Thoracic SurgeryInnovations

Innovations

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

VATS

• Sympathectomy• Pleurectomy• Lobectomy• Biopsy

– mass– lung

Pneumothorax

Pleurectomy

• VAT

• Muscle sparing

• Mini

• Full Thoracotomy

VAT Lobectomy

Biopsy Lung / Pleura

LVRS

LVRS

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

LVRS

• Unilateral / Bilateral

• Thoracotomy / Sternotomy / VAT

• Role of Physio

Chemotherapy and Radiotherapy

• Preoperative Neoadjuvant

• Operative

• Postoperative Adjuvant

Chemotherapy• Numerous agents

• Adjuvant

– Stage II (T2N0)– ? Role in N2 disease– All oat cell

• Neoadjuvant

• Stage IIIA (N2)– If respond are resected– No residual tumour at surgery means prolonged survival– Experimental

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

Radiotherapy• Primary treatment

– Stage 1 and 2 – Refuse or unfit for surgery– Failure 30 % stage 1 (T1N0), 70% stage 2 (T2N0)– 5 year survival 5 to 40%

• Adjuvant for N1 / N2

– Reduces rate local recurrence– Survival unchanged– ? Role in +Ve resection margins

Radiotherapy• Neoadjuvant

– T3 Pancoast prior to surgery

• Palliative

– Symptomatic relief– Pain, haemoptysis, bronchial, SVC obstruction– Bone met pain

• Brachytherapy

– Local application high local dose

Chemotherapy and Radiotherapy

• Adjuvant• Neoadjuvant

• Sequential / concurrent / alternating

• Good performance status• Not standard practice

• May increase risk surgery

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

Small Cell Lung Cancer

Small Cell

All need :

Mediasteinoscopy

CT head

Bone scan

Pre operative N2

• Young patients

• Pre op chemo downstage

• No evidence

Stents & Lasers

Malignant terminal conditions that are inoperable

Benign inoperable conditions

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

Left main bronchus extensive

squamous cell carcinoma

Metal stent in left main

Stapler In Oesophagogastrectomy

Epidural

• Pain• Poor PFTs• Cardiac history

• Contraindications– Low risk– On anticoagulants– Consent– Anatomical– Infective

SVC Stents

Any

Questions

?

Next Week

2nd March

Inotropes

ITU seminar room