Thoracic Surgery

1. Thoracic Surgery Innes Wan Cardiothoracic Surgery

2. Thoracic Surgery • Evaluation of solitary pulmonary nodule • Management of lung cancer • Simple pleural disease • Massive haemoptysis • Thoracic trauma

3. Solitary Pulmonary Nodule (SPN) • Single lesion in the lung < 3cm in diameter being surrounded by lung parenchyma on all sides with no associated hilar adenopathy or pleural effusion

4. SPN • Prompt identification and treatment of early lung cancer • Avoidance of surgical morbidity in the diagnosis of benign lung lesions

5. Smoking COAD TB Abestos exposure Prior malignancy Previous radiological exam Cough Haemoptysis Prev Surgery Chest pain Fever Wt loss Focused history taking

6. Physical Exam • General condition • Temp • Complete P/E of all systems • Any cervical LNs

7. Non-invasive investigations • Lateral CXR • HRCT thorax • PET scan

8. Invasive investigations • Bronchoscopy • Image guided FNAC • VATS wedge resection

9. Options • Follow-up • Biopsy: FNAC, trucut • Surgical resection

10. Recommendations

11. VATS technical considerations • Localization of small nodule • Pleural adhesion • One lung ventilation

12. Lung Cancer Epidemiology • in Hong Kong (2003): new cases 3972 deaths 2692 • men > women • related to smoking • >90% lung resections in the West • 80% NSCLC (Adenocarcinoma most common even for smokers) • Surgical resection is possible in 15% of cases in HK

13. Prognosis • small cell (~25%): metastasize early <5% amenable to surgery • Non small cell lung cancer: overall 5 year survival ~10% • with surgery: 5 year survival 30% - 50% • staging at operation is most accurate predictor of long-term survival From al-Kattan et al (1996) Thorax 51:1266-1269

14. T Stage

15. TNM Staging StageSurvival Ia T1 68.5% Ib T2 IIa T1N1 46.9% IIb T2N1, T3N0 IIIa T3N1, T(1-3)N2 26.1% IIIb any T4, any N3 9.0% IV any M1 11.2% From Naruke T et al (1997) Chest 112:242S-248S may be operable inoperable

16. Staging (I) • in general: stage I and II resectable • controversy over ?IIIa • in T3 disease with chest wall invasion • 94% complete pathologic resection • 5 year survival 50% From Harpole DH Jr et al (1996) Ann Surg Oncol 3:261-269

17. Staging (II) • at presentation: 40% resectable 5% partially resctable 55% unresectable From Holmes EC ‘Current status of adjuvant chemotherapy in the treatment of non-small cell lung cancer’ In DeVlta VT, Hellman S, Rosenberg SA, eds. ‘Important Advances in Oncology 1988’. Philadelphia: JB Lippincott, 1988:259-272 • ?role of screening: earlier detection of stage I From Satoh H et al (1997) Anticancer Res 17:2293-2296

18. Preoperative Assessment • Radiology • Bronchoscopy • mediastinoscopy • histology/cytology • arterial blood gas (pCO2) • Pulmonary Function testing (FEV1> 1.5 forlobectomy, FEV1 > 2.0 for pneumonectomy) • DLCO • physiotherapy

19. Principles • Surgical resection (lobectomy) is the only treatment modality proven to improve the prognosis • double lumen endotracheal intubation • posterolateral thoracotomy • divide draining veins first • lymph node sampling • chest drain • PAIN

20. Lobectomy • mortality ~2% • tumour does not cross fissures • fissure explored and dissected • also: Sleeve resection Segmentectomy

21. Pneumonectomy • 5-10% mortality (R>L) • fixation to aorta, SVC, heart, oesophagus implies irresectability (5-10%) • bronchial stump lies flush with trachea • NO suction on drains

22. Complications • bronchopleural fistula • empyema • haemorrhage • sputum retention • atrial fibrillation • persistent air leak • pain

23. Video Assisted Thoracoscopy • diagnostic • operative staging • wedge lung / mediastinal biopsy • therapeutic • major pulmonary resection • palliative • sclerotherapy • pericardial window

24. VATS Lung Resection • ‘utility thoracotomy’ • manipulation with blunt forceps, open thoracotomy instruments • location of nodule (finger palpation) • dissection of fissures • vessels encircled with ties, then tied/stapled • bupivicaine to trocar sites

25. Surgical incisions

26. VAT advantages • lower morbdity • reduced time for chest drainage • shorter hospital stay • patient acceptance (cosmesis) From Allen MS et al (1996) Mayo Clin Proc 71:351-359 Walker WS et al (1996) Int Surg 81:255-258

27. Challenges in VATS • complications of endoscopic surgery • incomplete fissures • pain • ‘mirror imaging’ • port site recurrence

28. The PWH Experience (I) • VAT staging prior to elective thoracotomies • no added morbidity • average 6.2 minutes added to operating time • no added cost to consumables • can influence subsequent management From Yim AP (1996) Chest 109:1099-1100

29. The PWH Experience (II) • for VAT major pulmonary resections: patient selection & technique important • early results: • shorter hospital stay (7.2 days mean) • significantly less analgesic requirement • relatively few complications From Yim AP & Liu HP (1997) Surg Laparosc Endosc 7:241-244 Yim AP et al (1996) Chest 109:13-17

30. The PWH Experience (III) • safe in elderly patients From Yim AP (1996) Surg Endosc 10:880-882 • port site recurrence reported From Yim AP (1995) Surg Endosc 9:1133-1135 • talc insufflation for malignant effusions • 94% success in controlling recurrence From Yim AP (1996) Chest 109:1234-1238

31. The PWH Experience (IV) • simultaneous bilateral VATS From Yim AP (1996) Surg Endosc 10:1029-1030 • ongoing research using VATS • e.g. thymectomy, mediastinal resections

32. Conclusion • lung cancer staging is an accurate indicator of prognosis • TNM staging system is being frequently reviewed and revised • VATS is a versatile, safe tool in the surgical management of lung cancer

33. Pleural Disease (Anatomy: histology) • Serous membrane • Single layer of mesothelial cells • Connective tissue containing capillaries & lymphatics

34. Anatomy: layers • Visceral • Adherent to entire lung surface • Parietal • Parietal: costal, mediastinal, diaphragmatic • ‘Pulmonary ligament’ hangs down from root of lung (like shirt sleeve around wrist)

35. What can go wrong ?

36. Pneumothorax “Accumulation of gas within the pleural space”

37. Types • Primary • Secondary: Spontaneous Traumatic Iatrogenic

38. Primary Spontaneous • “No cause” • 9 per 100,000 • Male:female is 6:1 • Simultaneous bilateral can occur • Recurs with increasing frequency

39. Secondary spontaneous • Due to underlying disease • e.g. COAD, malignancy, neonatal conditions, catamenial • 20% spontaneous • Older age group • ?more on right side

40. Traumatic • Blunt trauma • Penetrating injury: High velocity Low velocity

41. Iatrogenic Transthoracic FNA Subclavian needle Thoracocentesis Pleural biopsy Mechanical ventilation Nerve block • Variants: open, BP fistula etc.

42. Rarer causes • oesophageal rupture, gas producing organisms infecting pleural space etc.

43. Clinical presentation • Chest pain (pleuritic) • Dyspnoea • Cough, hemothorax, surgical emphysema • Asymptomatic • TENSION • Signs: hyper-resonance decreased breath sounds decreased tactile fremitus

45. Differential Diagnosis:Bullous Emphysema • Increase in size of airspaces distal to terminal bronchioles • Destruction of alveolar walls by proteolytic enzymes • Causes: smoking, a-1 anti-trypsin deficiency • Inappropriate chest drain insertion hazardous • Surgical options: bullectomy, LVRS

46. Management options • Observation • Needle aspiration (thoracocentesis) • Chest drain insertion (thoracostomy) • Recurrence prevention (pleurodesis) • Chemical • Surgical

47. Chest drainage

48. Indications for pleurodesis • Large/persistent air leak • Second episode of PSP • Recurrence rates: 40% after 1st episode 60% after 2nd episode 80% after 3rd episode • Tension or Bilateral pneumothorax • Complicated pneumothorax • e.g. hemothorax, empyema • Patient factors

49. VATS Pleurodesis

50. VATS Pleurodesis