Lung Volume Reduction Surgery

1
Lung Volume Reduction Surgery
Remove from nonfunctional lung

• Emphysematous lung compresses normal lung and
  depresses diaphragm.
• Paradoxically can improve FEV1 and exercise
  function by resecting focally emphysematous lung.
• Still investigational.

2
Lung Transplantation
Better prognosis, better candidate
Next in line
Not for CA

• Last resort for lung disease otherwise
  untreatable with death immanent.
• Selection
• disease, age, co-morbidity
• Surgical techniques
• lobe, one or both lungs
• Immunosuppression
• BOOP

3
Carcinoid Tumor
Submucosal tumor different from GI carcinoids
(causes carcinoid syndrome)

• Approx 1-3 of malignant tumors of lung.
• Central- smooth cherry red tumor.
• Peripheral nodule
• Airway obstruction and atelectasis
• Typical vs. atypical

4
Olser-Weber-RenduHemorrhagic Telangiectasia
Syndrome
In lung, skin, brain

• Familial
• Nosebleeds
• Lip and tongue telangiectasia on exam
• Cyanosis
• Cerebral abscess
• Peripheral pulmonary nodules
• Rx occlude feeding vessels by angio or surgery

• Rare type of A-V malformation arising from a
  central PA

5
Invasive Aspergillosis
Necrosis of lung

• Immunosuppressed pt. With prolonged neutropenia
• Fever
• Chest pain
• Hemoptysis
• Pathognomonic radiographic features
• Amphotericin /- pulmonary resection may be
  curative

Big cavity in lungs was thought to be TB
6
Esophageal Perforation
Know this for test

• Cervical or thoracic
• Spontaneous- Boorhave syndrome
• Iatrogenic- esophageal dilatation, intubation
• Chest pain, fever
• LgtR pleural effusion with low pH
• Dx by esophagram

• Survival will depend upon surgical repair or
  drainage within 6-24 hours.
• Very limited role for non-surgical management.

7
Clubbing and Osteoarthropathy
Pulmonary clubbing also seen in cyanotic heart Dz

• Clubbing may occur with chronic cyanosis ,
  inflammatory disease or tumor.
• Hypertrophic pulmonary osteoarthropathy (HPO)
  occurs only with tumor.
• Lung CA, fibrous tumor of pleural

Clubbing with arthralgias
8
Clubbing and HPO

• Pain in knees ankles and tibia gt wrists and
  elbows.
• Pain disappears almost immediately following
  resection of tumor.
• Clubbing resolves more slowly

• Recurrence of either clubbing or HPO means that
  there is recurrence of tumor.

9
Pneumothorax
Increased percussion note

• Very common.
• Spontaneous- young tall people.
• Apical blebs
• Chest tube drainage.
• Bleb resection and pleurodesis if recurrent.
• Secondary- older patients with COPD
• Much higher MM
• Tension- lethal

May cause recurrence
More difficult w/ underlying lung Dz.
10
Pneumothorax
Lung mets that is cystic

• Rarely pneumothorax is caused by necrotic or
  cystic tumors, typically sarcomas.
• In this case the pneumothorax was caused by lung
  metastasis from an angiosarcoma of the scalp.

11
Tracheal Neoplasms
Types that block the airway in bronchi, add
carcinoid

• Mucoepidermoid tumor
• Adenocystic carcinoma
• Squamous carcinoma

In anterior wall of trachea
May present with wheezing DDX for asthma
12
Laser Ablation

• YAG laser ablation of endobronchial tumor offers
  effective palliation in Lung CA patients with
  dyspnea.
• Mean 3 mo.
• EndobrachyRT increases palliation to mean 6 mo.

13
Cardiac Herniation

• If a defect is left in the pericardium more than
  approximately 3-4 cm in diameter, herniation of
  the heart may occur.
• Larger defects should be repaired with 2mm PFTE

• Sudden profound shock following right
  pneumonectomy

14
Continuing Medical Education

• The questions that will be asked on your exam
  will be the same questions that will be asked
  twenty years from now.
• BUT
• The answers will change.

• The bad news is that you will have to form a
  life-long practice of continuous self-education.
• The good news is that you will still be learning
  new and exciting information twenty years from
  now.

15
Thoracic Surgery An evolving practice

• Technological change occurs with blinding
  rapidity.
• The information and technical skills that allow
  one to successfully practice medicine WILL change.

• Success in practice will depend upon careful
  evaluation of new technology with retraining as
  indicated.