Tratamiento acelerado del empiema y cáncer de pulmón concomitantes mediante cirugía toracoscópica videoasistida / Accelerated treatment of concomitant empyema and lung cancer by video-assisted thoracoscopic surgery

INTRODUCCIÓN: La causa más frecuente de los empiemas pleurales son los derrames paraneumónicos, siendo el cáncer de pulmón el origen de los mismos en muy pocas ocasiones. EL objetivo de nuestro trabajo es analizar los resultados del tratamiento del empiema por vía toracoscópica previo al tratamiento oncológico definitivo. MÉTODOS: Estudio descriptivo retrospectivo en el que se recogen las diferentes variables clínicas durante el tratamiento de 332 pacientes entre 2002 y 2010. RESULTADOS: En 332 pacientes con empiema, la etiología de esta enfermedad fue el cáncer de pulmón en 11 casos. Entre ellos había 10 varones y una mujer (mediana de edad, 57,9 años; rango: 46-76). El tratamiento inicial fue la colocación de un tubo de toracostomía en 8 pacientes y la cirugía toracoscópica videoasistida en 3 pacientes. Se llevó a cabo un desbridamiento toracoscópico en 4 pacientes en los que el resultado del tubo de toracostomía no fue satisfactorio debido a un drenaje insuficiente. Se llevó a cabo una resección quirúrgica en 7 pacientes cuyas características eran apropiadas tras el control de la infección. Se produjo una fístula broncopleural y un empiema postoperatorio tras la neumectomía en un caso. No se observó mortalidad operatoria. La media de supervivencia fue de 32,8 meses en los pacientes tratados con resección. CONCLUSIONES: El empiema puede ser una forma de presentación muy poco frecuente del cáncer de pulmón cuyo abordaje puede realizarse por toracoscopia, si bien el mismo tiene sus limitaciones

BACKGROUND: The most common cause of pleural empyema are parapneumonic effusions, and lung cancer is a rare cause of empyema. The aim of the present study is to analyse the results of the thoracoscopic treatment of empyema before definitive oncological treatment. METHODS: Retrospective descriptive study of 332 patients including different clinical variables between 2002 and 2010. RESULTS: Among 332 patients with empyema, the etiology of this disease was lung cancer in 11 patients. Ten of these patients were male and one was female (median age, 57.9 years; range, 46-76). The initial treatment was tube thoracostomy in 8 patients and video-assisted thoracoscopic surgery in 3 patients. Thoracoscopic debridement was performed in 4 patients whose tube thoracostomy underperformed because of insufficient drainage. The methods used for diagnosis of lung cancer were fiberoptic bronchoscopy and video-assisted thoracoscopic surgery. Surgical resection was performed on 7 suitable patients following infection control. Postoperative bronchopleural fístula and empyema occurred after pneumonectomy in one case. No operative mortality was observed. The mean survival time was 32.8 months for patients undergoing resection. CONCLUSIONS: Empyema could be a rare presentation of lung cancer and those suitable for surgical treatment should undergo standard treatment with reasonable results

Accelerated treatment of concomitant empyema and lung cancer by video-assisted thoracoscopic surgery.

BACKGROUND: The most common cause of pleural empyema are parapneumonic effusions, and lung cancer is a rare cause of empyema. The aim of the present study is to analyse the results of the thoracoscopic treatment of empyema before definitive oncological treatment. METHODS: Retrospective descriptive study of 332 patients including different clinical variables between 2002 and 2010. RESULTS: Among 332 patients with empyema, the etiology of this disease was lung cancer in 11 patients. Ten of these patients were male and one was female (median age, 57.9 years; range, 46-76). The initial treatment was tube thoracostomy in 8 patients and video-assisted thoracoscopic surgery in 3 patients. Thoracoscopic debridement was performed in 4 patients whose tube thoracostomy underperformed because of insufficient drainage. The methods used for diagnosis of lung cancer were fiberoptic bronchoscopy and video-assisted thoracoscopic surgery. Surgical resection was performed on 7 suitable patients following infection control. Postoperative bronchopleural fístula and empyema occurred after pneumonectomy in one case. No operative mortality was observed. The mean survival time was 32.8 months for patients undergoing resection. CONCLUSIONS: Empyema could be a rare presentation of lung cancer and those suitable for surgical treatment should undergo standard treatment with reasonable results.

The experimental use of N-butyl cyanoacrylate tissue adhesive in pulmonary wedge resections.

BACKGROUND: In this experimental study, the effectiveness of N-butyl cyanoacrylate tissue adhesive on preventing air leakage after pulmonary wedge resection was observed. METHODS: Twenty pairs of sheep lungs were used. Before initiating the study, the sheep lungs were ventilated to identify any air leakage from the parenchyma. On positive results, those sheep lungs were then excluded from the study. Wedge resection was performed on the right and left lower lobes of sheep lungs by clamping the edges forming a triangle of 5 cm × 5 cm × 5 cm. One side of parenchyma was sutured by 3/0 vicryl (Group A) while the other side of parenchyma was sealed by N-butyl cyanoacrylate (Group B). After waiting for 5 min for N-butyl cyanoacrylate to dry, the sheep lungs were intubated by 6F endotracheal tubes. The lungs were soaked in a bath tub filled with 10 cm deep water and inflated by 40 mmHg pressure to record any air leakage from the parenchyma partially sutured by vicryl and sealed by N-butyl cyanoacrylate. RESULTS: Air leakages were observed on the parenchyma surfaces of group of lungs (100%) sutured by vicryl (minimal 30%, mild 50% or massive 20% levels), while only on four of (20%) the other group of lungs sealed by N-butyl cyanoacrylate, minimal air leakage was observed on the parenchymal surface. There was an extremely significant difference between Group A and Group B in terms of the development of air leakage (p=000). CONCLUSION: We consider that, N-butyl cyanoacrylate could be used effectively and safely to prevent air leakage from the pulmonary wedge resection surface.

False-positivity of mediastinal lymph nodes has negative effect on survival in potentially resectable non-small cell lung cancer.

OBJECTIVES: It has been shown that increased metabolic activity of primary tumour has a negative effect on survival in non-small cell lung cancer (NSCLC) staged with positron emission tomography integrated computed tomography (PET/CT). We hypothesized that an increased metabolic activity of mediastinal lymph nodes would have worse survival even if it is false. METHODS: Three hundred and twenty-eight consecutive patients with NSCLC histology were imaged with PET/CT within 90 days of surgery between September 2005 and March 2009. Patients who had neoadjuvant chemotherapy (n = 22), patients with prior history of NSCLC (n = 9) or other malignancies within 5 years (n = 11) were excluded from the study. Patients with negative mediastinoscopy underwent resection. Pathological results were revised according to the seventh tumor-node-metastasis staging system. Kaplan-Meier test was used for survival. Log-rank and Cox analyses were used for comparisons. RESULTS: A total of 286 patients (262 male; mean age: 58.5 years) were evaluated. There were 22 (6.7%) operative deaths and none of the patients were lost to follow-up. The median follow-up in the remaining 264 patients was 26 months (range, 2-61 months). Tumour size, nodal spread and stage were all strongly associated with survival from NSCLC (P < 0.001). There were 63 true-positive, 65 false-positive (FP), 152 true-negative (TN) and six false-negative findings on mediastinal staging after PET/CT. The maximum standardized uptake value of primary tumour was significantly higher in FP patients than in TN patients (P = 0.012). After excluding pN2-positive patients, TN patients had better survival than FP patients (P = 0.006). Multivariate analysis showed that false-positivity of mediastinal lymph nodes was independently associated with worse survival (hazard ratio = 0.63; P = 0.02). There were 146 patients with pT1-4, pN0 treated with R0 surgical resection. Disease-free survival and overall survival were also significantly better for TN patients in completely resected group (P = 0.009 versus 0.016). CONCLUSIONS: We have shown that false-positivity of mediastinal lymph nodes had yielded worse survival in surgically staged or resected NSCLC patients staged with PET/CT. This result may help to allocate patients with potentially poor prognosis for considered additional therapy.

Is there any maximum standardized uptake value variation among positron emission tomography scanners for mediastinal staging in non-small cell lung cancer?

The maximum standardized uptake value (SUV(max)) varies among positron emission tomography-integrated computed tomography (PET/CT) centers in the staging of non-small cell lung cancer. We evaluated the ratio of the optimum SUV(max) cut-off for the lymph nodes to the median SUV(max) of the primary tumor (ratioSUV(max)) to determine SUV(max) variations between PET/CT scanners. The previously described PET predictive ratio (PPR) was also evaluated. PET/CT and mediastinoscopy and/or thoracotomy were performed on 337 consecutive patients between September 2005 and March 2009. Thirty-six patients were excluded from the study. The pathological results were correlated with the PET/CT findings. Histopathological examination was performed on 1136 N2 lymph nodes using 10 different PET/CT centers. The majority of patients (group A: 240) used the same PET/CT scanner at four different centers. Others patients were categorized as group B. The ratioSUV(max) for groups A and B was 0.18 and 0.22, respectively. The same ratio for centers 1, 2, 3 and 4 was 0.2, 0.21, 0.21, and 0.23, respectively. The optimal cut-off value of the PPR to predict mediastinal lymph node pathology for malignancy was 0.49 (likelihood ratio +2.02; sensitivity 70%, specificity 65%). We conclude that the ratioSUV(max) was similar for different scanners. Thus, SUV(max) is a valuable cut-off for comparing-centers.

Pneumonectomy in children for destroyed lung: evaluation of 18 cases.

BACKGROUND: Destroyed lung is an uncommon condition; it describes a nonfunctional lung and is most often caused by inflammatory diseases. Surgical resection is used to resolve or prevent complications and improve quality of life. We reviewed our experience in surgery for destroyed lung in children. METHODS: The records of 18 children aged 16 years and younger who had undergone pneumonectomy for destroyed lung between 1991 and 2007 were analyzed retrospectively. RESULTS: Eighteen children, 10 males (55.5%) and 8 females, aged 5 to 16 years, with a mean age of 12.3 underwent pneumonectomy. Cough was the major presenting symptom (n = 18, 100%). The median preoperative period for symptoms was 6 years. Radiologic diagnostic methods included chest radiograph, computed tomography, bronchoscopy, and bronchography. Bronchiectasis (n = 13), tuberculosis (n = 4), and aspergillosis (n = 1) were the main pathologies. Five patients had tuberculosis history, and tuberculosis culture was positive in 2 patients. Pneumonectomy was applied to the left side in 14 and right side in 4 patients. There was no mortality. Complication occurred in 3 patients (atelectasis [n = 1], fistula and empyema [n = 1], and wound infection [n = 1]). Atelectasis was treated with bronchoscopy and stoma was needed for another patient for empyema. The mean follow-up was 64.9 months (range, 19 to 164 months). In their follow-up period, scoliosis was found in 1 patient. CONCLUSIONS: The morbidity and mortality rates of pneumonectomy are acceptable for selected and well prepared children. Antibiotics and antituberculosis treatment in certain cases and good timing in pneumonectomy are essential. Children grew and developed normally after pneumonectomy.

[Spontaneous pneumothorax: retrospective analysis of 348 cases]. / Spontan pnömotoraks: 348 olgunun geriye dönük olarak degerlendirilmesi.

BACKGROUND: In this study, spontaneous pneumothorax (SP) cases were divided into two groups and retrospectively evaluated according to age, sex, diagnostic methods, treatments, and results. METHODS: Between June 1997 and May 2005, 348 patients (320 males, 28 females; mean age 34.5; range 14 to 80 years) with SP were enrolled into our study. There were 274 (78.7%) primary SP and 74 (21.3%) secondary SP patients. Tuberculosis was the most common cause in secondary SP patients. Nasal oxygen and aspiration was the first-line therapeutic option in 10% of patients and tube thoracostomy was performed in 90%. RESULTS: Nasal oxygen and aspiration success ratio was 85.7% in primary SP patients and 66.7% in secondary SP patients. Tube thoracostomy success ratio was nearly the same in patients with primary and secondary SP (88.4% and 85.7%). Of the 29 patients (11.6%) with primary SP with unsuccessful result of tube thoracotomy, 15 underwent axillary thoracotomy and 14 underwent video-assisted thoracoscopic surgery (VATS). One patient among these 14 who underwent VATS (7.1%) had recurrence. CONCLUSION: Tube thoracostomy success ratio was high in both primary and secondary SP patients. Surgical procedures can be applied safely, with low recurrence rate, when the tube thoracostomy remains unsuccessful.

Bronchogenic cysts of the lung: report of 29 cases.

BACKGROUND: Intrapulmonary bronchogenic cysts are congenital anomalies of the tracheobronchial tree and foregut. The aim of this retrospective study was to review the diagnosis, clinical and histological features, operative techniques, outcomes and follow-up of intrapulmonary bronchogenic cysts treated in a single institute. METHODS: Twenty-nine patients with intrapulmonary bronchogenic cysts were treated surgically between 1990 and 2005. There were 17 female and 12 male patients and their ages ranged from 7 to 68 years. Patients were divided into two groups according to surgical procedure. Resection (lobectomy or wedge resection) was performed on Group I (n=18), and partial excision with de-epithelisation was performed on Group II (n=11). RESULTS: Twenty-five patients (86.2%) were symptomatic. Cough and sputum were the most common symptoms. Twenty-four of the 29 BCs were simple cysts (82.7%) whereas 5 (17.3%) were complicated cysts. Postoperative hospital stay was 4.55+/-0.86 days in group I and 6.54+/-3.34 days in group II (P=0.172). Complications in Group I were pneumonia in one case and wound infection in two cases; prolonged air leakage were observed in two cases of Group II. No statistical difference was determined between the complication rates of the two groups (P=0.91). However a significant difference was determined between the complication rates of simple and complicated cysts (P=0.026). Two cases in Group II showed recurrence, whereas no recurrence occurred in Group I. (P=0.065) No postoperative mortality was observed in any of the groups. CONCLUSIONS: All bronchogenic cysts should be treated surgically. We believe that partial excision with de-epithelisation may be an alternative to resection in symptomatic patients with limited respiratory capacity.

Clinicopathologic demonstration of complex bronchopulmonary foregut malformation.

Bronchopulmonary foregut malformations are rare and often prove to be extremely difficult to diagnose. The presented case is a 44-year-old man complaining about cough and hemoptysis. These symptoms continued despite medical treatment. A computed thorax tomographic scan depicted a paravertebral cystic lesion. The patient underwent surgical exploration, and communication between the cyst and the esophagus was found. A left lower lobectomy was performed. The pathologic result confirmed a duplication cyst of mixed bronchogenic and esophageal type with bronchiectasis of the lower lobe. We present this unusual malformation complex especially in an adult with the review of the literature.

[The role of video-assisted thoracoscopic surgery in the treatment of pleural empyema]. / Plevral ampiyemlerin tedavisinde videoyardimli torakoskopik cerrahinin rolü

Pleural empyema is a serious problem which affects any age group and still there is no standard approach. Our purpose in this study was to assess the safety, feasibility and efficacy of the video-assisted thoracoscopic surgery (VATS). Between 1997 and 2004 83 patients with empyema were enrolled in this study. Fifty-four patients were male, 29 females and the mean age was 39.4. The mean duration time of symptoms before VATS was 27.3 days. Twenty-two patients were in group-5, 44 in group-6 and 17 in group-7 according to Light's classification of parapneumonic effusions and empyema. Twenty-one patients underwent chest tube before VATS because of their conditions. VATS was converted to thoracotomy in 13 patients. All patients underwent debridement and irrigation during VATS. The cure was achieved in 58 (69.9%) patients with the mean 7.63 days drainage time. Twelve patients were underwent open decortication in the follow-up period. Ten of them were group-7 and 2 in group-6 (p= 0.006). The diagnosis was achieved in 60 (72.3%) patients as nonspecific pleuritis, tuberculosis in 19 and various diagnosis in 4. There was no mortality and minor complications occured in 14 patients. VATS is a safety and efficacy procedure in the treatment of early stage empyema. Use of VATS in early period of multiloculary empyema, prevents patients from unnecessary thoracotomies.

Effect of capitonnage and cystotomy on outcome of childhood pulmonary hydatid cysts.

OBJECTIVE: In this clinical retrospective study cystotomy and capitonnage were compared in patients with childhood pulmonary hydatid cysts with regard to postoperative period. METHODS: Between 1990 and 2004, 60 children with pulmonary hydatid cysts were treated surgically. There were 33 boys and 27 girls aged from 3 to 16 years. Cystotomy and closure of bronchial openings were performed in all patients. The patients were divided into 2 groups. While the residual cyst cavity was closed by means of capitonnage in group A (n = 37), cystotomy was applied in group B (n = 23). RESULTS: There was no mortality in either group. Chest tubes were removed after 3.59 +/- 1.04 days in group A and 5.83 +/- 2.84 days in group B. The hospital stay was 4.86 +/- 1.43 days for group A and 7.22 +/- 3.34 days for group B. Prolonged air leak was found in 2 children in group A and 7 children in group B. There was a significant difference between group A and group B with regard to chest tube removal time (P = .001), hospital stay (P = .003), development of prolonged air leak (P = .004), and all complications (P = .031). Follow-up information was available for 49 children, ranging from 13 to 86 months (mean, 56 months). Recurrence was seen in 2 children of group A and 1 child of group B during the follow-up period (P = .698). CONCLUSION: Capitonnage for pulmonary hydatid cysts is superior to cystotomy because it reduces morbidity (especially prolonged air leak) and hospital stay.

[Post-traumatic bronchial stenosis: a case report]. / Post-travmatik brons stenozu: olgu sunumu.

Bronchial rupture due to tracheobronchial trauma is a very rare condition. Early evaluation is necessary in order to avoid irreversible changes such as fibrosis and bronchial stenosis. Cases with post-traumatic hemo-pneumothorax, pneumomediastinum, subcutaneous emphysema and atelectasis require consideration of bronchial laceration with urgent bronchoscopy and early surgery, if needed. A 15 year-old patient with a history of blunt chest trauma two years ago presented with symptoms of pulmonary infection. Radiological and bronchoscopic evaluation revealed right upper lobe atelectasis secondary to fibrosis. Patient underwent right upper lobectomy.

Feasibility of imprint cytology for evaluation of mediastinal lymph nodes in lung cancer.

BACKGROUND: Intraoperative evaluation of mediastinal lymph nodes is a necessary step which helps us to decide whether or not to continue the operation of lung cancer. Imprint cytology (IC) can be used as an alternative method in staging. It is a more rapid and simpler procedure than frozen section (FS) analysis. Therefore, we compared the diagnostic accuracy of IC with permanent section on 1050 mediastinal lymph nodes. METHODS: A total of 255 non-small cell lung cancer patients who underwent surgical procedure between January 1995 and April 2004 were included. There were 236 males and 19 females with a mean age of 54.2 years (range 26-79 years). In order to obtain lymph node samples mediastinoscopy was performed in 232 (91%), anterior mediastinotomy in 50 (20%) and video-assisted thoracoscopic surgery in 16 (6.3%) patients. During final pathological diagnosis, both imprint and permanent section slides were compared. RESULTS: There were five false-positive and eight false-negative results. The sensitivity, specificity and the predictive values for positive and negative results were 93.1, 99.5, 95.6 and 99.1%, respectively. The overall efficiency was 98.8%. CONCLUSIONS: The diagnostic IC is an accurate, reliable, simple and less time-consuming method for evaluation of mediastinal lymph nodes in lung cancer, compared with FS method.

[Completion pneumonectomy: indications, complications, and results]. / Tamamlayici pnömonektomiler: endikasyonlari, komplikasyonlari ve sonuçlari.

Completion pneumonectomy is reported to be associated with high morbidity and mortality, especially when performed in patients with benign diseases. In our study we aimed to evaluate all patients underwent completion pneumonectomy in our clinic and to compare indications, complications and postoperative results with the literatures. Between January 1987 and December 2001, 27 consecutive patients who underwent completion pneumonectomy in our clinic were retrospectively reviewed. Postoperative morbidity and mortality rates were calculated according to indications and the results were compared to the standard pneumonectomies. There were 27 patients, 13 (48.1%) women and 14 (51.9%) men, with a median age of 26 (range, 10 to 62 years). Completion pneumonectomy was performed for benign diseases in 23 (85.2%) patients and for malign diseases in 4 (14.8%). Malign indications included 2 second primary tumors and 2 local recurrences. In the group with benign diseases; completion pneumonectomy was performed for tuberculosis in 5, bronchiectasis in 14, bronchopleural fistula in 2 and necrosis of lung in 2. Hospital mortality was 7.4% including 1 intraoperative and 1 postoperative deaths and both of them had undergone completion pneumonectomy for benign diseases. Complications occurred in 9 (33.3 %) patients, bronchopleural fistula + empyema were seen in 6 patients, cardiac rhythm disorders in 2 and wound infection in 1. All complications occurred in the patients operated for benign indications (39.1%). Completion pneumonectomy can be performed with an acceptable morbidity and mortality (similar to standard pneumonectomy) in selected cases. But the complication risk is higher in benign diseases, especially in tuberculosis. Surgical technique is important to avoid serious complications such as bronchopleural fistula and empyema.