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Thoracic Surgery Innovations And Complications

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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Thoracic Surgery Innovations And Complications

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  1. Thoracic SurgeryInnovations AndComplications

  2. Overview • Innovations • Complications

  3. Innovations • VATS • LVRS • Chemotherapy • Radiotherapy • PET • Small Cell • N2 • Stents & Lasers • Stapler In Oesophagogastrectomy • Epidural • SVC stents

  4. Complications ?

  5. 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

  6. Innovations

  7. VATS • Sympathectomy • Pleurectomy • Lobectomy • Biopsy • mass • lung

  8. Pneumothorax

  9. Pleurectomy • VAT • Muscle sparing • Mini • Full Thoracotomy

  10. VAT Lobectomy

  11. Biopsy Lung / Pleura

  12. LVRS

  13. LVRS

  14. 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

  15. LVRS • Unilateral / Bilateral • Thoracotomy / Sternotomy / VAT • Role of Physio

  16. Chemotherapy and Radiotherapy • Preoperative Neoadjuvant • Operative • Postoperative Adjuvant

  17. 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

  18. 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

  19. 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

  20. Radiotherapy • Neoadjuvant • T3 Pancoast prior to surgery • Palliative • Symptomatic relief • Pain, haemoptysis, bronchial, SVC obstruction • Bone met pain • Brachytherapy • Local application high local dose

  21. Chemotherapy and Radiotherapy • Adjuvant • Neoadjuvant • Sequential / concurrent / alternating • Good performance status • Not standard practice • May increase risk surgery

  22. 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

  23. Small Cell Lung Cancer

  24. Small Cell All need : Mediasteinoscopy CT head Bone scan

  25. Pre operative N2 • Young patients • Pre op chemo downstage • No evidence

  26. Stents & Lasers Malignant terminal conditions that are inoperable Benign inoperable conditions

  27. Tracheal obstruction-malignant - Pre and post Nd:Yag laser

  28. Left main bronchus extensive squamous cell carcinoma Metal stent in left main

  29. Stapler In Oesophagogastrectomy

  30. Epidural • Pain • Poor PFTs • Cardiac history • Contraindications • Low risk • On anticoagulants • Consent • Anatomical • Infective

  31. SVC Stents

  32. Complications

  33. AIR LEAK

  34. AIR LEAK • What operation • Aetiology • Conservative • Talc • Tetracycline • Blood • Flutter bag • Sort out in Theatre saline, bagging and prolene

  35. Atelectasis • Obstructive tumour, mucous or foreign body • Non obstructive effusion or mass • Pain • Double lumen tube malposition • Temperature • WCC • TNF alpha • Nebs • Physio • Bronch

  36. 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

  37. Chest Infections • Frequent • Pre op PFTs and performance predict • Medical and surgical causes • Pre op cultures from bronch • Pain relief, Nebs, Antibiotics and Physio

  38. Atrial Fibrillation • pO2, K+ • Intrapericardail dissection • Pneumonectomy > lobectomy > wedge • Chest infection / Atelectasis • Role digoxin prophylaxis • Beta blockers • Oesophageal leak

  39. 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

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