Late diagnosis of extralobar pulmonary sequestration: two cases with an uncommon malformation.

Pulmonary sequestration is a congenital bronchopulmonary malformation, characterized by a mass of nonfunctioning lung tissue which receives its blood supply from a systemic artery. This increased blood flow and the inflammation in the sequestrated segments are positive on PET imaging, arousing the suspicion of malignancy. We report two cases of PET-positive extralobar sequestration that presented in patients of middle age and were successfully treated with surgical resection, indicating the role of surgery and the false-positive PET-CT appearance of sequestration cases.

The role of fluoroscopy in the removal of tracheobronchial pin aspiration.

In this study, we investigated the role of fluoroscopy in the bronchoscopic removal of aspirated pins. Of 373 patients who underwent bronchoscopy for presumed tracheobronchial foreign body aspiration, 56 pin aspiration cases were selected and divided into two groups according to whether fluoroscopic guidance was required (group I) or not (group II). The localisation of foreign bodies, mortality and morbidity ratios and the duration of the procedures were investigated. Pin aspiration percentage was 15. Pins were mostly located in peripheral airways in group I, and in central airways in group II (p < 0.05). The mean duration of the procedure was 42 +/- 30 min in group I and 17 +/- 13 min in group II (p < 0.01). There was no mortality. Morbidity percentage was 7 in group I and 12 in group II (p > 0.05). No thoracotomy was required in any cases. Fluoroscopic guidance is safe and carries no additional morbidity and mortality and can be used for pins in the tracheobronchial tree.

Complications and management of long-term central venous access catheters and ports.

PURPOSE: Although prolonged venous access devices (PVADs) are used in case prolonged intravenous therapy is required, implantation and use of these devices is associated with complications. The purpose of this study was to evaluate perioperative and long-term complications associated with PVADs and the management of these complications. METHODS: A retrospective review was undertaken of 225 PVADs implanted in 217 patients from February 1993 to June 2004. This included 144 single-lumen port infusion systems, 49 single-lumen Hickman catheters and 32 double-lumen Groshong catheters. The PVADs were inserted using either the percutaneous Seldinger method (n=183) or cutdown access to the subclavian vein (n=42). Indications for placement were as follows: chemotherapy in 66.2% of patients, drug-infusion treatment in 31.6% of patients and total parenteral nutrition in 2.2% of patients. RESULTS: Perioperative complications occurred in 13 patients (5.7%): catheter malposition in seven patients (3.1%), pneumothorax in three patients (1.3%), hemorrhage in two patients (0.9%) and catheter embolization in one patient (0.4%). Long-term complications appeared in 15 patients (6.6%): infection in five patients (2.2%), thrombosis in three patients (1.3%), extravasation in three patients (1.3%), and catheter fracture in four patients (1.8%). The fractured fragments were removed by the Amplatz snare device. In 10 patients (4.4%) only were PVADs removed prior to completion of the intended therapy. Indications for removal were catheter infection in five patients (2.2%) and catheter fracture in five patients (2.2%). CONCLUSIONS: PVAD implantation is associated with some risk of serious perioperative and long-term complications. Care of the catheter and the patient should be maintained with the proper and immediate evaluation of the perioperative and long-term complications.

Intravenous allicin improves pulmonary blood flow after ischemia-reperfusion injury in rats.

BACKGROUND: Allicin is a sulfur-containing compound extracted from garlic, with antiaggregatory, anti- migratory, anti-oxidant and pulmonary vasodilator actions. We hypothesized that allicin might be beneficial in lung ischemia-reperfusion. METHODS: A non-nothermic rat lung ischemia-reperfusion model was established by clamping left pulmonary artery (PA) for 1 hr, followed by reperfusion for 2 hrs by clamping right PA to reflect solely the function of left lung. Groups were control (n=7), allicin 0.1 mg (n=8) and allicin 0.01 mg (n=4). In the beginning of reperfusion allicin/saline were injected. Pulmonary artery pressures (PAP), pulmonary artery flow (PAF), left atrial pressure (LAP) were monitored. At the end of reperfusion period arterial blood gas (ABG) analysis was done. RESULTS: Six of 7 control and 3 of 8 group 2 animals died before completing the experiment. In group 1 all animals completed the experiment (p=0.015 vs control). PAF was significantly increased after 30, 60 and 120 min of reperfusion in group 1 (p=0.0028, 0.0009, 0.0003 respectively vs control) and after 60 and 120 minutes in group 2 (p=0.0453, 0.018 respectively vs control). Pulmonary vascular resistance was lower at 30 min in allicin 0.01 mg group (p=0.0017 vs control). PAP was increased after 60 and 120 min of reperfusion in group 1 (p=0.016, 0.0029 respectively vs control) and after 120 min in group 2 (p=0.0104 vs control). CONCLUSIONS: This study shows that allicin improves postischemic PAF in this model. Allicin needs further investigation of potential utility and mechanism(s) of action.

Transthoracic esophagectomy with radical mediastinal and abdominal lymph node dissection and cervical esophagogastrostomy for esophageal carcinoma.

BACKGROUND: Several techniques for esophageal resection have been reported. This study examines the morbidity, mortality, and early survival of patients after transthoracic esophagectomy for esophageal carcinoma using current staging techniques and neoadjuvant therapy. The technique includes right thoracotomy, laparotomy, and cervical esophagogastrostomy (total thoracic esophagectomy) with radical mediastinal and abdominal lymph node dissection. METHODS: Three hundred forty-two patients had surgery for esophageal carcinoma between 1989 and 2000 at our institution. Two hundred fifty consecutive patients had esophagectomy using this technique. Kaplan-Meier curves and univariate and multivariate analyses were performed by postsurgical pathologic stage. RESULTS: Median age was 62.7 years (31 to 86 years). Fifty-nine were female. Eighty-one percent (202) had induction chemotherapy (all patients with clinical T3/4 or N1). Early postoperative complications included recurrent laryngeal nerve injury (14% [35]), chylothorax (9%, [22]), and leak (8%, [19]). Median length of stay was 13 days (5 to 330 days). In-hospital or 30-day mortality was 3.6% (9). Overall survival at 3 years was 44%; median survival was 25 months, and 3-year survival by posttreatment pathologic stage was: stage 0 (complete response) (n = 60), 56%; stage I (n = 32), 65%; stage IIA (n = 67), 41%; stage IIB (n = 30), 46%; and stage III (n = 49), 17%. Mean follow-up was 24 months (SEM 1.6, 0 to 138 months). Five patients with tumor in situ, 6 patients with stage IV disease, and 1 patient who could not be staged (12 pts) were excluded from survival and multivariate calculations. In univariate and different models of multivariate analysis, age more than 65 years, posttreatment T3, and nodal involvement were predictive of poor survival. For univariate analysis, p = 0.002, p = 0.004, p = 0.02, respectively; for multivariate analysis, p = 0.001, p = 0.003, p = 0.02, respectively. CONCLUSIONS: Total thoracic esophagectomy with node dissection for esophageal cancer appears to have acceptable morbidity and mortality with encouraging survival results in the setting of neoadjuvant therapy. Patients who show complete response after induction chemoradiotherapy appear to have improved long-term survival.

Rudolf Nissen's years in Bosphorus and the pioneers of thoracic surgery in Turkey.

Rudolph Nissen is one of the most distinguished pioneers in thoracic surgery, well known for his pneumonectomy operation performed for the first time in surgical history. He migrated to Istanbul like most of his contemporary colleagues, avoiding the fascist regime in Germany in the 1930s. He was enthusiastically welcomed in Turkey and appointed as the Chief of the First Surgery Clinic in Istanbul University in 1933. He worked with discipline and in cooperation with his Turkish colleagues, such as Ahmed Burhaneddin Toker, Fahri Arel, Dervis Manizade, and others, who were to become the leading authorities of general thoracic surgery in Turkey. During his 6 years of residence and working in Istanbul, he contributed highly to the practice of general and thoracic surgery. He had to leave for the United States in 1939 for treatment of his lung abscess due to a retained bullet from World War I. He stayed in New York and later in Basel until his death. He was presented an honorary professorship from Hacettepe University, Ankara in 1973.

Membrane stabilization in harvested vein graft storage: effects on adhesion molecule expression and nitric oxide synthesis.

OBJECTIVE: Expression of cellular adhesion molecules in human saphenous vein grafts may occur even during harvesting and storage, before the grafts have been implanted as bypass conduits. This may play a role in graft adaptation to arterial flow conditions, which may play an important role in late graft patency. In this study, ketotifen, a mast cell membrane stabilizing agent was studied for its effects on reducing endothelial reactivity during storage of harvested vein graft segments. METHODS: Human saphenous vein grafts, obtained from seven patients and then divided into two equal parts of control and study specimens, were stored in either heparinized blood (Group A) or heparinized blood containing 100 microg/ml ketotifen (Group B) for 1 h at room temperature. Specimens were analyzed by Western blotting to quantify ICAM-1, E-selectin, P-selectin, VCAM-1, and inducible nitric oxide synthase (NOS-2) expression, as well as tissue cGMP levels in response to topical application of an endothelium-independent vasodilator. RESULTS: ICAM-1, E-selectin and P-selectin expression did not differ between the groups. However, VCAM-1 expression was significantly lower in Group B (460 +/- 29 vs. 289 +/- 50, P = 0.01). NOS-2 expression (488 +/- 64 vs. 577 +/- 38, P = 0.02) and tissue cGMP levels (2.2 +/- 0.6 pmol/ml vs. 5.7 +/- 1.7 pmol/ml, P = 0.01) in response to nitroglycerin (24 +/- 10% vs. 11 +/- 5%, P = 0.02) were higher in Group B. CONCLUSIONS: Of all of the adhesion receptors studied, only VCAM-1 expression was reduced by a mast cell membrane-stabilizing agent, perhaps because of activation of the venous endothelium during harvest prior to ketotifen exposure. However, ketotifen also augmented NOS-2 expression, increased tissue cGMP levels in response to nitroglycerin. These actions may improve vascular homeostasis in the venous graft, suggesting the possibility that this strategy may improve long-term graft patency.

Early Islamic physicians and thorax.

Modern anatomic knowledge has developed throughout centuries with transfer of knowledge from generations to generations. Ibn-i Sina (980-1037), Razi (850-923), Davud El-Antaki (?-1008), Ali ibn Abbas (?-982), Ahmed bin Mansur (14th century), Semseddin-i Itaki (1570-1640), and Ibn-i Nafis (1210-1288) were Islamic physicians who all contributed to the understanding of anatomy. They benefited from Greek and Roman pioneers, as well as from each other. To show the situation of thoracic anatomy in early Islamic physicians, we analyzed two original manuscripts in the Süleymaniye Library and some contemporary texts. There were original drawings of the trachea, lung, and vascular system in Semseddin-i Itaki's and Ahmed bin Mansur's anatomy texts. Ibn-i Nafis's writings revealed that he was the first person to describe the pulmonary circulation. Also Ali ibn Abbas wrote that the pulmonary artery wall had two layers and these layers may have a role in constriction and relaxation of this vessel. He also stated that pulmonary veins branched together with the bronchial tree. Ahmed bin Mansur, Ali ibn Abbas, and Ibn-i Nafis each wrote that the heart has two cavities. They also added that the wall of the septum is very thick and there are no passages in between. These show that Islamic physicians had important contributions to thoracic anatomy and physiology. European physicians benefited from these contributions till the end of the 16th century.

Cemil Topuzlu Pacha and his arterial suture technique.

Cemil Topuzlu Pacha (1868-1958) is known to be one of the most famous surgeons in Turkey through the early decades of the twentieth century. Being a talented and courageous surgeon, he performed many of the avoided operations of that time. He presented his vascular suture techniques at the International Medical Congress in Moscow in August 1897 and at the annual Congress of the Societe de Chirurgie de Paris in July 1904. He reported 2 cases of arterial tear during breast carcinoma resection and repair within the same session. He also reported the removal of a pen cover from the right main bronchus of a 7-year-old girl through a tracheotomy in 1903. He worked for 3 years with the famous French surgeon Jules Pean and became a preferred surgeon of the Ottoman Imperial family in Istanbul. He was admired for his scientific studies in international congresses and was one of the first Turkish surgeons who became a member of important European surgical associations.

Isolated primary chylopericardium.

Isolated primary chylopericardum is known to be a rare clinical entity. A 17-year-old girl was diagnosed as isolated primary chylopericardium. She was unresponsive to conservative treatment with pericardial tube drainage and medium chain triglyceride diet. At 2 weeks after the conservative treatment, ligation and resection of the thoracic duct with establishment of a pericardial window through a left thoracotomy was performed. At 6 months, follow-up showed no accumulation of the pericardial fluid. This case also supports that ligation and resection of the thoracic duct with establishment of a pericardial window is the treatment of choice in isolated primary chylopericardium.

Thoracic surgery techniques of Serefeddin Sabuncuoglu in the fifteenth century.

Serefeddin Sabuncuoglu (1385 to 1470?) is known to be the author of the first surgery textbook, namely Cerrahiyyet'ül Haniyye (Imperial Surgery), written in Turkish in 1465. It is the first book to contain colored illustrations of surgical procedures, incisions, and instruments in the Turkish-Islamic medical literature. He was the first man to illustrate and mention introduction of a tube into the pharynx and upper esophagus, removal of foreign bodies in the esophagus by special instruments of his own design, and use of a silver ringlet in a man after tracheotomy. He also described and illustrated reduction of sternal fractures, thoracic puncture through the intercostal space for drainage of empyema cavities, and treatment of rib fractures that have severed the diaphragm. He was a humble, curious, and intelligent surgeon, and also a calligrapher and a miniature artist.

Correlation between sizes and intracystic pressures of hydatid cysts.

BACKGROUND: A bicentral prospective study was performed to assess the relationship between sizes and intracystic pressures (ICP) of pulmonary hydatid cysts as well as to compare these measurements in different age groups. METHODS: A total of 20 patients with 22 unperforated pulmonary hydatid cysts underwent surgery between April 1994 and September 1995. There were 12 males and 8 females with a mean age of 25.7 (7-62). Intraoperatively, ICP's were measured in cmH2O by direct cannulation. RESULTS: Out of a total of 22 cysts, 12 were located in the lower lobes. Mean diameter, volume and ICP of cysts were 9.6 cm (S.D. 4.2), 728.8 cm3 (S.D. 1014.9) and 36.6 cmH2O (S.D. 9.3), respectively. There was no significant correlation between various measurements of hydatid cysts, namely their short and long diameters, volumes and intracystic pressures (P > 0.05). There was no difference regarding the volume, ICP and age of patients, either among pulmonary lobes or between sexes. Patients who were 20 years old and less, presented a mean cystic diameter of 7.2 cm and mean ICP of 35.1 cmH2O, whereas the over 20 age group showed results of 11.9 cm and 38.1 cmH2O, respectively (P values were < 0.0083 for diameter and > 0.05 for ICP). CONCLUSIONS: Due to the small sample size and a few extreme measurements, the correlation between the sizes and the pressures of hydatid cysts turned out to be insignificant, but it is believed that a positive correlation is most probable with larger sample sizes. On the other hand, while the difference between the mean cystic diameters in age groups of below and over 20 was significant, the pressure difference between them was insignificant. This is why young patients carry the same risk of perforation as adults, although they present with relatively smaller cysts. Therefore, due to the well-known anaphylactic, obstructive and infectious risks of hydatid cyst perforation, urgent surgical removal is always necessary.

The effect of aqueous garlic extract on the levels of arachidonic acid metabolites (leukotriene C4 and prostaglandin E2) in rat forebrain after ischemia-reperfusion injury.

Leukotriene C4 (LTC4) and prostaglandin E2 (PGE2) are known to be highly potent cerebral vasoconstrictors which are formed from arachidonic acid (AA). They enhance vascular permeability, inducing vasogenic edema that may damage the ischemic penumbra after ischemia and reperfusion. The inhibitory effect of aqueous garlic extract (AGE) on AA metabolism in human platelets is known. In this study, following the global ischemic model application to the rats, all underwent 10 min ischemia and were reperfused for different periods. The levels of LTC4 and PGE2 in rat forebrain were then measured. One rat group consisted of 8 rats. In the combined reperfused groups both metabolites increased significantly when compared with the 10 min ischemia alone, no reperfusion group (p < 0.05). In the 8 min reperfused group, PGE2 and LTC4 levels increased significantly at 60 min of reperfusion compared with each corresponding control group (P < 0.005). PGE2 and LTC4 levels were reduced significantly at 60 min of reperfusion compared with the 8 min reperfused group (P < 0.005). AGE (1 ml/kg) reduced both LTC4 and PGE2 levels significantly in the 8 min and 60 min reperfused group (P < 0.001, P < 0.001, P < 0.05, P < 0.01). In conclusion, AGE reduced LTC4 and PGE2 levels at a dosage of 1 ml/kg following 8 and 60 min reperfusion. It may be helpful in reducing AA metabolite levels and preventing injury after ischemic phenomena.

The principles of surgical management in dumbbell tumors.

OBJECTIVE: Tumors located in posterior mediastinum that extends into spinal canal via intervertebral foramen are called as Dumb-bell or Sand-glass tumors. Most of these tumors are neurogenic in origin but sometimes other rare tumors can also form in this shape. Herein three neurogenic tumors of the mediastinum that extended into the spinal canal are presented METHODS: In all patients that have been operated in our clinic during 1992-1993, we preferred one-stage removal described by Akwari that consists of posterior laminectomy by neurosurgical team to free the tumor within the spinal cord followed by a posterolateral thoracotomy and excision of the tumor by thoracic surgeons in the same setting. RESULTS: All three patients are alive and free of symptoms after 23, 16 and 13 months respectively. According to the pathological examinations of the specimens in the three patients, the exact diagnosis were reported as neurofibroma, paraganglioma and pheochromocytoma respectively. CONCLUSIONS: In recent reports, a combined surgical approach is recommended for dumb-bell neurogenic tumors in posterior mediastinum. We also recommend a combined and one stage removal of dumb-bell neurogenic tumors if possible. A team-work of thoracic and neurosurgeons will minimize the morbidity and mortality after the surgical procedure, as well as giving the opportunity to remove the tumor totally in one session.