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Thoracic Surgery Innovations And Complications . Overview. Innovations Complications. Innovations. VATS LVRS Chemotherapy Radiotherapy PET Small Cell N2 Stents & Lasers Stapler In Oesophagogastrectomy Epidural SVC stents. Complications. ?. Complications. Air Leak Atalectasis

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overview
Overview
  • Innovations
  • Complications
innovations
Innovations
  • VATS
  • LVRS
  • Chemotherapy
  • Radiotherapy
  • PET
  • Small Cell
  • N2
  • Stents & Lasers
  • Stapler In Oesophagogastrectomy
  • Epidural
  • SVC stents
complications5
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
slide7
VATS
  • Sympathectomy
  • Pleurectomy
  • Lobectomy
  • Biopsy
    • mass
    • lung
pleurectomy
Pleurectomy
  • VAT
  • Muscle sparing
  • Mini
  • Full Thoracotomy
slide18
LVRS
  • Criteria
  • Dyspnoeic on daily activities
  • Age < 75
  • No bullae > 5cm
  • Generalised emphysema with regional heterogeneity
  • TLC > 125%
  • FEV1 < 30 %
  • PaCO2 < 50 mmHg, PaO2 > 40 mmHg on air
  • No CAD or Pulmonary hypertension
  • Steroid < 15 mg/day
slide19
LVRS
  • Unilateral / Bilateral
  • Thoracotomy / Sternotomy / VAT
  • Role of Physio
chemotherapy and radiotherapy
Chemotherapy and Radiotherapy
  • Preoperative Neoadjuvant
  • Operative
  • Postoperative Adjuvant
chemotherapy
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
radiotherapy
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
radiotherapy24
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
radiotherapy25
Radiotherapy
  • Neoadjuvant
    • T3 Pancoast prior to surgery
  • Palliative
    • Symptomatic relief
    • Pain, haemoptysis, bronchial, SVC obstruction
    • Bone met pain
  • Brachytherapy
    • Local application high local dose
chemotherapy and radiotherapy26
Chemotherapy and Radiotherapy
  • Adjuvant
  • Neoadjuvant
  • Sequential / concurrent / alternating
  • Good performance status
  • Not standard practice
  • May increase risk surgery
slide27
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
small cell
Small Cell

All need :

Mediasteinoscopy

CT head

Bone scan

pre operative n2
Pre operative N2
  • Young patients
  • Pre op chemo downstage
  • No evidence
stents lasers
Stents & Lasers

Malignant terminal conditions that are inoperable

Benign inoperable conditions

epidural
Epidural
  • Pain
  • Poor PFTs
  • Cardiac history
  • Contraindications
    • Low risk
    • On anticoagulants
    • Consent
    • Anatomical
    • Infective
air leak44
AIR LEAK
  • What operation
  • Aetiology
  • Conservative
  • Talc
  • Tetracycline
  • Blood
  • Flutter bag
  • Sort out in Theatre saline, bagging and prolene
atelectasis
Atelectasis
  • Obstructive tumour, mucous or foreign body
  • Non obstructive effusion or mass
  • Pain
  • Double lumen tube malposition
  • Temperature
  • WCC
  • TNF alpha
  • Nebs
  • Physio
  • Bronch
sputum retention
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
chest infections
Chest Infections
  • Frequent
  • Pre op PFTs and performance predict
  • Medical and surgical causes
  • Pre op cultures from bronch
  • Pain relief, Nebs, Antibiotics and Physio
atrial fibrillation
Atrial Fibrillation
  • pO2, K+
  • Intrapericardail dissection
  • Pneumonectomy > lobectomy > wedge
  • Chest infection / Atelectasis
  • Role digoxin prophylaxis
  • Beta blockers
  • Oesophageal leak
bleeding
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
wound infections
Wound Infections
  • Rare with thoracotomies
  • Empyema not unusual
  • MRSA
  • Surgical technique
    • Haemostasis
    • Suture tension
    • Diathermy on skin
recurrent disease
Recurrent Disease
  • Bronch and biopsy
  • ? Restage if fit
  • Further surgery
  • Chemo large field recurrence
  • Radio local recurrence
inadequate resection
Inadequate Resection
  • Positive resection margins
  • Different types
    • Obvious tumour
    • Microscopic +Ve
    • Odd cell
  • Nothing
  • Radiotherapy
  • Repeat Bronch and CT scan
  • No role for chemo
medical problems
Medical Problems
  • MI / Angina
  • Pain
  • CVA
  • Renal
  • GIT
  • MRSA
    • Isolate
    • Screen outside patients
    • ? Change antibiotic prophylaxis
    • Admit electively if possible
bronchopleural fistula
Bronchopleural Fistula
  • Usually pneumonectomy
  • 2 peaks early and late
  • Technical
  • Post radiotherapy
  • Recurrence
  • Infection
  • Lie on operated side
  • Drain
  • ? Clagget procedure
post pneumonectomy problems
Post Pneumonectomy Problems
  • Cardiac herniation / torsion
  • Haemorrhage
  • Pulmonary oedema
  • Chylothorax
  • Bronchopleural Fistula
  • Stump Clot
  • Empyema
  • Post-pneumonectomy Syndrome
  • Recurrent neoplasm
post pneumonectomy empyema
Post Pneumonectomy Empyema
  • Clinical suspicion
    • Temperature
    • WCC
    • Wound
  • Needle space
  • Drain
  • Irrigate
  • Instil antibiotics
lobectomy space problems
Lobectomy Space Problems
  • Space in thorax after resection
  • Adhesions
  • Stiff lung
  • Pleural tent
  • Muscle flap
  • Thoracoplasty