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  • 1. Mainly esophageal disease Thoracic surgery started with a man named block Proposed operating on the lung – first cases done on animals First clinical case was his niece who died – committed suicide The Hx of thoracic surgery was when you open the chest patient dies Killian 1898 invented bronchoscopy Physiology of the open chest Murphy and Graham Took rabitts and put hole in the chest Breuer – used postivive pressure ventilation. Sauerbruch – surgeon in Europe – use negative pressure in the operating room Endotracial tubes – since 1870s Laryngeoscope – used to place endotracheal tube with a ventilator 1909 the whole system was put into use with humans Lung cancer almost non existent in 20th century Graham pneumonectomy 1932  barbaric operation First resection of lung cancer 1903 Davies – first anatomical dissection Pleurodesis – Mickulyz – causes lung to stick to the lung wall – allows for lung not to collapse when during surgery Surgery using tourniquets Most people died because of not using chest tubes Use a tube to drain an empyema Tube was placed under water Pulmonary resection 1930 Components of Modern Thoracic Surgery Anatomic Pathologic Diagnosis Endotrachial intubation and positive pressure Anatomic dissection and knowledge Secure bronchial closure Repiratory therapy and ventilatory support Antibiotics to prevent infection Second slide Presentation Chest drainage First bottle is pressure, collection, and water seal Left the chest tube in place Done by Brunn
  • 2. Kent and Blades 1940 Anatomic Resection Ligate Ewart Boyden Brock veins and vessels Reinhoff did anatomical pneumonectomy Diagnosis – Modern CXR – Old and should be discontinued CT – Very good PET – Useful in proving pulmonary nodules is a cancer and if metastasis Bronchoscope – look to biopsy Needles – Trans Chest wall Throacentesis – Drainage of pleural fluid Toracoscopy – look through a scope placed in pleural cavity Pulmonary nodlules – number one sueing suit is missing lung cancer Calcivication – mostly bengined Popcorn – always beginen If eccentric then unsafe, needs to be removed PET Scan Putting in Glucose Sarcoidosis – not everything is cancer Bronchoscopy – Flexible scope – look into subsegmental areas of the lung. Place needles through, collect washings, brushings, etc Local anesthesia Throascope Resection of small nodules Have them home in a couple days What is the role of the surgeon Metastasis Tumor has spread through the blood to the lung Surgeon can biopsy and prove diagnosis R/o metastasis Potentially cure patient Diagnosis of Lung Metastasis The CT is 2-3 x more sensitive than CXR Picks up earlier and smaller Not all pulmonary nodules are metastasis Bronchogenic carcinoma
  • 3. Granulomata and beginning tumors 2nd neoplasms to prior treatment sarcoma lymphoma This particularly true in the case of solitary pulmonary nodules Diagnosis tests CEA, colon lung CA 125 Alpha FP testicular Thyrogolbulin –thyroid Chruchhill 1933 resected metastasis Can cure some metastasis Clagett’s Rules Primary tumor must be controlled Must be no other metastases All lung metastases must be resectable Patient has to be able to lose the lung tissue Has to be no better lung treatment Amended Primary must be controllable Any other metastases must be able to be resected or controlled with adjuvant theraphy Any residual tumor after resection must be controlled by adjuvant therapy Ther patient must be albe to tolerate the resection and adjuvant Multimodality therapy may salvage previously incurable patients Wilms Ewings, testicular carcinoma Osteosarcoma and soft tissue - chemo isn’t known how much it helps Prognostic factors Synchronous vs metachronous One vs many Uni vs bilat COMPLETE RESECTION Small vs large Primary vs recurrent Sugical Options Median sternotomy – middle of breast Thoracotomy – between ribs Thoracoscpy – through small incisions
  • 4. Sternotomy – One operation Major complications Limited exposre to lower lobes Thoracotomy Two operations if bilateral disease Longer recovery time Video Assisted Faster recovery Acceptable M+M Difficult locatlization May miss ipsilateral as well as contralateral diseae More difficult to ensure negative margins Primary Tumor Location 127 Colorectal biggest Breast Soft Tissue Sarcomas Surgery Wedge resection - 72 Lobectomy - Other 77 have unilateral metastasis 23 have bilateral Breast cancer has a fair survival 35% over 5 years Colorectal 41% 5 years Testicular 66% for 5 years Renal Cancer 50% Conclusion – Resection can cause long term survival in a select group of patients. There are no variables that determined who got surgery and who didn’t CT underestimates the number of lesions in at least half of patients. No cure without complete resection Surgical resection alone cures selected patients Repated resection with recurrent metastasis M and M is low and well tolerated in young people
  • 5. Young People Testis in adolescence Soft tissue sarcomas are common Hepatoma Big is osteosarcoma and Rhabdomyosarcoma – the main diseases are treated with chemo Lung metastasis Seen in pediatric cancer centers Numbers of cases are much less common Surgical resection Survival 20% 5 years 10-15% at 20 years Osteosarcoma St. judes’s 20% disease free survival for 5 years Contribution from both Chemotherapy and aggressive surgical series is under investigation Memorial hospital 4/6 ten year survivors lived 20 years – second recurrence due to chemo therapy Testicular cancer Seminoma – Almost always cured by chemotherapy Non Seminoma- contains other types of cells, more complicated – do a BHCG and AFP to see if other cell types are there NSGCT – have them resect any residual disease Can have rapid growth – could be teratoma, could be testicular cancer, or be another type of tumor. Medialstinal tumors Germ cell tumors – anterior mediastinum Thymoma Sarcomas – relatively uncommon Mediastinal Tumors Presentation Pruuitis – hodgkins disease Pain with alcohol Red cell aplasia - thymomas Myaesthenia gravis – thymomas Horner – Pancoast tumor DDX – Mediastinal Age
  • 6. Compartment Pain Mediastinal in Kids Neuroblastoma – common in children Lymphoma Germ Stell – puberty unless klinfelders Cingential Cysts Mediastinal Tumor Compartments Superio/Anterior – in front of heart – Thyroid Goiters, Thymoma, Germ Cell, Thymus tumors Middle – covered by cardiac silohouette – great vessels Lymphoma, Lymphadenopathy – metastatic, sarcoidosis – benign, Granulomatous disease – TB, Benign – cysts, and aneruysms Posterior – area between anterior spine – neurogenic tumors, esophageal masses, vascular aneurysm and abnormalities Age and compartment – we end up with common tumors Work up – Serum calcium – parathoid ACE level – sarcoidosis BHCG AFP – Germ Cell turmo LDH – lymphoma Catech – paragangliomas Anatomy – CXR, CT MRI – invading the spine Biopsies of Mediastinal tumor – needle biopsy may not be a good idea Anterior mediastinal stenotomy – remove on costocartilage Needle through the trachea Needle through esophagous – posterior spinal Mediastinoscopy – Down anterior to tracheal Sugerical approach Throascope Benign cysts Neurogenic tumors Malignant tumors need to be done open chest Thymoma Germ Cell Malignnat dumbbell Neurogenic tumor Sarcoma
  • 7. Median sternotomy – Thoracotomy is used for lateral tumors Anterior tumor Watch sternum Vasculature Watch the phrenic nerves Watch the recurrent nerve Anesthesia considerations Watch for compression of the trachea If airway compromised over 50% - hazardous to do surgery Large tumors that are too large to resect Use multimodality to shink it down and then remove it Anthrax causes mediastinal widening Goiter Substernal Can go posterior mediastinum Thymoma- 30-50% have myasthenia gravis 15% to have thymoma if you have myasthenia gravis 5% of thymomas have red cell aplasiea if you have red cell aplasia 50% chance of having Thymoma Thymoma – If it invades still stage two Add radiation therapy after resection Form drop metastases- inside chest Some can metastiss even if not supposed to Lymphoma Middle mediastinum – mediastinumscope Children and adults Anterior mediastinum – mostly middle NSGCC Chemotherapy can shint the tumor – complete repariative resection Kelinfelters Shyndrom Delayed Male development Also have higher incidence of Germ Cell tumors 50 x that of normal
  • 8. Most common outside of the testicle Normal people mostly inside testicles Occur at an earlier age Sarcoma – Can’t be cured if wrapped around aorta Lymph node involvement by NSCLC, SCLC, Breast CA etc Neurogenic tumors Neuroblastoma Ganglioneurblastomas – highly malignant Schawannoma Posterior – benign are adults and malignants are children Neuroblastoma Posterior mediastinal Teated with radio and chemo Dumb bell tumor Neurofibromatosis Most common Café au lai spots Get tumors Familial Paragangliomas Not on exam Malignant hypertension with anesthesia Pheocrhomocytomas 40% Cysts Bronchogenic Enteric Enteric esophageal Cysts Compress airway and esophagus Infection/ abcess Pericardial Contain water Clear Don’t have to be resected Vascular Aortic dissection Severe chest or back pain
  • 9. Superior Venal Caval Syndrom Complication of mediastinal tumors is SVCO syndrome Increased CVP central venous pressure Facial swelling Headache Facial swelling Collateral veins in upper torseo Blurred vision - Increased ICP and coma and death Collateral veins over chest and shoulders Rapidly responsive to Chemo Pericardial Effusion EXAM QUESTIONS Often missed – Dyspnea with hypotension Distended neck veins Heart tones muffled Paradox – drop in blood pressure with respiration – 15 mmHG lying down and breathing quietly Pulsus alternans Electrical alternans – QRS gets bigger and smaller with breathing Urgent high mortality DX Complication of cardiac surgery – number one cause Number on cause of death is malignant pericardial effusion Previous surgery Primary tumor etc TX Pericardialcentesis – dangerous  6% mortality only under image guidance usually echo Sclerosing agent or balloon dilation With certain cancer – chemo therapy Make an open window Sub ziphoid – come at periocardium below Thorascopically is best way 18% of patients dying with progressive cancer low rate of effusion recurrence Single lung anesthesia Baloon blocker down left main bronchus Needle into pericardium Can do drainage also through direct view with open chest
  • 10. Pericardial window patients usually die within a year – palliative procedure Lung cancer survival is worse than breast Pleural effusions Very common Fluid in chest that collapses the lung SOB by inverting the diaphragm Doing a thoracentesis between ribs – you drain the fluid Is effusion loculated – if so use an echo No pnuemothorax No blood vessel and hemothorax SOB, no breath sounds, percuss flat note, CXR, throacentesis, not as dangerous as cardiocentesis Light criteria – sp gravity, ldh, glucose If maybe TB or malignancy – thoroscopy Malignant pleural effusions – 30-40% Almost never a transudate – low ldh, low glucose, etc If exudates – Lung to breast to lymphoma – any cancer can cause pleural effusion Short survival Effective palliative RX – currently with pleurodesis – doxicycline and talc  basically they use these two drugs to scar the visceral and parietal layers together to prevent fluid Thoroscopy – Minimally invasive, better visualization, technical limitations, limited palpatin, technology is in evolution, good diagnostic Pleruodesis Substance that causes symphysis of pleura No residula space Chest tube alone <40% Doxi 60-70 % Talc – 90% PleurXcatheter – New technique Outpatient placement Outpatient drainage recurrent pleural effusion for palliation. Intrapleural Chemo can be used to Chylothroax-
  • 11. Leak of thoracic dust into the chest – Heavy Cream High fat, protein loss Death by starvation Etiology Congential Trauma Tumor Ligation of Thoracic duct is the Tx
  • 12. THIRD LECTURE Lung volume reduction surgery Used in emphysema Nonfunctional lung encroaches on good functional lung Sickest patients are hurt by these procedures Lung Transplant – sever lung emphysema that cannot undergo vol reducation Last resort – death immenent No malignant patients Above 60 no – but in some series age is increasing No CAD Lobe, one or both lungs COPD, PF are those most indicated CF can have lobe transplants by parents. Carcinoid tumors – second most common after bronchogenic. Cherry red tumor, metastasize to the Liver, Peripheral Olser-Weber-Redu – Hemorrhagic Telangiectasia Syndrom Familiarl – arterial malformation in skin brain and lung Lip and tongue spots and vessels Cyanosis R-> L shunt AV malformation Cerebral abscess Peripheral pulmonary nodules Invsive aspergillus Immunosuppressed pt with prolonged neurtopenia Fever Chest Pain Hemoptysis Pathognomatic readiographic features Forming fungus balls In the old days was thought to be TB until proven otherwise Esophageal Perforation – KNOW THIS Man Too much to drink Less common in women Borhob syndrome Vomiting History of Vomiting and fever, and progressive SOB CXR – Pleural effustion – low pH, bacteria are in pleural 6 hours Every minute – 24 hours 50% death
  • 13. Clubbing and osteoarthropathy Chronic cyanosis, inflammatory disease or tumor Hypertorophic pulmonary osteoarthropathy occurs only with tumor. – Joint pain and clubbing only in cancer and pleural cancer Pain will resolve with tumor resection – couple months for clubbing to leave – will return with cancer Pneumothorax – taller than norm Pain in the chest SOB Diminished breath sounds Not a flat note – increased tympanic sound large amount of air Treatment – chest tube to remove air – have to have an underwater seal Usually caused by a little blister on top of the lung. If continues  pleurodiesis to scar that area of the lung Secondary Pneumothorax – underlying lung disease Histiocytosis X Most common cause is emphysema  get bullous and they pop Sometimes you can see a tumor or cyst Tracheal neoplasms – not everything that wheezes is Asthma Mucoepidermoid tumor Adenocystic carcinoma Squamous carnicnoma Plus carcinoid tumor  especially localized to one part of the chest Continuaing Medical Education Same questions asked will be the same but the answers will change Bad nw is that yo will have to form life-long practice of continuous self-eduation Good new is that you will still be learning new and exciting information twenty years from now Technological change occurs rapily