Thoracic Surgery

Thoracic Surgery Susan Moffatt-Bruce, M.D., Ph.D. Assistant Professor of Surgery Ohio State University Medical Center Thoracic Surgery • Lung Cancer / Lung Nodules • Chest Trauma / Empyema • Mediastinal Disease • Benign lung disease Lung Cancer • Case 1: – 70 year old woman with hemoptysis for 3 weeks – History – Physical exam – Tests ordered Risk of Malignancy SUV 0-2.5 24% chance SUV 2.6-4.0 80% chance SUV <4.1 96% chance Lung Nodules <5mm Observe with CT 4 months, q6m for 2 years 6-10 mm Serial CT vs VATS resection >10 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!!!! 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? Lung Cancer Survival Rates 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, 70-100%pneumonectomy Empyema Case 2: 60 year old woman with SOB, increased temperature, fatigue and cough - History: causes - Tests - Procedures Empyema • Exudative Stage: <24 hours – Chest tube • Fibrinopurulent Stage: 24-72 hours – Chest tube – VATS – Thoracotomy • Organization Stage: >72 hours – VATS – Thoracotomy – Empyema tubes or not? High protein > 30 mg/dl, Low pH <7.2, High LDH > 1000 IU/l, Low glucose <50mg/dl Mediastinal Disease • Anterior – – – – – – – – – – – – Lymphoma (16%) Thymoma / Thymic carcinoma (12%) Germ Cell tumor (13%) Thyroid Goitre (6%) Lymphoma Lymphadenopathy Pericardial cysts/ bronchogenic cysts (14%) Tracheal tumors Neurogenic tumors (19%) Lymphomas Cysts Esophogeal disease • Middle • Posterior Mediastinal Disease • Diagnosis: – Serum markers: BHCG, AFP, LDH – CT guided biopsy – Mediastinoscopy – VATS – Chamberlain procedure 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 Benign Lung Disease • Spotaneous Pneumothorax – Primary versus Secondary – – – – – – – COPD CF PCP TB Catamenial Marfan’s Syndrome Sarcoid » 1.25% absorption per 24 hours Pneumothorax • Recurrence rates: 30% after first, 50% after second and 80% after third • Higher risk in pulmonary fibrosis, age >60, 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 Pleural Effusions • Transudates: – CHF – Hepatic Failure – Renal Failure • Exudates: – – – – – – – Infections Collagen vascular disease Malignancy Abdominal Disease / Esophogeal Disease Hemothorax Chylothorax Idiopathic Pleural Effusions • Malignant – 60-80% yield positive cytology – Male: lung > lymphoma > GI tract> mesothelioma – Female: breast > ovary> lung> lymphoma> GI tract> GU tract – Exudate: Total protein > 3g/dl, glucose < 60 mg/dl, pleural/serum LDH >0.6, pleural/serum protein >0.5 – Treatment: VATS, TALC pleurodesis 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 Indications for Adult Lung Transplantation Lung Transplantation Exclusion Criteria Age >65 Current Tobacco Use Malignancy: less than 2 years disease free Active Ethanol and / or substance abuse Obesity BMI > 35 Irreversible Renal Dysfunction (Cr > 2.0 or CrCl < 50 ml/min) Infection with Burkholderia cepacia Diabetic End Organ Injury HIV/ Active Hepatitis C/ B infection Major psychiatric illness Lung Transplant Recipient Survival Lung Volume Reduction Surgery • Emphysema • NETT trial: Apical predominance • Requirements: – – – – – – FEV1: 18-45% DLCO: >20% TLC> >150% TV: >110% PCO2 <55 PAP(mean) <35 mmHg – VATS versus Sternotomy – Pulmonary Rehab – Performance Status- 5% of all referrals LVRS 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