Lung Volume Reduction Surgery

• Emphysematous lung compresses normal lung and depresses diaphragm.

• Paradoxically can improve FEV1 and exercise function by resecting focally emphysematous lung.

• Still investigational.

Remove from nonfunctional lung

Lung Transplantation• Last resort for lung

disease otherwise untreatable with death immanent.

• Selection– disease, age, co-morbidity

• Surgical techniques– lobe, one or both lungs

• Immunosuppression• BOOP

Next in line:

Not for CA

Better prognosis, better candidate

Carcinoid Tumor

• Approx 1-3% % of malignant tumors of lung.

• Central- smooth cherry red tumor.

• Peripheral nodule• Airway obstruction and

atelectasis• Typical vs. atypical

Submucosal tumor; different from GI carcinoids (causes carcinoid syndrome)

Olser-Weber-RenduHemorrhagic Telangiectasia

Syndrome• 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

In lung, skin, brain

Invasive Aspergillosis• 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

Necrosis of lung

Esophageal Perforation:• Cervical or thoracic• Spontaneous-

Boorhave syndrome• Iatrogenic- esophageal

dilatation, intubation• Chest pain, fever• L>R 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.

Know this for test

Clubbing and Osteoarthropathy• Clubbing may occur

with chronic cyanosis , inflammatory disease or tumor.

• Hypertrophic pulmonary osteoarthropathy (HPO) occurs only with tumor.

• Lung CA, fibrous tumor of pleural

Pulmonary clubbing; also seen in cyanotic heart Dz

Clubbing with arthralgias

Clubbing and HPO

• Pain in knees ankles and tibia > 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.

Pneumothorax:• Very common.• Spontaneous- young tall

people.• Apical blebs• Chest tube drainage.• Bleb resection and

pleurodesis if recurrent.• Secondary- older patients

with COPD• Much higher M+M• Tension- lethal

Increased percussion note

May cause recurrence

More difficult w/ underlying lung Dz.

Pneumothorax:

• 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.

Lung mets that is cystic

Tracheal Neoplasms

• Mucoepidermoid tumor

• Adenocystic carcinoma

• Squamous carcinoma

In anterior wall of trachea

Types that block the airway; in bronchi, add carcinoid

May present with wheezing; DDX for asthma

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.

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

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.

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.