Surgery for Lung Cancer Jocelyn McLean

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Surgery for Lung Cancer Jocelyn McLean

  1. 1. Surgery for Lung Cancer Jocelyn McLean Case Manager for Thoracic Surgery
  2. 2. Surgery is offered to… <ul><li>CURE </li></ul><ul><li>Early (Stage 1&2 Primary NSCLC </li></ul><ul><li>Solitary metastatic lung tumors </li></ul><ul><li>DIAGNOSTIC </li></ul><ul><li>APPROACH </li></ul><ul><li>Thoracotomy – open surgery </li></ul><ul><li>PALLIATE </li></ul><ul><li>Advanced NSCLC – pleural effusions </li></ul><ul><li>Metastatic pleural effusions from other primary </li></ul><ul><li>Undiagnosed pleural effusions – primary unknown </li></ul><ul><li>DIAGNOSTIC </li></ul><ul><li>APPRAOCH </li></ul><ul><li>Thoracoscopy – keyhole surgery </li></ul>
  3. 3. For curative surgery - it’s as simple as ……. <ul><li>Diagnosis of NSCLC or High suspicion </li></ul><ul><ul><li>PET -ve supporting clinical history </li></ul></ul><ul><ul><li>Increasing size over 3 months </li></ul></ul><ul><li>Localised disease (within the chest) </li></ul><ul><li>Fit enough for an operation </li></ul><ul><ul><li>Anaesthetic </li></ul></ul><ul><ul><li>Respiratory function / capacity </li></ul></ul><ul><li>Technically possible - IF IN DOUBT – </li></ul><ul><li>ASK THE LUNG SURGEON !! </li></ul><ul><li>Stopped smoking min of 4 weeks (total cessation) </li></ul>
  4. 4. General principles <ul><li>Safe </li></ul><ul><li>Short anaesthetic time </li></ul><ul><li>Risks include </li></ul><ul><ul><li>bleeding, </li></ul></ul><ul><ul><li>infection, </li></ul></ul><ul><ul><li>cardiovascular event, </li></ul></ul><ul><ul><li>Air-leak </li></ul></ul><ul><li>Low mortality </li></ul><ul><ul><li>Overall (1%) </li></ul></ul><ul><ul><li>Pneumonectomy ( 2%) </li></ul></ul><ul><ul><li>More deaths from those with advanced malignancy </li></ul></ul><ul><li>Maximise health prior to op </li></ul><ul><li>Understand procedure and expected recovery - short LOS </li></ul><ul><li>Effective pain relief </li></ul><ul><li>Effective physiotherapy </li></ul><ul><li>Early removal of ICC- minimise air leaks </li></ul><ul><li>Early mobilisation </li></ul><ul><li>Reliable ICU/respiratory support </li></ul>
  5. 5. What makes surgery amenable to more patients? <ul><li>Double lumen ETT  </li></ul><ul><li>1 lung ventilation </li></ul><ul><li>Stapling techniques </li></ul><ul><li>Glue </li></ul><ul><li>Knowledge from LVRS </li></ul><ul><li>Older patients, worse lungs, shorter operation </li></ul>Insertion of a Double Lumen Tube W. John Russell 17th May 2000
  6. 6. Routine – pre-op for surgery <ul><li>Respiratory assessment </li></ul><ul><ul><li>RFT/spirometry, clinical assessment, What op ? pneumon </li></ul></ul><ul><li>Stop smoking </li></ul><ul><li>Stop anticoags- Plavix, Warfarin, Asprin </li></ul><ul><li>Maintain respiratory meds </li></ul><ul><li>Other co morbidities controlled – Diabetes, cardiac, </li></ul><ul><li>Preadmission clinic- bloods, ECG, CXR,G&H, MRSA screen, Physio consult, History, Pathway </li></ul><ul><li>Day of surgery admission </li></ul>
  7. 7. Intentions of surgery <ul><li>Surgical resection offers only chance of a cure. </li></ul><ul><li>Gold standard is lobectomy, bi-lobectomy or pneumonectomy </li></ul><ul><li>Formal lymph node resection. </li></ul><ul><li>If cure is intended but resp capacity prevents lobe etc then wedge resection or segmentectomy. </li></ul><ul><ul><li>price is > chance of local recurrence </li></ul></ul>
  8. 8. If the intent is palliative..…. <ul><li>Thoracoscopic approach. </li></ul><ul><li>Improve QOL – when reasonable quantity (time) is likely. </li></ul><ul><li>Symptom control – shortness of breath, pain </li></ul><ul><ul><li>Optimize re-expansion of lung </li></ul></ul><ul><li>Carries significant risk of post operative morbidity and mortality </li></ul><ul><li>Obtain diagnosis - significant if young / compensation </li></ul>
  9. 9. Right Lower Lobectomy Left Upper Lobectomy
  10. 10. Malignant Pleural Effusion - mesothelioma Thoracoscopy pleurodesis only Thoracotomy 6 Weeks after decortication

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