Thoracic Surgery Innovations

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Thoracic SurgeryInnovations
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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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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
• Stage II (T2N0)
• ? 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 (T1N0), 70 stage 2 (T2N0)
• 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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Any Questions ?
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Next Week2nd MarchInotropes ITU seminar
room