Thoracic Surgery

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Thoracic Surgery

• Susan Moffatt-Bruce, M.D., Ph.D.
• Assistant Professor of Surgery
• Ohio State University Medical Center

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Thoracic Surgery

• Lung Cancer / Lung Nodules
• Chest Trauma / Empyema
• Mediastinal Disease
• Benign lung disease

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Lung Cancer

• Case 1
• 70 year old woman with hemoptysis for 3 weeks
• History
• Physical exam
• Tests ordered

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Risk of Malignancy SUV 0-2.5 24 chance SUV
2.6-4.0 80 chance SUV lt4.1 96 chance
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Lung Nodules

• lt5mm Observe with CT 4 months, q6m for 2 years
• 6-10 mm Serial CT vs VATS resection
• gt10 mm Obtain tissue diagnosis (VATS vs FNA)

Early Lung Cancer Action Project 1993- CT scan
in smokers 80 of people had Stage I lung
cancer- 88 10 year survival rate!!!!
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Lung Nodules

• Bronchoscopy 20 yield for peripheral nodules
• FNA Only 20-20 of benign disease diagnosed
• VATS 45-75 malignant at resection
• The only nodules that are unchanged for 2 years
  can be considered benign
• Role of CT / CXR screening?

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Lung Cancer Survival Rates
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Chest Trauma

• Tracheobronchial injuries
• 1-3 of MVA with 80 mortality at scene
  persistent airleak
• Rib fractures / Flail chest
• Pain control, pulmonary toilet
• Sternal fractures
• Associated injuries, pain control
• Hemothorax
• 1500cc /24 hours, 200cc/ 3 hours
• Parenchymal Injuries
• 2 of blunt, 6 of penetrating
• 3-50 lobectomy, 70-100pneumonectomy

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Empyema

• Case 2
• 60 year old woman with SOB, increased
  temperature, fatigue and cough
• History causes
• Tests
• Procedures

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Empyema

• Exudative Stage lt24 hours
• Chest tube
• Fibrinopurulent Stage 24-72 hours
• Chest tube
• VATS
• Thoracotomy
• Organization Stage gt72 hours
• VATS
• Thoracotomy
• Empyema tubes or not?

High protein gt 30 mg/dl, Low pH lt7.2, High LDH gt
1000 IU/l, Low glucose lt50mg/dl
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Mediastinal Disease

• Anterior
• Lymphoma (16)
• Thymoma / Thymic carcinoma (12)
• Germ Cell tumor (13)
• Thyroid Goitre (6)
• Middle
• Lymphoma
• Lymphadenopathy
• Pericardial cysts/ bronchogenic cysts (14)
• Tracheal tumors
• Posterior
• Neurogenic tumors (19)
• Lymphomas
• Cysts
• Esophogeal disease

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Mediastinal Disease

• Diagnosis
• Serum markers BHCG, AFP, LDH
• CT guided biopsy
• Mediastinoscopy
• VATS
• Chamberlain procedure

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Mediastinal Disease

• 15 of patients with MG have thymoma 30-50 of
  patients with thymoma have MG
• Treat MG before surgery pryidostigmine,
  steroids, azathioprine,cyclosporin, IV Ig,
  plasmapheresis
• Serum markers for Germ Cell Tumors
• Seminoma -/- BHCG, AFP
• Chemotherapy / radiotherapy/ surgery residual
• Non-seminoma / BHCG, AFP, LDH
• Chemotherapy, Surgery, no radiotherapy

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Benign Lung Disease

• Spotaneous Pneumothorax
• Primary versus Secondary
• COPD
• CF
• PCP
• TB
• Catamenial
• Marfans Syndrome
• Sarcoid
• 1.25 absorption per 24 hours

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Pneumothorax

• Recurrence rates 30 after first, 50 after
  second and 80 after third
• Higher risk in pulmonary fibrosis, age gt60,
  increased height-weight ratio
• Early surgical intervention for persistent air
  leak (5 days), high risk activities and bilateral
  involvement
• VATS (bilateral)
• Pleurectomy
• Blebectomy
• NO TALC

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Pleural Effusions

• Transudates
• CHF
• Hepatic Failure
• Renal Failure
• Exudates
• Infections
• Collagen vascular disease
• Malignancy
• Abdominal Disease / Esophogeal Disease
• Hemothorax
• Chylothorax
• Idiopathic

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Pleural Effusions

• Malignant
• 60-80 yield positive cytology
• Male lung gt lymphoma gt GI tractgt mesothelioma
• Female breast gt ovarygt lunggt lymphomagt GI tractgt
  GU tract
• Exudate Total protein gt 3g/dl, glucose lt 60
  mg/dl, pleural/serum LDH gt0.6, pleural/serum
  protein gt0.5
• Treatment VATS, TALC pleurodesis

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Lung Transplantation

• Chronic Obstructive Pulmonary Disease
• Idiopathic Pulmonary Fibrosis
• Cystic Fibrosis
• Alpha 1 Anti-Trypsin Deficiency Emphysema
• Pulmonary Hypertension
• Sarcoidosis
• Bronchiectasis
• Lymphangioleiomyomatosis
• Congenital Heart Disease
• Obliterative Bronchiolitis
• Connective Tissue Disease
• Interstitial Pneumonitis

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Indications for Adult Lung Transplantation
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Lung Transplantation
Exclusion Criteria

• Age gt65
• Current Tobacco Use
• Malignancy less than 2 years disease free
• Active Ethanol and / or substance abuse
• Obesity BMI gt 35
• Irreversible Renal Dysfunction (Cr gt 2.0 or CrCl
  lt 50 ml/min)
• Infection with Burkholderia cepacia
• Diabetic End Organ Injury
• HIV/ Active Hepatitis C/ B infection
• Major psychiatric illness

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Lung Transplant Recipient Survival
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Lung Volume Reduction Surgery

• Emphysema
• NETT trial Apical predominance
• Requirements
• FEV1 18-45
• DLCO gt20
• TLCgt gt150
• TV gt110
• PCO2 lt55
• PAP(mean) lt35 mmHg
• VATS versus Sternotomy
• Pulmonary Rehab
• Performance Status- 5 of all referrals LVRS

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References

• Mastery of Cardiothoracic Surgery
• Kaiser, Kron, Spray
• Current Therapy in Thoracic and Cardiovascular
  Surgery
• Yang, Cameron
• Key Topics in Thoracic Surgery
• Casson, Johnston
• Clinical Scenarios in Thoracic Surgery
• Kalimi, Faber