Thoracic Surgery Clinic Research Articles

The effect of transcutaneous electrical nerve stimulation on post-thoracotomy pain

Background: Pain guidelines suggest transcutaneous electrical nerve stimulation (TENS) as a reliable analgesic method in postoperative pain. Objectives: This study was conducted as a randomized controlled study to determine the effect of TENS on postoperative pain and analgesic consumption in patients who have undergone posterolateral thoracotomy (PLT). Design: The study was conducted in the Thoracic Surgery Clinic of a university hospital with 40 patients (test group: 20, control group: 20) and its power was 99%. While, test group patients were administered TENS, the control group patients were not. The pain assessment and analgesic consumption in both groups were recorded. Results: The pain levels and analgesic consumption of the test group were lower than that of the control group (p < .05). Conclusions: TENS reduced PLT pain and analgesic consumption. Thus, TENS can be recommended as an easy and reliable analgesic method in PLT.

Invited Commentary

The goal of thoracic aortic replacement is to prevent aortic rupture or dissection, both of which can be fatal. Unfortunately, the main tool we have to guide our decision making (aortic diameter) is neither sensitive nor specific for predicting these potentially fatal outcomes. Recent evidence has demonstrated that a large percentage of patients present with type A aortic dissection at smaller aortic diameters. International Registry of Acute Aortic Dissections data demonstrated that 40% of patients had aortic dissection at diameters less than 5 cm [1Pape L.A. Tsai T.T. Isselbacher E.M. et al.Aortic diameter >or = 5.5 cm is not a good predictor of type A aortic dissection: observations from the International Registry of Acute Aortic Dissection (IRAD).Circulation. 2007; 116: 1120-1127Crossref PubMed Scopus (565) Google Scholar], whereas another study showed that 87% of patients without a connective tissue disorder experienced dissection at less than 5.5 cm [2Kim E.K. Choi S.H. Sung K. et al.Aortic diameter predicts acute type A aortic dissection in patients with Marfan syndrome but not in patients without Marfan syndrome.J Thorac Cardiovasc Surg. 2014; 147: 1505-1510Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar]. One third of patients with ACTA2 mutations experience dissection at less than 5 cm [3Regaldo E.S. Guo D. Prakash S. et al.Aortic disease presentation and outcome associated with ACTA2 mutations.Circ Cardiovasc Genet. 2015 Mar 10; ([Epub ahead of print])Google Scholar]. We replace aortas to prevent complications of aneurysms, but clearly, using current guidelines, we are not 100% successful at our intended goal. Operating at smaller diameters in everyone is not the answer, because many patients whose aortas would never undergo dissection would be subject to the risks of a major operation with potential complications. Thus we need a way to identify the specific patients who are at highest risk for experiencing dissection at smaller aortic diameters. In this article, Dr Ziganshin and his colleagues at Yale [4Ziganshin B.A. Bailey A.E. Coons C. et al.Routine genetic testing for thoracic aortic aneurysm and dissection in a clinical setting.Ann Thorac Surg. 2015; 100: 1604-1612Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar] have tried to identify these patients by bringing routine genetic testing to their clinic. Using whole-exome sequencing, the authors examined 21 genes known to be associated with thoracic aortic aneurysms and dissections in patients presenting to their clinic. The majority of patients (72.5%) had no mutations in the 21 genes studied. However, the remainder of the patients had either known or unstudied mutations in these 21 genes. Although at first glance this may seem a low yield, as a pilot or proof of feasibility study these results are meaningful. First, identification of certain genetic mutations altered the clinical management of select patients, namely, more frequent follow-up and earlier prophylactic operations. Second, this study will allow investigators to link the rate of aneurysmal progression to specific genetic mutations, thus further identifying mutations that put patients at higher risk of accelerated aneurysmal growth and dissection. Third, the article identified novel genetic variants in genes known to be associated with thoracic aortic aneurysms and dissections. Finally, and perhaps most importantly, this study made the formidable translational leap of bringing our basic science knowledge to everyday clinical practice, with the hope of solving a common clinical problem. Limitations of this study include the cost, time delay, and reimbursement for whole-exome sequencing. Additionally, only a select set of genes was tested, and it is likely that there are many other genes associated with thoracic aortic aneurysms and dissections. Finally, the impact of the interaction of environmental factors on genetically susceptible individuals was not assessed and remains difficult to elucidate. Is it time to bring routine genetic testing to all patients in the surgical thoracic aorta surgery clinic? Unfortunately, with the limitations listed here, as well as others, probably not just yet. However, the work by Dr Ziganshin and his group in this study has laid the foundation for hopefully making genetics a part of our diagnostic assessment and risk stratification of patients with thoracic aortic conditions in the near future. Routine Genetic Testing for Thoracic Aortic Aneurysm and Dissection in a Clinical SettingThe Annals of Thoracic SurgeryVol. 100Issue 5PreviewHereditary factors play an important etiologic role in thoracic aortic aneurysm and dissection (TAAD), with a number of genes proven to predispose to this condition. We initiated a clinical program for routine genetic testing of individuals for TAAD by whole exome sequencing (WES). Here we present our initial results. Full-Text PDF

Surgical Treatment of Lung Metastases of Colorectal Carcinoma – Survival and Prognostic Factors

Colorectal carcinoma has the third highest incidence of all tumor diseases in the world. In the long term, Slovak republic is among countries with highest occurrence of this disease. About 25% of patients have distant metastases at the time of diagnosis, and about 50% of patients progress. The first possibility of colorectal carcinoma lung metastases treatment is metastasectomy which may have a curative character. In this paper, the authors retrospectively evaluated 50 patients who had undergone surgical treatment to establish the diagnosis of colorectal carcinoma lung metastases at the Clinic of thoracic surgery of JLF UK and UH Martin between 2003 and 2014. Altogether, 27 men and 23 women were operated (average age: 62 and 61 years). 52% of patients had solitary metastasis.We chose thoracotomy as a surgical access for majority of the surgeries (76%), and the most common type of surgical procedure was a wedge resection (74%). 3-year survival of patients after complete metastasectomy was 55.5%, and 5-year survival was 31.8% with a median survival of 42 months. We did not record any statistically significant influence of number of metastases (p = 0.3297) and length of disease-free interval (p = 0.4423) on the long-term survival, but we confirmed a significant difference of survival in different prognostic groups according to the International registry of lung metastases (p = 0.049). A surgical removal of colorectal carcinoma lung metastases in selected patients is an important curative modality that might prolongsurvival, improve the prognosis and at the same time have minimum complications. The results show that the strongest predicative indicator of prognosis is incorporation of the patients to the prognostic groups determined by the International Registry of Lung Metastases.

Recruiting family dyads facing thoracic cancer surgery: Challenges and lessons learned from a smoking cessation intervention

PurposePersistent smoking after a cancer diagnosis has adverse effects. Most smoking cessation interventions focus on individual behaviors; however, family members who smoke are major barriers to success. This article describes challenges and lessons learned related to recruitment and retention to a longitudinal, dyadic-centered smoking cessation intervention study for individuals confronting a new diagnosis of thoracic cancer and their family members who smoke. MethodsA prospective, one-group repeated measures, mixed-method feasibility study measured recruitment, retention, adherence, and acceptability over a 6-month period in a thoracic surgery clinic at a university cancer center. A multidisciplinary, multi-component decision aid—“Tobacco Free Family”—was used to intervene with the dyads. Study recruitment occurred preoperatively with a thoracic surgery team member assessing smoking status. ResultsDuring the 6-month recruitment period, 50 patients who smoked were screened, and 18 eligible families were approached to participate. Sixteen participants (8 dyads) enrolled. Patients were all male, and participating family members were all female—either spouses or long-term girlfriends. Others types of family members declined participation. ConclusionRecruitment was lower than anticipated (44%), retention was high (100%), and maximizing convenience was the most important retention strategy. Oncology nurses can assess the smoking status of patients and family members, facilitate understanding about the benefits of cessation, refer those willing to stop to expert resources, and help motivate those unwilling to quit. Research is needed to continue developing strategies to help patients with thoracic cancer and their families facing surgery as an impetus for stopping smoking. Novel intervention delivery and communication need further exploration.

Assessment of patients' quality of life after haemorrhoidectomy using the LigaSure device.

IntroductionHaemorrhoids are small anatomical structures within the anal canal that are involved in the proper functioning of the lower gastrointestinal tract. Factors favouring the development of haemorrhoidal disease are insufficient physical activity, prolonged sitting and hence a shortage of physical activity, as well as poor diet which lacks adequate amounts of fibre. The main symptom of this disease is bleeding with bright red blood just after defecation. Haemorrhoidal disease occurs when the ligamentous apparatus comes loose and the internal haemorrhoidal plexus translocates down, whereas haemorrhoids enlarge and move out of the anal canal. Haemorrhoidal disease treatment includes conservative, instrumental and surgical therapy.AimTo assess treatment and satisfaction in particular life domains after haemorrhoidectomy.Material and methodsThe research was undertaken in the General, Thoracic and Vascular Surgery Clinic of the 10th Military Clinical Hospital with Polyclinic in Bydgoszcz among 50 patients treated due to haemorrhoids and operated on in the period 2007–2008. The study evaluated quality of patients’ life after haemorrhoidectomy by Ferguson's method using a LigaSure appliance.ResultsThe study investigated whether patients perceived a difference before and after surgery. The research proved that patients can describe disease symptoms and know the risk factors for haemorrhoids. In the studied group patients are able to describe characteristic signs of haemorrhoidal disease and also indicate differences in everyday life before and after the surgery. They can also describe and classify the pain before and 1 year after the haemorrhoidectomy, which was statistically significantly lower already 3 months after the operation.ConclusionsConducted examinations showed that sick people in the precise way were able to determine manifestations and know risk factors of the prevalence of disease hemorrhoidal. Operated sick people indicated the difference in quality of the life both before, as well as after the undergone treatment. After the operation of the haemorrhoids with method of Ferguson using LigaSure apparatus operated sick persons could distinguish and classify pain before the treatment as well as in a year after which was statistically characteristically lower already after three months from treatment.

Surveillance of moderate-size aneurysms of the thoracic aorta.

BackgroundThere are no evidence based guidelines for the surveillance of patients with moderate-sized (<5 cm) thoracic aortic aneurysms (MTAA), who do not warrant surgical intervention. The purpose of this study was to review the MTAA patient surveillance strategy used currently at the Northport Veterans Affairs Medical Center, to assess outcomes over time and accrue data to develop guidelines to optimize MTAA patients’ follow-up.MethodsThe study group included veterans referred to the Thoracic Surgery clinic for the management of moderate-sized (<5 cm) thoracic aortic aneurysms (MTAA) not warranting immediate surgical repair.As a pilot study, all MTAA patients’ charts from 2005–2013 were reviewed to describe imaging practices and evaluate patient-specific long-term outcomes. An adverse composite endpoint was defined if a patient’s aneurysm grew substantially (≥0.5 cm/year or reached 5.5 cm) or a MTAA-related event (surgery or death) occurred.Additionally, number of CT scans obtained during the follow up period were documented.ResultsFor 110 MTAA patients, the average presenting index size was 4.45 ± 0.4 cm with average growth of 0.04 cm total (0.03 cm/year). Fourteen (13%) patients met the adverse composite endpoint, with no MTAA-related deaths. Patients achieving the adverse composite endpoint had higher index sizes (4.81 vs. 4.40 cm, p = 0.001) and higher average growth rates as compared to non-endpoint patients (0.16 vs. 0.01 cm, p = 0.0009). Optimizing the negative likelihood ratio defined a new “not-at-risk” population with aneurysm index size < 4.3 cm. A shorter time to adverse event for “at-risk” patients was found versus “not-at-risk” patients (p = 0.02). On average, there were 4.8 CT scans/patient and estimated cumulative radiation dose of 34 mSv/patient. Only one “not-at-risk” patient had substantive MTAA growth (≥0.5 cm/year) over the 8 year follow-up period.Conclusion and relevanceAnnual imaging of MTAA “not-at-risk” patients appears unwarranted, resulting in potentially excessive radiation exposure. Although additional research is necessary for validation, longer surveillance imaging intervals (beyond one year) seem appropriate for MTAA patients presenting with < 4.3 cm index aneurysms.

Transthoracic Needle Biopsy (TNB) under Different Guiding Methods - the Experience of the Thoracic Surgery Clinic of Craiova after the First 235 Cases.

ABSTRACT: Transthoracic needle biopsy (TNB) is a fast and safe method used to establish definitive diagnosis for most thoracic lesions, whether the lesion is located in the pleura, the lung parenchyma, or the mediastinum. Diffuse disease and solitary lesions are equally approachable.TNB can avoid (when technically possible) more complex diagnostic interventions such asmediastinoscopy, thoracoscopy and exploratory thoracotomy. This article focuses on the advantages of TNB which is a safe, affordable and quick method to obtain histopathological confirmation of intrathoracic tumors. Material and MethodsThe study included a total of 235 cases over a period of 4 and a half years (01.01.2011-30.04.2015). We investigated the demographic and clinical parameters, the guiding methods, the histological results and the complications of the procedure. ResultsThe median age of the patients was 62 years and the predominent sex was male. We could obtain a tissue biopsy in 99% with a histopathological confirmation of 88%. The most frequently used guiding method was the previous CT scan of the patient and the anathomical landmarks (53%). The main histopathological result was squamous cell carcinoma.ConclusionsTNB is generally a safe procedure with limited morbidity and extremely rare mortality. It is an affordable and quick method to obtain histopathological confirmation of intrathoracic tumors.Most TNBs can be performed by using local anesthesia without conscious sedation and virtually any location in the chest can be safely addressed.

Emergency surgery for spontaneous hemopneumothorax.

Emergency management of spontaneous hemopneumothorax patients was retrospectively analysed in this study. From November 2009 to August 2012, 221 patients with spontaneous pneumothorax were treated in the thoracic surgery clinic. Among them, 9 (4.07%) were diagnosed with spontaneous hemopneumothorax. Chest X-ray and computed tomography were the diagnostic tools. Emergency thoracotomy was performed for 7 of 9 patients because of massive hemothorax and continuous bleeding from the chest tube. Massive hematoma was documented in 2 of 7 patients at tomography. Bridging veins and torn pleural adhesion between parietal and visceral pleura were the source of bleeding determined at thoracotomy. Hematoma evacuation, resection of bullae, ligation of pleural adhesions and apical pleurectomy were performed. Spontaneous hemopneumothorax is an emergency due to massive hemorrhage and hematoma formation. Early surgical treatment is recommended for patients with spontaneous hemopneumothorax.

Pulmonary sublobar resections in pediatric patients

Background: This study aims to evaluate the outcomes of pulmonary sublobar resection in pediatric patients. Methods: We retrospectively reviewed the medical records of 405 children who were operated in the Thoracic Surgery Clinic of Ä°stanbul University Medical Faculty between January 2001 and June 2011. Only 43 patients (20 girls, 23 boys; mean age 11.4±0.5 years; range 0 to 16 years) who underwent pulmonary sublobar resection were included in the study. Patients were evaluated in terms of age, gender, complaints on admission, history of previous diseases, diagnostic methods, operative indications, surgical procedures, complications, duration of hospitalization and outcome of the procedure. Results: Indications for pediatric resections were oncological (n=29), non-oncological (n=9) and congenital pathologies (n=5). The mean duration of hospitalization was 3.6 days after surgical procedure. Morbidity was observed in two patients postoperatively, whereas mortality was not observed. Conclusion: Indications of pulmonary sublobar resections varies in pediatric patients compared to adults. Pulmonary sublobar resection is a good option for children, as less functioning lung tissue is removed with fewer postoperative complications. It is also relatively simple and fast surgical method, than lobectomy.

Primary Mediastinal Hydatid Cysts

Hydatid disease is endemic in many parts of the world. Mediastinal hydatidosis is seen less than 0.1% of all hydatid diseases. We want to report our primary mediastinal hydatid cysts. In this retrospective study, from January 2010 to December 2012, 158 patients with intrathoracic hydatid cysts were operated in our thoracic surgery clinic. Nine of 158 (5.69%) patients had mediastinal hydatid cyst. Chest X-ray and computed tomography (CT) were used as diagnostic tools. Hydatid cyst was confirmed surgically and pathologically in all the patients. Anterior mediastinal hydatid cysts and one cardiac involvement were determined in our study. While total cyst excision was performed in seven patients, partial pericystectomy could be done in two patients. In one patient, left ventricle invasion was seen and it was totally excised. Postoperative albendazole was applied to patients and there was no recurrence of disease till now. Mediastinal hydatid cysts are uncommon and should be kept in mind in differential diagnosis of mediastinal cystic lesions especially in endemic regions. Surgical resection must be done and then medical therapy is needed to prevent recurrence.

Pleural ultrasound as an adjunct to physical examination in the preoperative evaluation of lung cancer patients

Preoperative evaluation of patients with suspected or confirmed lung cancer consists of clinical and radiological staging. Malignant pleural effusion is a poor prognosticator in non-small-cell lung cancer. Pleural ultrasound (PU) allows for the assessment of pleural effusion, providing real-time guidance for its aspiration and cytological analysis. Pleural Ultrasonography in Lung Cancer (PULC) as an adjunct to physical examination has the potential to improve preoperative staging of non-small-cell lung cancer during first surgical encounter by allowing the evaluation of previously unassessed pleural effusion. This study consisted of a prospective trial of surgeon-performed PU in the preoperative evaluation of lung cancer patients. All patients evaluated in the thoracic surgery clinic with the new or presumed diagnosis of lung cancer were eligible. A portable ultrasound machine was used to evaluate pleural fluid in the bilateral costophrenic sulci with pleural fluid aspiration for cytological analysis. Forty-five patients were prospectively enrolled over a 3-month period. Thirteen patients had ultrasound evidence of a pleural effusion, of which 3 were significant enough for aspiration. Cytological analysis of these effusions yielded malignant cells in 1 patient. Positive PULC evaluation led to a change in clinical staging (M0 to M1a) in 10 patients and a change in pathological staging (pleural fluid cytology positive) in 1 patient. The time required for PULC examination was 15 ± 7 min. There were no complications related to the procedures. Preoperative pleural ultrasonography is a rapid and effective way to improve precision of staging in patients with lung cancer. More precise staging may allow for more appropriate testing, patient prognostication and operative planning.

Accuracy of the Masimo Pronto-7® system in patients with left ventricular assist device

BackgroundThe Masimo Pronto-7® calculates hemoglobin (Hb) values using the pulsoximetry technique and a variety of mathematical algorithms analyzing the pulse waveform. Although this system has demonstrated a high level of accuracy in average patients, the performance might be altered in special patient populations. Regarding patients with left ventricular cardiac failure, a rotary blood pump generates a constant, continuous, non-pulsatile flow to improve effective cardiac output. Due to this alteration in both, blood flow and arterial blood pressure we hypothesized a reduced accuracy of the Masimo Pronto-7® to detect Hb in patients with left ventricular cardiac failure. To test our hypothesis, we evaluated the Pronto-7®SpHb system in outpatients after continuous-flow-left ventricular assist device (cf-LVAD) implantation (HeartMate II, Thoratec).Methods21 cf-LVAD outpatients from the Clinic for Cardiac, Thoracic and Vascular Surgery were investigated during routine follow up examinations. After venous blood samples were drawn, the Pronto-7® sensor was attached to one randomly selected finger of one hand. The collected SpHb data were compared with Hb values measured by our central laboratory. The difference between the methods was determined using Bland – Altman analysis. The study was registered in the DRKS (DRKS00004415).ResultsIn all cf-LVAD patients evaluated, the Pronto-7® successfully detected SpHb values. Using Bland – Altman analysis, a bias of 0.14 g/dl (95% upper and lower limits of agreement ± 2.76 g/dl) was calculated.ConclusionThe Pronto-7® overestimated the actual Hb value in cf-LVAD outpatients with the HeartMate II. Due to this, we conclude that the system is suitable for screening in routine examinations and further analysis can be performed if needed. However, its use as an emergency tool is questionable because of the increased inaccuracy when Hb values are critically low.

Temporary right ventricular mechanical circulatory support for the management of right ventricular failure in critically ill patients

Management of right ventricular (RV) failure after left ventricular assist device (LVAD) implantation is not evidence based. Temporary circulatory assistance has recently been reported to be of value for managing postoperative RV failure after LVAD implantation, but only in small series of patients or isolated case reports. We report here our experience with the use of temporary right ventricular assist devices (RVADs) in LVAD recipients. Forty-five of the 488 (9%) patients undergoing LVAD implantation between 2001 and 2011 at the Clinic for Thoracic and Cardiovascular Surgery in Bad Oeynhausen had RV failure requiring temporary RVAD. We analyzed preoperative data, complications, mortality at 6 months, and risk factors of death. The LVAD patients receiving temporary RVAD were younger than the 443 recipients of LVAD alone. They were more likely to have mechanical ventilation and haemofiltration and their Michigan right ventricular risk score was higher. The LVAD patients with temporary RVAD had a higher mortality at 6 months: 53%, versus 25% for patients receiving LVAD only (P<.001). The univariate risk factors for death were high blood urea nitrogen and C-reactive protein concentrations, preoperative mechanical ventilation, preoperative hemofiltration, destination therapy, the use of temporary RVAD, and the development of RV failure. Multivariate analyses did not identify predictors of death. The development of RV failure in LVAD recipients is a serious problem associated with high mortality. Temporary RV mechanical support is an acceptable way to manage postoperative RV failure in these severely ill LVAD recipients.

Spontaneous Pneumothorax Recurrence and Surgery.

Spontaneous pneumothorax that occurs in patients with no underlying lung disease is termed primary spontaneous pneumothorax (PSP). Recurrence of pneumothorax is usually seen without surgical procedures at any time. The aim of this study was to determine the recurrence time and rate of PSP after the first episode. A total of 82 PSP patients who had been treated in a thoracic surgery clinic between March 2011 and August 2012 were studied retrospectively. Video-assisted thoracoscopic surgery (VATS) was performed in 14 of 82 patients because of prolonged air leakage. These patients were excluded from the study to determine the recurrence period of PSP in our cases. Simple endotracheal intubation with low-volume high-frequency ventilation and three-port VATS technique were applied. Bullae or blebs were excised using an endoscopic linear stapler. Apical pleurectomy was performed in all of the patients. There were no cases in which VATS was converted to open thoracotomy. Recurrence of PSP was seen in 18 (26.47%) of 68 patients. We found 26.47% recurrence at the first 7months, of which 94.4% occurred at the first 6months. About 77.77% of these recurrences occurred at 3months after discharge from hospital. Recurrence after the first episode of PSP is a common problem within the first 6months. The thoracic surgeon should give knowledge about it to all patients. With the greater use of VATS for thoracic pathologies, it could be performed for the first period of pneumothorax in the future.

Intrathoracic anastomotic stenosis after resection in esophageal cancer

Background: In this study, we assessed the postoperative anastomotic stenosis in patients undergoing intrathoracic esophagogastric anastomosis with the stapler. Methods: Between January 2000 and December 2007, 132 patients who were operated due to esophageal cancer in Thoracic Surgery Clinic were retrospectively analyzed. The reconstruction was performed by the resection of 7-8 cm tumor free tissue proximally and distally. For all patients, the transthoracic esophagogastric anastomosis with end-to-end anastomosis (EEA) stapler was performed. Results: The in-hospital mortality rate was 5.3% (n=7), while 15 patients (12.0%) developed anastomotic stenosis. The incidences of the anastomotic stenosis in female and male patients were 11.7% (9/77) and 12.5% (6/48), respectively. The anastomotic stenosis was developed in nine (13.4%) and six (10.3%) patients in which the anastomosis were performed by using 25 mm and 28 mm stapler, respectively. The rate of the anastomotic stenosis were 25% (13/52) and 2.9% (2/69) in patients with the tumor located in 1/3 middle or 1/3 distal and cardia, respectively. The mean duration of the stenosis development was 3.9 months (range, 2-8 months). The mean dilatation cure was 1.7 sessions (range, 2-6 sessions). Symptoms of all patients were relieved by means of balloon dilatation and no complication related to the procedure was seen. Conclusion: Although the stapler contributes to the improvement of morbidity and mortality after the resection in esophageal cancer, it usually does not decrease the incidence of the anastomotic stenosis. We believe that surgical techniques should be improved and appropriate stapler devices should be developed to reduce the complications which may affect the patient comfort and psychology adversely.

A Case of Pleomorphic Liposarcoma in a Patient with Crohn's Disease Taking Azathioprine

Azathioprine is frequently used for the treatment of inflammatory bowel diseases (IBD) such as Crohn's disease and ulcerative colitis. Lymphomas, squamous cell carcinomas, and undifferentiated pleomorphic sarcomas have been reported among patients receiving azathioprine therapy. Herein, we report a case of pleomorphic liposarcoma of chest wall which occurred in a 44-year-old man with Crohn's disease taking azathioprine. He was diagnosed with Crohn's disease 3 years ago after suffering from abdominal pain and hematochezia for 12 years. He had been taking 50 mg of azathioprine per day for 23 months when he visited the thoracic and cardiovascular surgery clinic due to right chest palpable mass that had rapidly grown during the past 2 months. Excisional biopsy was performed and the mass was diagnosed as pleomorphic liposarcoma. Therefore, he underwent radical excision of the right chest wall mass, which measured 11.0 × 6.5 cm in size. He is scheduled to receive radiation therapy and chemotherapy.

A clinical decision support system for femoral peripheral arterial disease treatment.

One of the major challenges of providing reliable healthcare services is to diagnose and treat diseases in an accurate and timely manner. Recently, many researchers have successfully used artificial neural networks as a diagnostic assessment tool. In this study, the validation of such an assessment tool has been developed for treatment of the femoral peripheral arterial disease using a radial basis function neural network (RBFNN). A data set for training the RBFNN has been prepared by analyzing records of patients who had been treated by the thoracic and cardiovascular surgery clinic of a university hospital. The data set includes 186 patient records having 16 characteristic features associated with a binary treatment decision, namely, being a medical or a surgical one. K-means clustering algorithm has been used to determine the parameters of radial basis functions and the number of hidden nodes of the RBFNN is determined experimentally. For performance evaluation, the proposed RBFNN was compared to three different multilayer perceptron models having Pareto optimal hidden layer combinations using various performance indicators. Results of comparison indicate that the RBFNN can be used as an effective assessment tool for femoral peripheral arterial disease treatment.

Early results of minimal invasive surgery in patients with pectus carinatum

Background: In this study, we reported the results of minimal invasive surgery in our patients with pectus carinatum. Methods: Between July 2008 and December 2010, a total of nine male patients (mean age 10.6 years; range 4.4 to 15 years) were operated for pectus carinatum deformity with minimal invasive surgery (Abramson method) in Thoracic Surgery Clinic. The patients were hospitalized in the previous day of surgery for surgical preparation. The mean duration of operation was 83 minutes. The patients were operated using a bar and two fixators attached to the chest wall, as defined by Abramson. The bar was inserted through a subcutaneous tunnel in the first patient. In other patients, the bar was inserted via a submuscular tunnel passing through chest wall. Systemic analgesics and antibiotics were used postoperatively. Results: In the first patient, the bar which was inserted subcutaneusly was perforated the skin due to an infection on day 15 following surgery. This bar was removed and the deformity was corrected with Ravitch method. There was no complication in other patients. The most frequent postoperative complaint was pain within the first two days following surgery; however it was relieved thereafter. All patients were discharged on day five following surgery. There was no mortality and morbidity. Conclusion: The surgery of pectus carinatum deformity with minimal invasive surgery is a recently introduced method, therefore the results are not clear yet. We consider that small and lateral incision scar with minimal complications may lead to patient satisfaction. We also consider that this approach would be an alternative to much more invasive techniques.

Preoperative Prediction of Lung Function in Pneumonectomy by Spirometry and Lung Perfusion Scintigraphy

Introduction:Nowadays an increasing number of lung resections are being done because of the rising prevalence of lung cancer that occurs mainly in patients with limited lung function, what is caused by common etiologic factor - smoking cigarettes. Loss of lung tissue in such patients can worsen much the postoperative pulmonary function. So it is necessary to asses the postoperative pulmonary function especially after maximal resection, i.e. pneumonectomy.Objective:To check over the accuracy of preoperative prognosis of postoperative lung function after pneumonectomy using spirometry and lung perfusion scinigraphy.Material and methods:The study was done on 17 patients operated at the Clinic for thoracic surgery, who were treated previously at the Clinic for Pulmonary Diseases “Podhrastovi” in the period from 01. 12. 2008. to 01. 06. 2011. Postoperative pulmonary function expressed as ppoFEV1 (predicted postoperative forced expiratory volume in one second) was prognosticated preoperatively using spirometry, i.e.. simple calculation according to the number of the pulmonary segments to be removed and perfusion lung scintigraphy.Results:There is no significant deviation of postoperative achieved values of FEV1 from predicted ones obtained by both methods, and there is no significant differences between predicted values (ppoFEV1) obtained by spirometry and perfusion scintigraphy.Conclusion:It is necessary to asses the postoperative pulmonary function before lung resection to avoid postoperative respiratory failure and other cardiopulmonary complications. It is absolutely necessary for pneumonectomy, i.e.. maximal pulmonary resection. It can be done with great possibility using spirometry or perfusion lung scintigraphy.

Right diaphragmatic lipoma: report of five cases and review of the literature

Approximately 40 diaphragmatic lipoma cases have been reported in the literature to date. Diaphragmatic lipoma is 2 times more likely to appear on the left rather than the right side. In the present study, diaphragmatic lipoma was evaluated in patients who underwent surgical management in light of the literature data. Materials and methods: This study retrospectively evaluated 5 consecutive diaphragmatic lipoma patients who underwent surgical treatment at the Thoracic Surgery Clinic between January 2003 and April 2012. Results: Of the patients, 3 were female and 2 were male. The average age of the patients was 62.2 years (range: 54-77). All of the cases were symptomatic and the most common symptom was chest pain (3 cases). Diaphragmatic lipomas were located on the right posterolateral side in all cases. The methods of approach were thoracotomy in 4 cases and video-assisted thoracoscopic surgery in 1 case. Postoperative complications and mortality did not occur in any of the cases. The average hospital stay was 5 days (range: 3-7). There were no recurrences during the average follow-up of 21.4 months (range: 2-58). Conclusion: A surgical approach to diaphragmatic lipomas offers histopathological diagnosis, curative treatment, and prevention of malignant transformation.