L31 Thoracic Surgery

• -assess safety of resection from residual lung fxn standpoint
• -reduce CV morbidity and mortality (always err on the more conservative side)
• -evaluate functional capacity and tailor tx to preserve functional status

• NEED:
• FEV1 and DLCO >60%
• Predicted Post-resection FEV1 >40%
• VO2 max > 10ml/kg/min

• Malignant
• -SCLCa
• -NSCLCa
• -Metastatic Ca

• Benign
• -Infectious
• -Autoimmune
• -AV malformation
• -Pneumoconioses

• 
• -Lungs consist of lobes
• -Lobes consist of segments
• -LN throughout mediastinum

• -size > 3cm
• -doubling of volume q2yr
• -ground-glass nodule
• -"corona radiata" sign
• -irregular, multilobulated, spiculated
• -patient age > 55
• -stippled calcification
• -PET positive

• -stable in size
• -diffuse/solid/central/lamellar calcification (healed granuloma)
• -popcorn calcification (hamartoma)
• -patient age < 35
• -PET negative

• < 4mm
• -F/U in high risk patients

• >4-6mm
• -F/U CT in all

• >6-8 mm
• -F/U CT x2

• >8 mm
• -F/U CT
• -PET
• -biopsy (gold standard, FNA or core)

• -establish/confirm diagnosis
• -complete resection of tumor
• -sampling/complete dissection of the LN stations
• -reconstruction as necessary

*unless all gross tumor can be encompassed in the resection, the operation should not be undertaken*

• -palpate entire lung (important! catches missed nodules)
• -frozen sections
• -FNA or core bx
• -pleural fluid --> cytology

• 1. Lobectomy
• -ideal operation
• -usually well tolerated
• -decreased complications vs pneumonectomy
• -mortality 2% (not much higher in older pts)

• 2. Bronchoplastic Lobectomy
• -indicated for endobronchial tumors and densely affixed LNs
• -local recurrence 17%

• 3. Bilobectomy
• -mortality higher than lobectomy but lower than pneumonectomy

• 4. Pneumonectomy
• -central tumors that involve mainstem bronchus
• -bulky tumors that violate the fissures or invade interlobar vessels
• -mortality 3-15%
• -carinal pneumonectomy has even higher mortality

• 5. Segmentectomy
• -survival worse than lobectomy
• -appropriate for patients with limited fxnl reserve

• 6. Wedge Resection
• -very specific indications
• -role in metastatic disease but not really in lung cancer

• -all accessible enlarged LNs
• -all PET+ LNs

• Distinguish between N1 and N2
• -N1: same side as primary lesion, double digit
• -N2: same side as primary lesion, single digit

• -cardiac procedures first
• -not routinely done

• 2/5 Conditions:
• 1. Anatomically distinct
• 2. Presence of associated premalignant lesions
• 3. Absence of systemic mets
• 4. No mediastinal disease
• 5. Different ploidy

• -Only in 1% of NSCLCa
• -anatomic resection

-5 year survival ranges from 43-85%

• Prognostic Factors:
• 1. Tumor size
• 2. Cancer type (squamous better than adeno)
• 3. Location matters (central tumors worse than peripheral tumors)

• -cT1N1 (33%) has worse survival than pT1N1 (53-56%)
• -single N1 better than multiple N1
• -Hilar N1 worse than lobar N1

• Node Negative Stage II (T3N0)
• -resection

• -Mostly N2 disease (vs. T3N1)
• -N2 disease is usually not resectable

• -no resection (high mortality, no oncologic value)
• -exception: carinal tumors

• -generally not surgical tx
• -can improve survival in patients with isolated brain mets

• 1. Survival higher in women
• 2. No significant difference for age groups (young pts present with more advanced disease)
• 3. Survival worse in African Americans
• 4. Survival higher in squamous vs adeno
• 5. Survival higher with fibrosis, infiltration by plasma cells and lymphocytes

• 1. Complicated
• -growth regulating ptoeins
• -apoptosis proteins
• -cell cycle proteins
• -angiogenesis factors
• -etc....

• 2. Simple
• -CEA

• Simple vs Complex
• -complex effusion when it develops loculations

• Light's Criteria for Exudative Effusion
• 1. Pleural fluid:serum protein ratio > 0.5
• 2. Pleural fluid:LDH ratio > 0.6
• 3. Pleural fluid LDH > 200 IU

• Different Stages of Empyema
• 1. Exudative
• 2. Fibrinopurulent (Thin hardened peel)
• 3. Organizing

• 1. Drainage of pus
• 2. Re-expansion of lung
• 3. Control of pleural space (drains)
• 4. Augmentation of host immune response by abx

Surgical treatment preferred for advanced disease (postponing surgery leads to prolonged hospital course)

• Drainage:
• -Thoracentesis
• -Tube thoracostomy
• -Thoracoscopy (gaining popularity b/c less invasive)
• -Thoracotomy
• -Open window thoracotomy and thoracomyoplasty (leave chest open and pack it, may last for months, avoid if possible

• Complications
• -pneumothorax

• 1. SLT
• -pulmonary fibrosis
• -emphysema
• -primary pulmonary HTN

• 2. BLT (more common)
• -septic lung disease
• -CF
• -Bronchiectasis
• -Emphysema
• -Primary pulmonary HTN

• 3. HLT
• -irreversible disease of both heart and lung

• Most Common Causes of Lung Transplant
• 1. COPD
• 2. IPF
• 3. CF
• 4. IPAH

• Trends in Lung Transplants:
• -increase in BLT
• -age of recipients has gone up

• -age <65
• -other disease processes
• -previous surgery
• -steroids
• -smoking (absolute)
• -nutrition
• -ventilator dependence
• -timing of transplant
• -psychosocial factors (absolute)

Selection criteria are being relaxed

• -HYPOTHERMIA
• -lung inflation
• -PGE1 (pulmonary artery vasodilation)
• -flush pulmonary arteries

• Rehabilitation
• -marginal organs can be rehabilitated and checked to see if they will work before they are transplanted

-Can do on or off bypass (try and do off to avoid complications)

• -chest opened
• -inferior and superior pulmonary veins and pulmonary artery are separated
• -lung removed
• -bronchus of donor lung is connected to patient's bronchus
• -Vessels connected

• -ICU
• -ventilator
• -drips to maintain tight control of hemodynamics and kidney function
• -drainage tubes/catheters
• -immunosuppression

• 1. Reperfusion pulmonary edema
• 2. Primary graft failure
• 3. Hemorrhage
• 4. Bronchial dehiscence
• -blood supply to bronchi is limited, and not anastamosed
• -bronchial anastamoses are ischemic and can dehisce
• 5. Non-infectious pleural space problems
• -effusions
• -pneumothorax

• -transplanted organs are exposed to external environment
• -CMV
• -PCP

*Infection can trigger rejection

Transbronchial bx and BAL to differentiate between infection and rejection

• -routine screening
• -lung allografts are more antigenic and more vulnerable to rejection

• Symptoms:
• -malaise
• -SOB-lung infiltrate

• Diagnosis:
• -biopsy
• -BAL
• -serial daily spirometry (FEV1)

• -Primary factor limiting long-term survival
• -etiology unknown
• -most important cause of mortality and morbidity after lung transplant
• -affects 50% of long term survival
• -50% respond to enhanced immunosuppression
• -some will have progressive deterioration of lung fxn

• -Survival better after BLT
• -Median Survival 5.3 years
• -If patient survives past 1 year median survival goes up to 7.9 years

• One year survival = 80%
• Five year survival = 50%