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Lung Cancer: Surgical Treatment

This chapter provides an overview of the surgical treatment for lung cancer. The indications for surgery, types and extent of lung resection, and mediastinal lymphadenectomy are reviewed, with an emphasis on recent published evidence and the new international tumor-node-metastasis (TNM) staging system (seventh edition, 2009). Minimally invasive lung resection (see Chapter 18 ), tracheal lesions (see Chapter 8 ), tumor invading the chest wall (see Chapter…

Lung Cancer Workup and Staging

In 2010, the most recent year for which numbers are available, there were 201,144 new cases of lung cancer (107,164 men and 93,984 women) in the United States. With 158,248 deaths, lung cancer remains the leading cause of cancer-related deaths in both men and women. Of newly diagnosed cases, approximately 80% will be non–small cell lung cancer (NSCLC), and of these, 80% will involve metastatic or…

Screening for Lung Cancer: Challenges for the Thoracic Surgeon

Lung cancer is a global health burden and is among the most common and deadliest of all malignancies worldwide. In the United States, lung cancer accounts for more than 25% of all cancer deaths, exceeding deaths from breast, colon, and prostate cancers combined. More than 80% of individuals with lung cancer die of the disease, primarily because a large proportion of patients with lung cancer present…

Lung Transplantation

The first successful human lung transplant was done in 1983 by the Toronto Lung Transplant Group. Thirty years have passed since this landmark operation and more than 15,000 lung transplants have been done. Lung transplantation is now the preferred treatment option for a variety of end-stage pulmonary diseases. Remarkable progress has been made through refinements in technique and a better understanding of transplant immunology and microbiology.…

Surgery for Emphysema

The prospect of improving the debilitating symptoms of advanced pulmonary emphysema has long attracted the interest of thoracic surgeons. Previous surgical approaches such as costochondrectomy, phrenic crush, pneumoperitoneum, pleural abrasion, lung denervation, and thoracoplasty have largely fallen out of favor. Today, only three surgical procedures are offered for patients with severe emphysema refractory to intensive medical management: bullectomy, lung transplantation, and lung volume reduction surgery (LVRS).…

Infectious Lung Diseases

The development of techniques to treat complications of infectious lung disease formed the cornerstone of modern thoracic surgery, dominating the specialty until approximately 1960. Although advances in critical care, antibiotic therapy, and other alternative treatments have lessened the impact of many lung infections in the practice of today's cardiothoracic surgeons, current evidence suggests other categories of pulmonary infection are on the rise. There are several reasons…

Interstitial Lung Diseases

Interstitial lung disease (ILD) is a group of more than 200 clinical entities that manifest with chronic, progressive, diffuse inflammation of the pulmonary interstitium. This inflammatory process can result from a primary pulmonary process, or it can be the result of a systemic illness such as a connective tissue disease. ILD does not include inflammatory responses secondary to known malignant or infectious etiologies, and for the…

Benign Lesions of the Lung

Definition and Incidence Benign lesions of the lung are rare. A benign lung nodule is difficult to define and classify because some lesions that are called benign have malignant properties. However, the best definition of a benign lesion is one in the pulmonary parenchyma that does not metastasize and does not penetrate through surrounding tissue planes. When it is completely resected, a benign tumor should not…

Congenital Lung Diseases

Various congenital abnormalities involve the pulmonary system. Some of these result in arrested development and stillbirth. Some infants survive delivery only to die shortly thereafter. Neonates with severe anomalies typically display dyspnea and cyanosis at birth. Older children with less critical anomalies may have feeding problems, respiratory infections, developmental delays, or activity limitations. For neonates who are in respiratory distress, speed of diagnosis and early treatment…

Tracheal Lesions

A variety of benign and malignant lesions can develop in the trachea and lead to airway obstruction. The infrequent occurrence of tracheal pathology and its frequently insidious nature can lead to a delayed diagnosis for patients in whom these conditions exist. Advances in surgical and anesthetic techniques have enabled safe and effective resection with primary reconstruction for many of these lesions. For obstructive lesions whose extent…

Thoracic Trauma

The earliest recorded reference to thoracic trauma is found in The Edwin Smith Surgical Papyrus, written around 3000 bc . In this report of 58 cases, three were related to the chest: a penetrating injury to the cervical esophagus, a stab wound to the sternum, and blunt trauma resulting in rib fractures. Homer reported on many thoracic injuries during the Trojan War in his Iliad, perhaps…

Endoscopic Therapies for Thoracic Diseases

The first recorded bronchoscopic intervention is attributed to Gustav Killian, who in 1897 used an esophagoscope to remove a piece of pork bone from a patient's right mainstem bronchus. A few decades later, Chevalier Jackson, now known as the father of endoscopy, became instrumental in the advancement of the field of rigid endoscopy of both the airway and esophagus. Advancements in endoscopic technology have led to…

Endoscopic Diagnosis of Thoracic Disease

Endoscopy, especially fiberoptic endoscopy, has revolutionized nearly all theaters of medicine in terms of diagnosis and therapeutic intervention. This revolution is particularly true for thoracic surgery, where bronchoscopy and esophagoscopy are essential modalities in the diagnosis, approach, and treatment of tracheal, bronchial, and alimentary tract pathology. As the technology of optics, endoscope instrumentation, and appurtenances such as endoscopic ultrasound and yttrium-aluminum-garnet (YAG) laser have evolved, so…

Perioperative Care of the Thoracic Surgical Patient

Patients who are undergoing thoracic surgery require careful attention in the perioperative period. These patients are often older and have baseline abnormalities of lung function, decreased nutritional status, and other comorbid diseases. Postoperatively, factors that influence patient recovery include removal of all or a portion of a lung, the esophagus, or the chest wall, painful incisions, retention of secretions, change in the shape and mechanics of…

Preoperative Evaluation of Patients Undergoing Thoracic Surgery

The decision to proceed with any surgical procedure involves a careful consideration of the anticipated benefits of surgery and an assessment of the risks associated with the surgical procedure. An important component of estimating the benefit of surgery is knowledge of the natural history of the condition in question in the absence of surgery. A popular, and inaccurate, conception of preoperative evaluation is that the evaluating…

Radiologic Imaging of Thoracic Abnormalities

Since the late 1990s advances in imaging technology, including digital subtraction chest radiographs, multi­detector spiral computed tomography (MDCT), dual-energy computed tomography (CT) techniques, electrocardiograph (ECG)-gated CT, positron emission tomography (PET) with CT, and magnetic resonance imaging (MRI), have improved diagnostic accuracy and management of patients with thoracic abnormalities. The electronic distribution of these studies as digital images via a picture archiving and communication system, has also…

Anatomy of the Thorax

The thorax is the upper part of the trunk, bounded by the diaphragm inferiorly, the thoracic inlet superiorly, and the thoracic cage between. Vital organs, such as the heart and lungs, reside completely within the thoracic cavity, and other, equally vital organs, such as the aorta and esophagus, extend into the abdominal cavity. The thorax can be divided into a right and left hemithorax, separated by…

Chronic Thromboembolic Pulmonary Hypertension

Step 1 Preoperative Considerations ◆ Chronic thromboembolic pulmonary hypertension (CTEPH) is an increasingly recognized clinical entity. Pulmonary embolism (PE) is a common disease, with an annual incidence of about 100/100,000 in the United States. Many episodes of PE, however, are silent; from 30% to 50% of patients with CTEPH have no history of a PE. Patients with a prior PE who do not have complete fibrinolysis…

Heart Transplantation

Donor Step 1 Surgical Anatomy and Exposure ◆ The potential donor is placed supine on the operating room table. The standard incision for the multiorgan donor is a midline sternotomy incision extended into a midline abdominal incision to expose the liver, kidneys, small bowel, and pancreas ( Fig. 33.1 ). ◆ The superior vena cava (SVC) lies partly outside the pericardium. It is anterior and to…

Ventricular Assistance and Support

See Video 32.1 on ExpertConsult.com . ◆ Since the first implantation of a left ventricular assist device (LVAD) by Dr. Michael DeBakey in 1966, the search for durable short- and long-term mechanical support has resulted in a myriad of devices and expanded indications. Targeted funding by the National Institutes of Health (NIH) and industry has resulted in several innovative technologies with which the surgeon must be…