The Efficacy of Intrathecal Morphine in Post-thoracotomy Pain Management

This study compared the analgesic efficacy of intrathecal (IT) morphine plus IV patient-controlled analgesia (PCA) morphine with IV PCA morphine alone in 33 patients undergoing thoracotomy randomized to two groups: the IT morphine group ( n = 17) received 10 μg/kg morphine 1 h before the end of surgery, while the control group ( n = 16) did not. All patients had access to an IV PCA pump post-operatively that delivered 2 mg morphine boluses. Post-operative pain and sedation scores, respiratory and haemodynamic parameters, and morphine demand and delivery were assessed up to 48 h. Post-operative pain scores and morphine consumption were significantly reduced, while peak expiratory flow rates were significantly increased in the IT morphine group compared with controls. We concluded that IT morphine in addition to IV PCA established superior analgesia and maintained better respiratory function compared with IV PCA alone in post-thoracotomy patients.

Thoracic endometriosis syndrome with bloody pleural effusion in a 28 year old woman

Thoracic endometriosis, rarely encountered, is characterized with the localization of functional endometrium tissue in pleura, lung parenchyma or tracheobronchial system. A 28 years old female patient visited our clinic with complaints of cough and shortness of breath for the last two months. Right-sided massive pleural effusion was detected in the chest radiography and thorax computed tomography. Exudative fluid was aspirated with a haemorrhagic appearance on thoracentesis. Cytology was evaluated as suspicious. "Signet ring cells" were reported in pleural biopsy. Diagnostic biopsy was performed by video-assisted thoracic surgery (VATS) on the patient whose fiber-optic bronchoscopy was normal. The histopathological diagnosis was reported as "pleural endometriosis". Chemical pleurodesis was applied with asbestos-free chalk. The thorax HRCT (high resolution computed tomography) performed during menstruation was normal. Thoracentesis was needed 3 times for recurrent pleural effusion in the follow-ups and then parietal pleurectomy was performed. The patient is in postoperative 10th month follow-up and evaluated as normal clinically and as radiologically. Pleural endometriosis should be considered as a differential diagnosis in female patients with infertility with chest symptoms. Video-assisted thoracoscopic surgery can be useful in the diagnosis and treatment of these patients and chemical pleurodesis and parietal pleurectomy should be considered among the treatment options.

The effects of neoadjuvant chemotherapy on pulmonary structures: a quantitative analysis

BACKGROUND

The effects of neoadjuvant therapy on perioperative and postoperative outcomes of patients with stage IIIA non-small cell lung cancer remain controversial. We investigated histopathological changes possibly caused by neoadjuvant chemotherapy and their effect on the tensile forces of pulmonary structures.

METHODS

A prospective study of 30 patients who had undergone lung resection was performed. The patients were divided into two groups. Group 1 included those who received neoadjuvant chemotherapy, and Group 2 included those who underwent surgery alone. Tensile stress tests were performed on freshly excised vascular and bronchial strips after lung resection. The pulmonary artery, veins, and bronchi that had not been invaded by the tumor were histopathologically examined in both groups. Intraoperative and postoperative complications were recorded.

RESULTS

This study showed that the tensile strength of pulmonary vessels and bronchi was less in the neoadjuvant group than in the control group. There were statistically significant differences in the tissue strips obtained from arteries, veins, and bronchi between the two groups. In the chemotherapy group, most cases exhibited extensive fibrosis. There was no statistically significant difference in complications between the groups.

CONCLUSIONS

Neoadjuvant chemotherapy did not increase postoperative morbidity or mortality. The decreased tensile strength of pulmonary vessels and bronchi after neoadjuvant therapy should alert thoracic surgeons to possible surgical complications.

The effect of blood vessel invasion on prognosis of operated stage I non-small cell lung cancer patients

OBJECTIVE

A retrospective study was conducted to identify the effect of blood vessel invasion on prognosis in surgically treated stage I non-small cell lung cancer patients.

METHODS

A total of 71 consecutive patients who had undergone complete resection for stage I primary non-small cell lung cancer (NSCLC) between 1998 and 2007 were evaluated. All pathological specimens were examined for evidence of blood vessel invasion. The follow-up period was 5-118 months. Survival data were analyzed for all patients using the Kaplan-Meier test.

RESULTS

There were 63 men and 8 women (mean age 59.2, age range 35-86). The most common tumor types were adenocarcinoma (35 patients, 49 %) and squamous cell carcinoma (26 patients, 37 %). Twenty-five patients (35 %) had stage IA disease, and 46 had (65 %) stage IB disease. In 13 cases (18 %) blood vessel invasion was demonstrated, whereas in the remaining 58 cases there was no evidence of vascular invasion. Minimum and maximum follow-up periods were 5 and 118 months respectively, with a mean of 41.76 +/- 27 months (median 33.5 months). Overall disease-free survival was 79.6 +/- 6.4 months: 38.3 +/- 12.0 months for the group with blood vessel invasion and 87.5 +/- 6.7 months for the remaining group. The difference between the two groups was statistically significant ( P < 0.003). Overall survival rate was 86.7 +/- 6.7 months: 44.5 +/- 11.3 months for blood vessel invasion group and 98.2 +/- 6.2 months for the remaining group. The difference between the two groups was statistically significant ( P < 0.001).

CONCLUSION

Vascular invasion can be an important factor for predicting unfavorable prognosis in stage I NSCLC patients.

[Congenital cystic adenomatoid malformation of the lung resembling bronchiectasis in an adult]

Congenital cystic adenomatoid malformation (CCAM) of the lung is a rare anomaly which is characterized by a proliferation of dilated bronchiolar-like air spaces. It is generally seen in newborns and infants. When seen in adults, which is more uncommon, it presents itself mostly with recurrent pulmonary infections. In this article, 31-year-old man with cough and purulent expectoration and a history of recurrent pulmonary infections who had cystic changes resembling bronchiectasis at the left lower lobe on the computed tomography of the chest and diagnosed CCAM-type 2 after the histopathological examination of the left lower lobectomy specimen is presented.

Experimental Use of N-Butyl Cyanoacrylate Tissue Adhesive on Lung Parenchyma after Pulmonary Resection

BACKGROUND

The aim of this study was to investigate the effectiveness of N-butyl cyanoacrylate tissue adhesive for the prevention of air leak together with the morphological changes to lung parenchyma.

METHODS

Twelve New Zealand rabbits were used. The rabbits were ventilated with pressure-controlled ventilation during the experiment, beginning with a pressure level of 10 cm H (2)O. After a 2 x 2-cm pulmonary wedge resection, the resection surface was sealed with N-butyl cyanoacrylate and the pressure level was increased every five minutes in 5-cm H (2)O increments. The pressure level which caused an air leak from the resection surface was recorded. The morphological damage to the lung parenchyma was evaluated under light microscopy.

RESULTS

The mean value of the pressure levels that caused air leak was 43.3 +/- 8.8 cm H (2)O. No tissue damage to lung parenchyma was recorded after histopathological examination.

CONCLUSION

N-butyl cyanoacrylate was effective in preventing air leak from the pulmonary resection surface even with high airway pressure levels. It could be used as an aid for pulmonary resection lines or to control the air leak from pulmonary parenchyma.

[Surgical results of large cell neuroendocrine carcinoma of the lung]

Large cell neuroendocrine carcinoma is rare in the group of primary lung cancers and its appropriate treatment and prognosis are controversial. In this report, patients diagnosed as large cell neuroendocrine carcinoma of the lung were presented and discussed in the light of pertaining literature. Between February 1997 and March 2005, eight patients, who were diagnosed as large cell neuroendocrine carcinoma postoperatively among the patients with a preoperative diagnosis of nonsmall cell lung cancer, were analyzed retrospectively, by means of treatment method, disease free survival and overall survival. All eight patients were male and their mean age and age range were 64 +/- 7.6 and 50-72, respectively. Four patients had lobectomy, two had pneumonectomy and two had limited resections. One patient received neoadjuvant chemotherapy and seven patients received adjuvant chemotherapy, radiotherapy, or chemoradiotherapy. Follow-up period was 19.7 +/- 12.5 (3-39) months and disease-free interval was 19 +/- 12.9 (3-39) months. Two patients died of recurrence 14 and 16 months postoperatively, whereas six of the cases are alive with disease-free. Large cell neuroendocrine carcinomas are aggressive tumors with poor prognosis but better prognosis is also revealed after surgery at early stages. Most of the series in the literature are small in number of patients, as in our report, and treatment strategies are tried to be formed according to these data.