Surgery for Lung Surgery for Lung CancerCancer

Jocelyn McLeanJocelyn McLean

Case Manager for Thoracic Case Manager for Thoracic SurgerySurgery

Surgery is offered to… Surgery is offered to…

CURECURE Early (Stage 1&2 Early (Stage 1&2

Primary NSCLC Primary NSCLC Solitary metastatic Solitary metastatic

lung tumorslung tumors DIAGNOSTICDIAGNOSTIC

APPROACH APPROACH Thoracotomy – open Thoracotomy – open

surgerysurgery

PALLIATEPALLIATE Advanced NSCLC – pleural Advanced NSCLC – pleural

effusionseffusions Metastatic pleural effusions Metastatic pleural effusions

from other primary from other primary Undiagnosed pleural Undiagnosed pleural

effusions – primary effusions – primary unknown unknown

DIAGNOSTICDIAGNOSTIC

APPRAOCHAPPRAOCH

Thoracoscopy – keyhole Thoracoscopy – keyhole surgerysurgery

For curative surgery - it’s as simple For curative surgery - it’s as simple

as …….as ……. Diagnosis of NSCLC or High Diagnosis of NSCLC or High

suspicionsuspicion PET -ve supporting clinical history PET -ve supporting clinical history Increasing size over 3 monthsIncreasing size over 3 months

Localised disease (within the chest)Localised disease (within the chest)

Fit enough for an operationFit enough for an operation Anaesthetic Anaesthetic Respiratory function / capacityRespiratory function / capacity

Technically possible - IF IN DOUBT – Technically possible - IF IN DOUBT – ASK THE LUNG SURGEON !! ASK THE LUNG SURGEON !!

Stopped smoking min of 4 weeks Stopped smoking min of 4 weeks (total cessation)(total cessation)

General principlesGeneral principles SafeSafe Short anaesthetic timeShort anaesthetic time Risks include Risks include

bleeding, bleeding, infection, infection, cardiovascular event, cardiovascular event, Air-leak Air-leak

Low mortalityLow mortality Overall Overall (1%)(1%) Pneumonectomy (Pneumonectomy (2%)2%) More deaths from those More deaths from those

with advanced with advanced malignancymalignancy

Maximise health prior to Maximise health prior to opop

Understand procedure Understand procedure and expected recovery - and expected recovery - short LOSshort LOS

Effective pain relief Effective pain relief Effective physiotherapyEffective physiotherapy Early removal of ICC- Early removal of ICC-

minimise air leaksminimise air leaks Early mobilisationEarly mobilisation Reliable ICU/respiratory Reliable ICU/respiratory

supportsupport

What makes surgery amenable to more What makes surgery amenable to more

patients?patients? Double lumen ETT Double lumen ETT

1 lung ventilation1 lung ventilation

Stapling techniquesStapling techniques GlueGlue Knowledge from Knowledge from

LVRSLVRS

Older patients, worse Older patients, worse lungs, shorter lungs, shorter operationoperation

Insertion of a Double Lumen TubeW. John Russell 17th May 2000

Routine – pre-op for Routine – pre-op for surgerysurgery

Respiratory assessment Respiratory assessment RFT/spirometry, clinical assessment, What op ? RFT/spirometry, clinical assessment, What op ?

pneumonpneumon Stop smokingStop smoking Stop anticoags- Plavix, Warfarin, Asprin Stop anticoags- Plavix, Warfarin, Asprin Maintain respiratory medsMaintain respiratory meds Other co morbidities controlled – Diabetes, Other co morbidities controlled – Diabetes,

cardiac, cardiac, Preadmission clinic- bloods, ECG, CXR,G&H, Preadmission clinic- bloods, ECG, CXR,G&H,

MRSA screen, Physio consult, History, MRSA screen, Physio consult, History, PathwayPathway

Day of surgery admissionDay of surgery admission

Intentions of surgeryIntentions of surgery

Surgical resection Surgical resection offers only chance of a offers only chance of a cure.cure.

Gold standard is Gold standard is lobectomy, bi-lobectomy lobectomy, bi-lobectomy or pneumonectomyor pneumonectomy

Formal lymph node Formal lymph node resection.resection.

If cure is intended If cure is intended but resp capacity but resp capacity prevents lobe etc prevents lobe etc then wedge then wedge resection or resection or segmentectomy.segmentectomy. price is > chance of price is > chance of

local recurrencelocal recurrence

If the intent is palliative..If the intent is palliative..….….

Thoracoscopic approach.Thoracoscopic approach.

Improve QOL – when reasonable quantity (time) is Improve QOL – when reasonable quantity (time) is likely.likely.

Symptom control – shortness of breath, painSymptom control – shortness of breath, pain Optimize re-expansion of lung Optimize re-expansion of lung

Carries significant risk of post operative morbidity Carries significant risk of post operative morbidity and mortalityand mortality

Obtain diagnosis - significant if young / Obtain diagnosis - significant if young / compensation compensation

Right Lower Lobectomy Left Upper Lobectomy

Malignant Pleural EffusionMalignant Pleural Effusion - mesothelioma - mesothelioma

Thoracoscopy pleurodesis only

Thoracotomy6 Weeks after decortication