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Staging Techniques for Carcinoma of the Esophagus

There were 17,460 estimated new cases of esophageal cancer diagnosed in the United States in 2012 and 15,070 estimated deaths. The overall survival from esophageal cancer remains dismal at less than 17% at 5 years in the United States. The poor prognosis can be attributed to advanced stage at diagnosis and biological characteristics of the cancer. Less than 50% of the patients will be eligible for…

Surgical Treatment of Benign Esophageal Diseases

The esophagus actively transports solids and liquids from the pharynx to the stomach. It has no digestive, absorptive, metabolic, or endocrine functions. A muscular tube subtended by two sphincters performs this rudimentary transfer task. Despite simplicity in esophageal function and form, surgical treatment of benign esophageal disorders is challenging. Few options are available to repair damaged sphincters; disorders of the esophageal body are rarely amenable to…

Surgery for Congenital Lesions of the Esophagus

Embryology At approximately the 18th or 19th day of fetal life, the notochord, the anlage of the vertebral column, starts to form, first in close association with endodermal cells and then separating from them. The foregut develops from the endodermal cells as they are separating from the notochord. At approximately 3 weeks of embryonic development, the tracheal primordium appears as a ventral diverticulum in the cephalad…

Esophageal Anatomy and Function

The esophagus is a muscular tube that starts as the continuation of the pharynx with the upper esophageal sphincter (UES), or cricopharyngeus, and ends with the lower esophageal sphincter at the fundus of the stomach. Knowledge of the anatomy of the esophagus and its relationship with other organs and structures is essential for the surgeon to evaluate the location of lesions seen through use of endoscopy,…

Congenital Diaphragmatic Hernia

Definition Different congenital diaphragmatic anomalies include one or more defects that allow for herniation of abdominal contents into the chest. However, the term congenital diaphragmatic hernia (CDH), also referred to as Bochdalek hernia, refers specifically to congenital defects located on the posterior-lateral aspect of the diaphragm. Despite the name diaphragmatic “hernia,” there is a true hernia sac in only 15% to 20% of cases. History The…

Surgery of the Diaphragm: A Deductive Approach

And on a day we meet to walk the line And set the wall between us once again. We keep the wall between us as we go. … He only says, “Good fences make good neighbors.” ROBERT FROST, “MENDING WALL” The muscular diaphragm acts as a boundary between the positive-pressure abdominal cavity and the negative-pressure thoracic cavity. Perhaps because it is a boundary structure, or perhaps…

Pleural Tumors

Pleural Embryology and Anatomy The pleura is a thin continuous membrane that separates during embryologic development into two layers as the developing lung buds encroach on the pleural cavity. The component of the pleural membrane that envelopes the lung is called the visceral pleura, which then continues as a contiguous serosal layer, called the parietal pleura, to cover the chest wall, the mediastinum, and the diaphragm.…

Malignant Pleural and Pericardial Effusions

Malignant Pleural Effusions Pleural effusions are common clinical problems occurring in more than 1 million patients each year. In some settings, up to 22% of these effusions are caused by malignant disease and more than 100,000 malignant effusions require treatment annually. Affected patients with advanced neoplastic diseases experience considerable morbidity as a result of these pleural fluid collections. Physiology Pleural effusion results from a derangement in…

Chylothorax

Definition Chylothorax is the collection of an excessive amount of chyle in the pleural space. The continued loss of chyle, which can add up to 2 to 3 liters a day after a thoracic duct injury, leads to significant depletion of fats (up to 70% of dietary intake), proteins, and T lymphocytes. As a consequence, marked disturbances in the immunologic and nutritional profile are the rule…

Empyema

Epidemiology In the United States, empyema is seen in approximately 60,000 patients annually, with a mortality rate of 15%. Approximately 50% of empyemas in the United States today result from pneumonia. Pleural infection may also result from lung surgery, trauma, esophageal perforation, or transdiaphragmatic spread of an intra-abdominal infection. At least 40% of all patients hospitalized with pneumonia have an ipsilateral pleural effusion. The average length…

Spontaneous Pneumothorax

The term pneumothorax was first coined by Jean Marc Gaspard Itard in 1803, when he called attention to five cases in which free air was found in the thorax after trauma. Derived from the Greek words pneuma (air) and thorakos (breastplate or chest), it is an apt description for the accumulation of air in the pleural space that leads to partial or total collapse of the…

Thoracic Outlet Syndrome and Dorsal Sympathectomy

† Deceased. Thoracic outlet syndrome, a term coined by Rob and Standover, refers to compression of the subclavian vessels and brachial plexus at the superior aperture of the chest. It was previously designated, according to presumed etiologies, as scalenus anticus, costoclavicular, hyperabduction, cervical rib, and first thoracic rib syndromes . The various syndromes are similar, and the compression mechanism is often difficult to identify. Most compressive…

Chest Wall Tumors

Chest wall tumors are relatively rare tumors that include a variety of soft tissue and bone tumors. Although rarely seen by physicians practicing in a nonspecialized practice, patients who have these tumors need careful consideration because the evaluation and management are varied and full of pitfalls. Some of the tumors need no therapy, others need radical surgical resection, some need preoperative chemotherapy or radiation therapy, and…

Congenital Chest Wall Deformities

A great variety of congenital abnormalities of the chest wall occur. Their physiologic implications are also quite varied and span the spectrum from the rare entities of ectopia cordis and asphyxiating thoracic dystrophy, which are often lethal, to the much more common pectus excavatum and pectus carinatum with their limited physiologic impact. In this chapter anterior thoracic deformities will be considered in five categories: pectus excavatum,…

Secondary Lung Tumors

After the liver, the lung is the second most common site for metastatic involvement in neoplastic disease when all tissues and organs are considered, and 20% to 54% of patients with cancer will have pulmonary metastases at some point in the natural history of their disease ( Boxes 23-1 and 23-2 ). In the absence of extrathoracic metastases (i.e., in approximately 25% of patients with disseminated…

Other Primary Tumors of the Lung

Most primary lung cancers comprise the histologic variants described in other chapters of this text. On occasion, however, the thoracic surgeon must diagnose and treat an unusual primary lung cancer. These tumors frequently have a similar clinical presentation to more common tumors, but there are often subtle differences in treatment. Hence, knowledge of these tumors, their characteristics, and the ensuing diagnostic and treatment paradigms are important…

Anterior Approach to Superior Sulcus Lesions

Historical Note Henry K. Pancoast, a radiologist at the University of Pennsylvania, described a patient afflicted with a carcinoma of uncertain histologic origin occupying the extreme apex of the chest, associated with shoulder and arm pain, atrophy of the hand muscles, and Horner syndrome. This clinical entity has become known as Pancoast syndrome. Unknown to Pancoast, Tobias had already characterized the anatomic and clinical aspects of…

Lung Cancer : Surgical Strategies for Tumors Invading the Chest Wall

Introduction and History Lung cancer continues to be the leading cause of cancer-related deaths in both men and women. Over 75% of non–small cell lung cancer (NSCLC) is advanced in stage at presentation, with extensive locoregional disease or distant metastasis. Most resectable lung cancers are confined to the pulmonary parenchyma, but 5% to 8% extend beyond the lungs and invade the pleura, soft tissues, or osseous…

Lung Cancer: Multimodal Therapy

Although long regarded as the best chance for cure, surgery alone has significant shortcomings in the management of non–small cell lung cancer (NSCLC). Even in the most favorable of circumstances (stage I), failure of therapy is anticipated in 20% to 40% of patients. Moreover, because most patients do not have localized disease at time of initial diagnosis, surgical resection is offered to only a minority of…

Lung Cancer : Minimally Invasive Approaches

The surgical approach in the management of patients with lung cancer continues to evolve and improve. Conventional surgical approaches (including standard posterolateral thoracotomy, muscle-sparing thoracotomy, trans-sternal thoracotomy, and median sternotomy) remain viable options for some patients with resectable lung cancer. However, minimally invasive procedures have increasingly gained acceptance as a standard surgical modality for early-stage lung cancer, with increasing application to more advanced disease, as a…