided pleural effusion, but her subsequent computerized chest tomography revealed a heterogeneous hypodense soft tissue mass, which was pleural in origin, sitting on the diaphragm bathed in fluid. At thoracotomy, we detected two distinct masses in the left hemithorax, both arising from the visceral pleura via their vascular pedicles.

Neurogenic tumours of the mediastinum: a report of 60 cases.

OBJECTIVES: To analyze retrospectively 60 patients (13 infants and children, 47 adults--21 men and 39 women) with mediastinal neurogenic tumours admitted to Atatürk Centre for Chest Disease and Chest Surgery, Ankara, Turkey between 1988 and 1999. This comprised 21.2% of 283 patients who had surgical operations for all mediastinal masses during the same period. PATIENTS AND METHODS: The patients ranged from four to 67 years of age. Thirteen patients were younger than 15 years and 47 were 15 years of age or older. Medical records were reviewed for demographic data, clinical presentation, diagnostic investigations, operative procedures, and tumour location and invasion. Postoperative morbidity and mortality were noted as well as long term follow-up. The clinical investigations included chest x-ray and computed tomography of the thorax in all patients, and spinal magnetic resonance imaging and bronchoscopical examination in some. Clinical variables were compared. RESULTS: The tumours had the following characteristics: 42 (70%) were nerve sheath tumours; 15 (25%) were autonomic ganglion tumours; two (3.6%) were paragangliomas; and one (1.4%) was a malignant peripheral neuroectodermal tumour (Askin's tumour). Nerve cell tumours comprised the majority of tumours in infants and children (nine of 13, 69%), whereas the nerve sheath tumours were most frequent in adults (39 of 47, 83%). There were 48 benign and 12 (20%) malignant tumours when all age groups were considered; the malignancy rate was 61.5% (eight of 13) in children and 8.5% (four of 47, P<0.05) in adults. All patients were operated via a posterolateral thoracotomy. Surgical resection of the tumour was complete in 56 of 60 patients (93.3%). Resection of malignant tumours was grossly incomplete in four cases (four of 12, 33.3%). All benign tumours were totally excised. There were two major complications (respiratory failure and pulmonary emboli) and 14 minor complications in the perioperative period. The mean follow-up period was five years and seven months. Tumours recurred in 5.3% (three of 56) of patients who had a complete resection initially. There were no late deaths related to benign tumours. CONCLUSIONS: Complete resection of tumours can be performed safely by a thoracotomy approach and is important for achieving satisfactory long term survival in most mediastinal neurogenic tumours.

Childhood chronic pleural empyema: a continuing surgical challenge in developing countries.

BACKGROUND: Surgical treatment may be necessary in childhood chronic pleural empyema. METHODS: Over a 21-year period 642 children with pleural empyema were hospitalized and 104 of them underwent surgical treatment. The records of the children who underwent surgery for the treatment of empyema were retrospectively reviewed to describe the role, indications, and results of surgical treatment of childhood chronic pleural empyema. RESULTS: Etiologic diseases or conditions leading to empyema were pneumonia in 69 patients, tuberculosis in 13, hydatid cyst in eight, postpneumonectomy empyema in five, and other causes in nine patients. Indications for surgery were severe pleural thickening in 54 cases (51.9%), trapped lung in 36 cases (34.6%), loculated empyema in eight cases (7.7%) and broncho-pleural fistula in six cases (5.8%). Operations performed were decortication in 90 patients, pulmonary resection and decortication in seven, muscle flap closure in five, and pneumonectomy in two. Success rates in the treatment of nonspecific and tuberculous empyema were 93% and 54%, respectively. CONCLUSIONS: Surgical treatment is still necessary in childhood pleural empyema in developing countries, and success rates are very high in nonspecific pleural empyema and acceptable in tuberculous pleural empyema.

Pleurectomy/decortication for palliation in malignant pleural mesothelioma: results of surgery.

OBJECTIVE: Surgery can only offer palliation in an attempt to slow the progression of malignant pleural mesothelioma (MPM). We want to assess the effectiveness and safety of pleurectomy/decortication in establishing a tissue diagnosis, and controlling pleural fluid accumulation and symptoms in patients with MPM. METHODS: We reviewed our pleurectomy results in 100 patients with MPM over a 19 year period. Major symptoms were chest pain, cough and dyspnea, and radiographic findings included pleural mass, pleural fluid and constriction of involved hemithorax. RESULTS: Approximately two thirds of the patients underwent surgery prior to tissue diagnosis. Eighty-nine patients had stage I and stage II disease, 8 and 81%, respectively. The patients underwent subtotal (44%) or total pleurectomy (56%). The surgical mortality rate was 1% (1/100) and the morbidity rate was 22%. Morbidity included prolonged air leak (n = 12), empyema (n = 6), reaccumulation of pleural fluid (n = 2) and wound infection (n = 2). Palliative results included dyspnea and cough relief in all patients, chest relief in 60 (85%) and pleural fluid control in 52 (96%) patients. Median survival was 17 months in MPM patients. CONCLUSIONS: We conclude that pleurectomy/decortication safely provides both tissue diagnosis and effective of pleural effusion and symptoms and therefore excellent palliation in patients with MPM.

One-stage operation for treatment after delayed diagnosis of thoracic esophageal perforation.

Perforation of the thoracic esophagus can be fatal unless diagnosed promptly and treated effectively. The high mortality with delayed treatment is principally due to the inability of effectively closing the perforation and preventing the leakage. We operated one patient with a delayed diagnosis of thoracic esophageal perforation developed after a rigid esophagoscopic procedure. The perforation was closed with primary sutures and reinforced with a intercostal muscle flap wrap. Radical decortication and wide mediastinal and pleural toilet were also done. Total parenteral nutrition was begun and antibiotics were administered according to the results of cultures. Esophagography and esophagoscopy performed 10 days after the operation showed a well healed esophagus without stenosis or leakage. We conclude that primary closure of the perforation and muscle flap wrap can provide a one-stage operation with good results for repair of thoracic esophageal perforations which are not diagnosed on time.

Combined chemotherapy in pleurectomized malignant pleural mesothelioma patients.

A phase II clinical trial of 20 cancer patients who presented with malignant pleural mesothelioma (MPM) between November 1991 and April 1993 was conducted. Of the histologically proven cases, 16 (80%) were epitheloid and 4 (20%) were mixed type MPM. Patients were treated with mitomycin C, cisplatin, and alpha interferon after pleurectomy. Our schedule consisted of 10 mg/m2 mitomycin C i.v. infusion, 50 mg/m2 cisplatin i.v. infusion, 10 mil Ur-alpha interferon i.m. and 10 mil Ur-alpha interferon i.v. infusion on the first day of treatment. Patients were given a mean of 4.5 chemotherapy cycles (range: 2-6). None of the patients showed complete or partial response. Stable disease was observed in 15 patients, while 5 patients had progressive courses. The overall median survival time after chemotherapy was 12 months (range: 3-31 months). Median survival after chemotherapy was 15 months (range: 4-31 months) in the stable disease group (n:15, 75%), and 5 months (range: 3-13 months) in progressive cases (n:5, 25%). The overall survival rates were 55% [95% Confidence Interval (CI):43%-88.8%] at one year and 15% (95% CI:5%-39.1%) at 2 years. Five patients had grade 3 alopecia, three had grade 2 vomiting and nausea, two had grade 2 leukopenia, one had grade 2 cardiotoxicity and another had discoloration on his fingernails. In our multimodal therapy protocol, we found no difference in survival and relapse rates between our combined modal therapy and other single modal therapies in the literature.

Clinical experience with minitracheotomy.

In minitracheotomy, a relatively simple percutaneous technique for tracheal cannulation, a small-bore tube is inserted via the cricothyroid membrane to provide access to suction removal of excess secretion or aspirated material from the tracheobronchial tree. It allows efficient tracheobronchial toilet while preserving glottic function and avoiding the disadvantages of conventional tracheostomy and endotracheal intubation. The indications for minitracheotomy in 20 cases were excessive postoperative or postpneumonic secretion (14), difficulty with endotracheal suction (5) and acute airway obstruction (1). The only major complication was bleeding in one case. Minor bleeding occurred at the incision in two cases. The cannula was retained for 3-8 days and removal was followed by closure within 48 hours. There were no adverse laryngeal effects. Minitracheotomy was well tolerated by the patients and is a useful adjunct for removal of airway secretion and hospitalized patients.

Management of intrathoracic goitre.

A retrospective review is presented of 20 cases with resection of intrathoracic goitre between 1975 and 1993. The mean age of the 11 men and nine women was 53 years. The intrathoracic goitre was primary in seven cases and secondary in 13. The presenting clinical features and the pathology, surgical risks and optimal approaches are discussed. Primary intrathoracic goitre should be approached via a thoracotomy, because of the independent vascular supply. As secondary intrathoracic goitres are supplied by vascular pedicles arising from the inferior thyroid artery, a cervical collar incision is preferable. In the event of significant mediastinal bleeding, which is difficult to control from a cervical incision, a T-shaped incision for partial or full sternotomy can be performed, or even thoracotomy.

Surgical treatment of bronchiectasis: a collective review of 487 cases.

Pulmonary resection to treat bronchiectasis in a total of 487 patients between December 1976 through June 1988 is reported on. The surgical treatment consisted of pneumonectomy in 190 cases (144 left and 46 right), lobectomy in 202 cases, bilobectomy in 23 cases and lobectomy combined with segmental resection in 72 cases. The overall mortality rate was 3.5%. Patients were followed up for a period ranging between 4 months to 10 years: at the end of the study 71% of the patients were completely asymptomatic. It is concluded that though the first choice of therapy must be conservative, in those patients with bronchiectasis in whom disease progresses despite medical treatment and in those whose disease requires frequent hospitalization, continuing medical treatment is unwarranted and surgery must be the choice of therapy.