THORACIC SURGERY
Indications for
Surgery
The most common reason for
pulmonary and oesophageal resection is a malignant tumour (carcinoma). A small
percentage of tumours can be benign.
Lung and oesophageal
cancer
Lung cancer is the most common form of
cancer in the UK. In 1998 there were 38,840 new cases of lung cancer diagnosed in
the UK. This represents around 500 cases per million population. The male to female
ratio is 7:4 (Cancer Research UK). Oesophageal cancer is the ninth most common form
of cancer in the UK. There are approximately 7000 new cases of oesophageal
cancer diagnosed in the UK every year. The male to female ratio is 4:3.
There are two histological types
of lung cancer
(World
Health Organization):
- squamous-cell type: 45-60%
- adenocarcinoma: 11-28%
- large-cell type: fewer than 1%
Non-small-cell tumours are treated
by resection if possible, if the tumour can be safely removed with clear margins
and if metastatic disease is not in evidence. Small-cell cancer is virtually
always widespread at diagnosis so surgery is usually not an option. Malignant
tumours of the oesophagus are generally adenocarcinoma, especially in the lower
end. They may
have arisen in the cardia of the
stomach and spread proximally. In the middle and upper oesophagus squamous carcinomas
predominate. Benign tumours of the oesophagus and lungs are rare.
Pneumothorax
This is a collection of air in
the pleural cavity. It usually occurs spontaneously and is due to rupture of
the visceral pleura of an otherwise healthy lung. This is more common in men
than women and more usual in the under-40s.
Patients with chronic obstructive
pulmonary disease (COPD) can rupture a bulla resulting in a pneumothorax. Other
much rarer causes include tumour, abscess and tuberculosis (TB). Traumatic
pneumothoraces can occur with blunt trauma to the chest wall, such as following
a car accident or heavy fall, or from a penetrating chest wound i.e. stabbing
or gunshot, latrogenic (medical in origin) pneumothoraces can occur following
intravenous line insertion, pacemaker insertion or in ventilated patients on
high levels of PEEP (positive end expiratory pressure).
Empyema
Empyema is a collection of pus in
the pleural cavity. The cause is commonly pneumonia, lung carcinoma or abscess,
bronchiectasis or more rarely tuberculosis. It can occur in patients with
septicaemia or osteomyelitis of the spine or ribs. Most empyemas are located
basally but they can occur between two lobes.
Bronchiectasis
Bronchiectasis is a chronic lung
condition in which abnormal dilatation of the bronchi occurs associated with
obstruction and infection. Patients present with excessive production of
purulent secretions, which become chronically infected. Bronchiectasis is
generally managed medically with a physiotherapy regime and antibiotics. In
some severe cases where the condition is localised to one area of the lung,
lobectomy can offer some relief of symptoms.
Oesophageal perforation
Trauma and perforation to the
oesophagus may result from the accidental swallowing of a foreign body (such as
a dental plate). The oesophagus can rupture in cases of severe vomiting
especially if the patient tries to suppress
the vomiting action. latrogenic
perforation can occur following oesophagoscopy or surgery associated with the
pharynx.
Preoperative
Investigations
Patients are assessed
preoperatively in order to establish the nature of the lesion, and whether they
are fit for operation. The following investigations are commonly done.
Chest X-ray
A standard chest X-ray will be
done on all patients to establish preoperative lung status.
CT scan
In patients with cancer a CT scan
is done universally. The scan will locate the lesion accurately and show if
there is invasion into
surrounding structures, which determines operability. The presence of metastases
in
distant organs is a
contraindication to surgery.
BronchoscopyI
oesophagoscopy
This will establish the site of
the lesion and allow biopsy or bronchial washings to be sent for histology. It
can be carried out under sedation
or general anaesthetic.
Pulmonary function
tests (PTFs)
Respiratory function tests will
help the surgeon decide whether the patient can withstand lung resection. It
will also provide the
anaesthetist with valuable information to assess suitability for general
anaesthesia.
Arterial blood gases
(ABGs)
Blood gases may be analysed
routinely at some hospitals or on high-risk patients such as those with a
preexisting
lung condition.
Types of Thoracic
Incision
Posterolateral
thoracotomy
This incision is most commonly
used for operations on the lung. It is a curved incision, which starts at the
level of the third thoracic vertebra and follows the vertebral border of the
scapula and the line of the rib extending forward to the anterior angle or
costal margin. An incision through the bed of the fifth or sixth rib is used
for pneumonectomy or lobectomy.
The muscles cut are trapezius,
latissimus dorsi, rhomboids, serratus anterior and the corresponding intercostal.
A small piece of rib, approximately 1 cm, may be removed to allow easier
retraction and avoid a painful fracture.
Anterolateral
thoracotomy
This incision is used primarily
for cardiac surgery but can be used to perform pleurectomy. The incision starts
at the level of the fifth costal cartilage. At the sternal edge it follows the
rib line below the breast to the posterior axillary line. The muscles cut are
pectoralis major and minor, serratus anterior, and the corresponding intercostals.
Median sternotomy
This incision is used for lung
volume reduction surgery and bilateral pleurectomy. It is a vertical incision
that involves splitting the sternum. The incision extends from just above the
suprasternal notch to a point about 3cm below the xiphisternum. No muscle is
cut except the aponeuroses of pectoralis major.
Left thoraco-laparotomy
This incision is used for surgery
on the lower oesophagus and stomach. The thoracotomy incision follows the curve
of the seventh rib and extends anteriorly over the costal margin towards the
umbilicus. The muscles involved are lattisimus dorsi, serratus anterior, the
corresponding intercostal and the abdominal muscles.
Video-assisted
thoracoscopic
incisions
This relatively new technique aims to carry
out conventional thoracic operations through several very small (1-2cm)
incisions, as opposed to a posterolateral thoracotomy. Instead of the surgeon
seeing inside the patient directly, an endoscope with video camera attachment
is introduced into the chest through one of the small incisions – the surgeon
sees the image produced on television monitors in theatre. Specialised
instruments are
inserted via the other incisions so the
operation can be completed. Advantages are reduced pain and less impact on
respiratory mechanics in the postoperative period, and much smaller scars.
If an oesophageal tumour is
involving the middle third of the oesophagus, surgical access may be easier through
a right thoracotomy and a separate abdominal incision. If the tumour is in the
upper third, then a cervical incision will also be required.
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