Thoracic Surgery Innovations And Complications

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Thoracic SurgeryInnovations AndComplications
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Overview

• Innovations
• Complications

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Innovations

• VATS
• LVRS
• Chemotherapy
• Radiotherapy
• PET
• Small Cell
• N2
• Stents Lasers
• Stapler In Oesophagogastrectomy
• Epidural
• SVC stents

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Complications

• ?

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Complications

• Air Leak
• Atalectasis
• Sputum Retention
• Chest Infections
• Atrial Fibrillation
• Bleeding
• Wound Infections
• Recurrent Disease
• Inadequate Resection
• Medical Problems
• MRSA
• Bronchopleural Fistula
• Post Pneumonectomy Problems
• Post Pneumonectomy Empyema
• Lobectomy Space Problems

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Innovations
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VATS

• Sympathectomy
• Pleurectomy
• Lobectomy
• Biopsy
• mass
• lung

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Pneumothorax
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Pleurectomy

• VAT
• Muscle sparing
• Mini
• Full Thoracotomy

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VAT Lobectomy
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Biopsy Lung / Pleura
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LVRS
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LVRS
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LVRS

• Criteria
• Dyspnoeic on daily activities
• Age lt 75
• No bullae gt 5cm
• Generalised emphysema with regional heterogeneity
• TLC gt 125
• FEV1 lt 30
• PaCO2 lt 50 mmHg, PaO2 gt 40 mmHg on air
• No CAD or Pulmonary hypertension
• Steroid lt 15 mg/day

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LVRS

• Unilateral / Bilateral
• Thoracotomy / Sternotomy / VAT
• Role of Physio

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Chemotherapy and Radiotherapy

• Preoperative Neoadjuvant
• Operative
• Postoperative Adjuvant

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Chemotherapy

• Numerous agents
• Adjuvant
• No evidence
• Role in N2 disease
• All oat cell
• Neoadjuvant
• Stage IIIA (N2)
• If respond are resected
• No residual tumour at surgery means prolonged
  survival
• Experimental

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Radiotherapy

• External beam external rays
• Single / multiple beam / Fraction No
• Brachy local ie intra bronchial
• Interstitial directly into tumour
• Intra cavity in bronchus
• Adjuvant Postoperative
• Neoadjuvant Preoperative

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Radiotherapy

• Primary treatment
• Stage 1 and 2
• Refuse or unfit for surgery
• Failure 30 stage 1, 70 stage 2
• 5 year survival 5 to 40
• Adjuvant for N1 / N2
• Reduces rate local recurrence
• Survival unchanged
• ? Role in Ve resection margins

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Radiotherapy

• Neoadjuvant
• T3 Pancoast prior to surgery
• Palliative
• Symptomatic relief
• Pain, haemoptysis, bronchial, SVC obstruction
• Bone met pain
• Brachytherapy
• Local application high local dose

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Chemotherapy and Radiotherapy

• Adjuvant
• Neoadjuvant
• Sequential / concurrent / alternating
• Good performance status
• Not standard practice
• May increase risk surgery

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PET

• 2-(fluorine-18) fluo-2-deoxy-D-glucose (18-FDG)
• 18-FDG competes with glucose for facilitated
  transport into tumour cells and also competes
  with glucose for phosphorylation by hexokinase
• Positive and negative predictive power

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Small Cell Lung Cancer
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Small Cell
All need Mediasteinoscopy CT head Bone scan
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Pre operative N2

• Young patients
• Pre op chemo downstage
• No evidence

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Stents Lasers

• Malignant terminal conditions that are inoperable
• Benign inoperable conditions

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Tracheal obstruction-malignant - Pre and post
NdYag laser
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Left main bronchus extensive squamous cell
carcinoma
Metal stent in left main
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Stapler In Oesophagogastrectomy
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Epidural

• Pain
• Poor PFTs
• Cardiac history
• Contraindications
• Low risk
• On anticoagulants
• Consent
• Anatomical
• Infective

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SVC Stents
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Complications
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AIR LEAK
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AIR LEAK

• What operation
• Aetiology
• Conservative
• Talc
• Tetracycline
• Blood
• Flutter bag
• Sort out in Theatre saline, bagging and prolene

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Atelectasis

• Obstructive tumour, mucous or foreign
  body
• Non obstructive effusion or mass
• Pain
• Double lumen tube malposition
• Temperature
• WCC
• TNF alpha
• Nebs
• Physio
• Bronch

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Sputum Retention

• Pain
• Phrenic nerve block
• Anatomical stenosis
• Surgical,
• Foreign body,
• Tumour
• Preoperative sputum and smoking
• Physio, Nebs, stop smoking, pain relief-
  epidural, pre op admission for a week

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Chest Infections

• Frequent
• Pre op PFTs and performance predict
• Medical and surgical causes
• Pre op cultures from bronch
• Pain relief, Nebs, Antibiotics and Physio

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Atrial Fibrillation

• pO2, K
• Intrapericardail dissection
• Pneumonectomy gt lobectomy gt wedge
• Chest infection / Atelectasis
• Role digoxin prophylaxis
• Beta blockers
• Oesophageal leak

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Bleeding

• Should be rare unless on anticoagulants
• Usually massive or from chest wall
• Probably little role for platelets, FFP or
  Aprotinin
• CXR most helpful, if collecting TAKE BACK

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Wound Infections

• Rare with thoracotomies
• Empyema not unusual
• MRSA
• Surgical technique
• Haemostasis
• Suture tension
• Diathermy on skin

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Recurrent Disease

• Bronch and biopsy
• ? Restage if fit
• Further surgery
• Chemo large field recurrence
• Radio local recurrence

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Inadequate Resection

• Positive resection margins
• Different types
• Obvious tumour
• Microscopic Ve
• Odd cell
• Nothing
• Radiotherapy
• Repeat Bronch and CT scan
• No role for chemo

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Medical Problems

• MI / Angina
• Pain
• CVA
• Renal
• GIT
• MRSA
• Isolate
• Screen outside patients
• ? Change antibiotic prophylaxis
• Admit electively if possible

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Bronchopleural Fistula

• Usually pneumonectomy
• 2 peaks early and late
• Technical
• Post radiotherapy
• Recurrence
• Infection
• Lie on operated side
• Drain
• ? Clagget procedure

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Post Pneumonectomy Problems

• Cardiac herniation / torsion
• Haemorrhage
• Pulmonary oedema
• Chylothorax
• Bronchopleural Fistula
• Stump Clot
• Empyema
• Post-pneumonectomy Syndrome
• Recurrent neoplasm

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Post Intra Pericardial Pneumonectomy Cardiac
Herniation
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Post Pneumonectomy Empyema

• Clinical suspicion
• Temperature
• WCC
• Wound
• Needle space
• Drain
• Irrigate
• Instil antibiotics

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Lobectomy Space Problems

• Space in thorax after resection
• Adhesions
• Stiff lung
• Pleural tent
• Muscle flap
• Thoracoplasty

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Any Questions ?