Datasets:

MedRAG
/

textbooks

Dataset card Data Studio Files Files and versions Community

Split (1)

train · 126k rows

Subsets and Splits

No community queries yet

The top public SQL queries from the community will appear here once available.

id stringlengths 14 28	title stringclasses 18 values	content stringlengths 2 999	contents stringlengths 19 1.02k
Surgery_Schwartz_4702	Surgery_Schwartz	CHAPTER 19699CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAConfirm T3–4, N0-1 M0 NSCLCNo evidence for metastatic or N2 nodal diseaseTumor progression orpoor performance statusDefinitivechemoradiotherapyMetastatic disease or N2nodal diseaseConcurrent induction chemotherapy (Cisplatin/Etoposide)And radiotherapy: 45 Gy over 5 weeksCT chest/upper abdomenMRI/MRA of vessels/brachialplexusMediastinoscopyBrain CT or MRI andPET scanReassessment performance score, physiologic reserve,tumor responseRadiographic evaluation: CT scans of thechest, upper abdomen, and brain. PET scan for metastasesAdditional chemotherapyas toleratedAssess performance status:performance score, cardiopulmonary reserve,renal function and neurologic functionInitial evaluation, biopsy and stagingThoracotomy, en bloc chest wall resection, lobectomy, chest wall with reconstructionTumor stable/regression; good toexcellent performance statusPoor performance statusGood to excellent performance statusFigure 19-25. Treatment	Surgery_Schwartz. CHAPTER 19699CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAConfirm T3–4, N0-1 M0 NSCLCNo evidence for metastatic or N2 nodal diseaseTumor progression orpoor performance statusDefinitivechemoradiotherapyMetastatic disease or N2nodal diseaseConcurrent induction chemotherapy (Cisplatin/Etoposide)And radiotherapy: 45 Gy over 5 weeksCT chest/upper abdomenMRI/MRA of vessels/brachialplexusMediastinoscopyBrain CT or MRI andPET scanReassessment performance score, physiologic reserve,tumor responseRadiographic evaluation: CT scans of thechest, upper abdomen, and brain. PET scan for metastasesAdditional chemotherapyas toleratedAssess performance status:performance score, cardiopulmonary reserve,renal function and neurologic functionInitial evaluation, biopsy and stagingThoracotomy, en bloc chest wall resection, lobectomy, chest wall with reconstructionTumor stable/regression; good toexcellent performance statusPoor performance statusGood to excellent performance statusFigure 19-25. Treatment
Surgery_Schwartz_4703	Surgery_Schwartz	wall resection, lobectomy, chest wall with reconstructionTumor stable/regression; good toexcellent performance statusPoor performance statusGood to excellent performance statusFigure 19-25. Treatment algo-rithm for Pancoast’s tumors. CT = computed tomography; MRA = magnetic resonance angiography; MRI = magnetic resonance imaging; NSCLC = non–small cell lung cancer; PET = positron emission tomography.cisplatin-based regimen (two to three cycles) has become stan-dard for patients with N2 disease. Table 19-15 summarizes the findings of a systematic review and meta-analysis reporting response rates, progression-free survival, and overall survival after induction chemotherapy followed by surgical resection.Postoperative (Adjuvant) Chemotherapy for NSCLC Post-operative adjuvant chemotherapy was previously thought to confer no benefit based on multiple prospective randomized tri-als, in part because patients who had undergone thoracotomy and lung resection had difficulty tolerating the	Surgery_Schwartz. wall resection, lobectomy, chest wall with reconstructionTumor stable/regression; good toexcellent performance statusPoor performance statusGood to excellent performance statusFigure 19-25. Treatment algo-rithm for Pancoast’s tumors. CT = computed tomography; MRA = magnetic resonance angiography; MRI = magnetic resonance imaging; NSCLC = non–small cell lung cancer; PET = positron emission tomography.cisplatin-based regimen (two to three cycles) has become stan-dard for patients with N2 disease. Table 19-15 summarizes the findings of a systematic review and meta-analysis reporting response rates, progression-free survival, and overall survival after induction chemotherapy followed by surgical resection.Postoperative (Adjuvant) Chemotherapy for NSCLC Post-operative adjuvant chemotherapy was previously thought to confer no benefit based on multiple prospective randomized tri-als, in part because patients who had undergone thoracotomy and lung resection had difficulty tolerating the
Surgery_Schwartz_4704	Surgery_Schwartz	was previously thought to confer no benefit based on multiple prospective randomized tri-als, in part because patients who had undergone thoracotomy and lung resection had difficulty tolerating the adjuvant regi-mens. More recently, however, newer, more effective agents have shown promise, and adjuvant therapy is better tolerated after minimally invasive lung resection (i.e., VATS or robotic anatomic resection). Targeted therapies, which have been shown to be beneficial in advanced-stage lung cancer, are of particular interest.Any patient with nodal metastasis (N1 or N2) or with T3 tumors (defined as tumors >5 to ≤7 cm or separate tumor in same lobe or direct invasion of chest wall [includes parietal pleura and superior sulcus]/parietal pericardium/phrenic nerve) should receive adjuvant chemotherapy if they are able to toler-ate the regimen. In the situation where the margins of resec-tion are positive, re-resection is recommended. If not possible, concurrent chemoradiation is	Surgery_Schwartz. was previously thought to confer no benefit based on multiple prospective randomized tri-als, in part because patients who had undergone thoracotomy and lung resection had difficulty tolerating the adjuvant regi-mens. More recently, however, newer, more effective agents have shown promise, and adjuvant therapy is better tolerated after minimally invasive lung resection (i.e., VATS or robotic anatomic resection). Targeted therapies, which have been shown to be beneficial in advanced-stage lung cancer, are of particular interest.Any patient with nodal metastasis (N1 or N2) or with T3 tumors (defined as tumors >5 to ≤7 cm or separate tumor in same lobe or direct invasion of chest wall [includes parietal pleura and superior sulcus]/parietal pericardium/phrenic nerve) should receive adjuvant chemotherapy if they are able to toler-ate the regimen. In the situation where the margins of resec-tion are positive, re-resection is recommended. If not possible, concurrent chemoradiation is
Surgery_Schwartz_4705	Surgery_Schwartz	chemotherapy if they are able to toler-ate the regimen. In the situation where the margins of resec-tion are positive, re-resection is recommended. If not possible, concurrent chemoradiation is recommended for macroscopic residual tumor and sequential chemoradiation for microscopic residual tumor.Definitive Nonsurgical Treatment for NSCLC. Recent advances in targeted therapies have changed the management of advanced NSCLC from a generalized, platinum-based approach to one in which molecular analysis and targeted, personalized therapies are now standard of care. It is now mandatory that the pathologist clearly differentiate between squamous cell carcinoma and adenocarcinoma because the therapeutic options are different and use of bevacizumab, while beneficial in patients with adenocarcinoma, has been found to cause exces-sive pulmonary hemorrhage in patients with squamous histol-ogy. For the surgeon, this requirement translates into a much more aggressive approach to tissue diagnosis.	Surgery_Schwartz. chemotherapy if they are able to toler-ate the regimen. In the situation where the margins of resec-tion are positive, re-resection is recommended. If not possible, concurrent chemoradiation is recommended for macroscopic residual tumor and sequential chemoradiation for microscopic residual tumor.Definitive Nonsurgical Treatment for NSCLC. Recent advances in targeted therapies have changed the management of advanced NSCLC from a generalized, platinum-based approach to one in which molecular analysis and targeted, personalized therapies are now standard of care. It is now mandatory that the pathologist clearly differentiate between squamous cell carcinoma and adenocarcinoma because the therapeutic options are different and use of bevacizumab, while beneficial in patients with adenocarcinoma, has been found to cause exces-sive pulmonary hemorrhage in patients with squamous histol-ogy. For the surgeon, this requirement translates into a much more aggressive approach to tissue diagnosis.
Surgery_Schwartz_4706	Surgery_Schwartz	has been found to cause exces-sive pulmonary hemorrhage in patients with squamous histol-ogy. For the surgeon, this requirement translates into a much more aggressive approach to tissue diagnosis. At our institution, the cytopathologist provides onsite rapid assessment of the fine-needle aspirate to determine whether tumor cells are present and confirm that sufficient tumor cells are present to enable molecu-lar testing. This has increased the number of passes performed during an EBUS-guided FNA or during CT-guided aspiration of a pulmonary or intrathoracic lesion; typically, an additional two to three passes are made for cell block material after confirming the presence of tumor cells in the target area. When insufficient cells are obtained for molecular testing, despite having a diag-nosis, additional sampling is warranted; this is mandatory in patients with adenocarcinoma and likely to become necessary for other non–small cell histologic types as advances in targeted therapies	Surgery_Schwartz. has been found to cause exces-sive pulmonary hemorrhage in patients with squamous histol-ogy. For the surgeon, this requirement translates into a much more aggressive approach to tissue diagnosis. At our institution, the cytopathologist provides onsite rapid assessment of the fine-needle aspirate to determine whether tumor cells are present and confirm that sufficient tumor cells are present to enable molecu-lar testing. This has increased the number of passes performed during an EBUS-guided FNA or during CT-guided aspiration of a pulmonary or intrathoracic lesion; typically, an additional two to three passes are made for cell block material after confirming the presence of tumor cells in the target area. When insufficient cells are obtained for molecular testing, despite having a diag-nosis, additional sampling is warranted; this is mandatory in patients with adenocarcinoma and likely to become necessary for other non–small cell histologic types as advances in targeted therapies
Surgery_Schwartz_4707	Surgery_Schwartz	additional sampling is warranted; this is mandatory in patients with adenocarcinoma and likely to become necessary for other non–small cell histologic types as advances in targeted therapies become available for clinical use. Acquiring adequate tissue for diagnosis may require mediastinoscopy or VATS; close communication between the oncologist, surgeon, patholo-gist, and patient is needed to ensure that the benefits to the patient clearly outweigh the risks and that results obtained through more aggressive diagnostic measures are needed to direct subsequent care.8Brunicardi_Ch19_p0661-p0750.indd 69901/03/19 7:01 PM 700SPECIFIC CONSIDERATIONSPART IITable 19-15Selected randomized trials of neoadjuvant chemotherapy for stage III non–small cell lung cancerTRIAL (REFERENCE)NO. OF PATIENTS (STAGE III)CHEMOTHERAPYRESPONSE RATE (%)PCR (%)COMPLETE RESECTIONPFSOS5-YEAR SURVIVALRosell et al8560 (60)MitomycinIfosfamideCisplatin60485%12 vs. 5 mo (DFS; P = .006)22 vs. 10 mo (P = .005)16% vs.	Surgery_Schwartz. additional sampling is warranted; this is mandatory in patients with adenocarcinoma and likely to become necessary for other non–small cell histologic types as advances in targeted therapies become available for clinical use. Acquiring adequate tissue for diagnosis may require mediastinoscopy or VATS; close communication between the oncologist, surgeon, patholo-gist, and patient is needed to ensure that the benefits to the patient clearly outweigh the risks and that results obtained through more aggressive diagnostic measures are needed to direct subsequent care.8Brunicardi_Ch19_p0661-p0750.indd 69901/03/19 7:01 PM 700SPECIFIC CONSIDERATIONSPART IITable 19-15Selected randomized trials of neoadjuvant chemotherapy for stage III non–small cell lung cancerTRIAL (REFERENCE)NO. OF PATIENTS (STAGE III)CHEMOTHERAPYRESPONSE RATE (%)PCR (%)COMPLETE RESECTIONPFSOS5-YEAR SURVIVALRosell et al8560 (60)MitomycinIfosfamideCisplatin60485%12 vs. 5 mo (DFS; P = .006)22 vs. 10 mo (P = .005)16% vs.
Surgery_Schwartz_4708	Surgery_Schwartz	(STAGE III)CHEMOTHERAPYRESPONSE RATE (%)PCR (%)COMPLETE RESECTIONPFSOS5-YEAR SURVIVALRosell et al8560 (60)MitomycinIfosfamideCisplatin60485%12 vs. 5 mo (DFS; P = .006)22 vs. 10 mo (P = .005)16% vs. 0%Roth et al9060 (60)Cyclophosphamide EtoposideCisplatin35NR39% vs. 31%Not reached vs. 9 mo (P = .006)64 vs. 11 mo (P = .008)56% vs. 15%aPass et al9127 (27)EtoposideCisplatin62885% vs. 86%12.7 vs. 5.8 mo (P = .083)28.7 vs. 15.6 mo (P = .095)NRNagai et al9262 (62)CisplatinVindesine28065% vs. 77%NR17 vs. 16 mo (P = .5274)10% vs. 22%Gilligan et al93519 (80)Platinum basedb49482% vs. 80%NR54 vs. 55 mo (P = .86)44% vs. 45%Depierre et al94355 (167)MitomycinIfosfamideCisplatin641192% vs. 86%26.7 vs. 12.9 mo (P = .033)37 vs. 26 mo (P = .15)43.9% vs. 35.3%cPisters et al95354 (113)dCarboplatinPaclitaxel41NR94% vs. 89%33 vs. 21 mo (P = .07)75 vs. 46 mo (P = .19)50% vs. 43%Sorensen et al9690 (NR)PaclitaxelCarboplatin46079% vs. 70%NR34.4 vs. 22.5 mo (NS)36% vs. 24% (NS)Mattson et al97274	Surgery_Schwartz. (STAGE III)CHEMOTHERAPYRESPONSE RATE (%)PCR (%)COMPLETE RESECTIONPFSOS5-YEAR SURVIVALRosell et al8560 (60)MitomycinIfosfamideCisplatin60485%12 vs. 5 mo (DFS; P = .006)22 vs. 10 mo (P = .005)16% vs. 0%Roth et al9060 (60)Cyclophosphamide EtoposideCisplatin35NR39% vs. 31%Not reached vs. 9 mo (P = .006)64 vs. 11 mo (P = .008)56% vs. 15%aPass et al9127 (27)EtoposideCisplatin62885% vs. 86%12.7 vs. 5.8 mo (P = .083)28.7 vs. 15.6 mo (P = .095)NRNagai et al9262 (62)CisplatinVindesine28065% vs. 77%NR17 vs. 16 mo (P = .5274)10% vs. 22%Gilligan et al93519 (80)Platinum basedb49482% vs. 80%NR54 vs. 55 mo (P = .86)44% vs. 45%Depierre et al94355 (167)MitomycinIfosfamideCisplatin641192% vs. 86%26.7 vs. 12.9 mo (P = .033)37 vs. 26 mo (P = .15)43.9% vs. 35.3%cPisters et al95354 (113)dCarboplatinPaclitaxel41NR94% vs. 89%33 vs. 21 mo (P = .07)75 vs. 46 mo (P = .19)50% vs. 43%Sorensen et al9690 (NR)PaclitaxelCarboplatin46079% vs. 70%NR34.4 vs. 22.5 mo (NS)36% vs. 24% (NS)Mattson et al97274
Surgery_Schwartz_4709	Surgery_Schwartz	vs. 89%33 vs. 21 mo (P = .07)75 vs. 46 mo (P = .19)50% vs. 43%Sorensen et al9690 (NR)PaclitaxelCarboplatin46079% vs. 70%NR34.4 vs. 22.5 mo (NS)36% vs. 24% (NS)Mattson et al97274 (274)Docetaxel28NR77% vs. 76%e9 vs. 7.6 mo (NS)14.8 vs. 12.6 mo (NS)NRa3-year survival.bOptions included MVP (mitomycin C, vindesine, and platinum), MIC (mitomycin, ifosfamide, and cisplatin), NP (cisplatin and vinorelbine), PacCarbo (paclitaxel and carboplatin), GemCis (gemcitabine and cisplatin), and DocCarbo (docetaxel and carboplatin).c4-year survival.d113 patients (32%) were reported to have stage IIB or IIIA disease.e22 patients in the chemotherapy arm and 29 patients in the control arm had resectable disease.Abbreviations: DFS = disease-free survival; NR = not recorded; NS = not significant; OS = overall survival; pCR = pathologic complete response; PFS = progression-free survival.Reproduced with permission from Allen J, Jahanzeb M: Neoadjuvant chemotherapy in stage III NSCLC, J Natl Compr Canc Netw.	Surgery_Schwartz. vs. 89%33 vs. 21 mo (P = .07)75 vs. 46 mo (P = .19)50% vs. 43%Sorensen et al9690 (NR)PaclitaxelCarboplatin46079% vs. 70%NR34.4 vs. 22.5 mo (NS)36% vs. 24% (NS)Mattson et al97274 (274)Docetaxel28NR77% vs. 76%e9 vs. 7.6 mo (NS)14.8 vs. 12.6 mo (NS)NRa3-year survival.bOptions included MVP (mitomycin C, vindesine, and platinum), MIC (mitomycin, ifosfamide, and cisplatin), NP (cisplatin and vinorelbine), PacCarbo (paclitaxel and carboplatin), GemCis (gemcitabine and cisplatin), and DocCarbo (docetaxel and carboplatin).c4-year survival.d113 patients (32%) were reported to have stage IIB or IIIA disease.e22 patients in the chemotherapy arm and 29 patients in the control arm had resectable disease.Abbreviations: DFS = disease-free survival; NR = not recorded; NS = not significant; OS = overall survival; pCR = pathologic complete response; PFS = progression-free survival.Reproduced with permission from Allen J, Jahanzeb M: Neoadjuvant chemotherapy in stage III NSCLC, J Natl Compr Canc Netw.
Surgery_Schwartz_4710	Surgery_Schwartz	survival; pCR = pathologic complete response; PFS = progression-free survival.Reproduced with permission from Allen J, Jahanzeb M: Neoadjuvant chemotherapy in stage III NSCLC, J Natl Compr Canc Netw. 2008 Mar;6(3):285-293.Brunicardi_Ch19_p0661-p0750.indd 70001/03/19 7:01 PM	Surgery_Schwartz. survival; pCR = pathologic complete response; PFS = progression-free survival.Reproduced with permission from Allen J, Jahanzeb M: Neoadjuvant chemotherapy in stage III NSCLC, J Natl Compr Canc Netw. 2008 Mar;6(3):285-293.Brunicardi_Ch19_p0661-p0750.indd 70001/03/19 7:01 PM
Surgery_Schwartz_4711	Surgery_Schwartz	CHAPTER 19701CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAOnce a treatment plan has been devised, two strategies for delivery are available. “Sequential” chemoradiation involves full-dose systemic chemotherapy (i.e., cisplatin combined with a second agent) followed by standard radiotherapy (approxi-mately 60 Gy). The combination of chemotherapy followed by radiation has improved 5-year survival from 6% with radio-therapy alone to 17%.76 An alternative approach, referred to as “concurrent chemoradiation,” administers chemotherapy and radiation at the same time. Certain chemotherapeutic agents sen-sitize tumor cells to radiation and, thus, enhance the radiation effect. The advantages of this approach are improved primary tumor and locoregional lymph node control and elimination of the delay in administering radiotherapy that occurs with sequential treatment. A disadvantage, however, is the necessary reduction in chemotherapy dosage in order to diminish over-lapping toxicities; this can	Surgery_Schwartz. CHAPTER 19701CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAOnce a treatment plan has been devised, two strategies for delivery are available. “Sequential” chemoradiation involves full-dose systemic chemotherapy (i.e., cisplatin combined with a second agent) followed by standard radiotherapy (approxi-mately 60 Gy). The combination of chemotherapy followed by radiation has improved 5-year survival from 6% with radio-therapy alone to 17%.76 An alternative approach, referred to as “concurrent chemoradiation,” administers chemotherapy and radiation at the same time. Certain chemotherapeutic agents sen-sitize tumor cells to radiation and, thus, enhance the radiation effect. The advantages of this approach are improved primary tumor and locoregional lymph node control and elimination of the delay in administering radiotherapy that occurs with sequential treatment. A disadvantage, however, is the necessary reduction in chemotherapy dosage in order to diminish over-lapping toxicities; this can
Surgery_Schwartz_4712	Surgery_Schwartz	in administering radiotherapy that occurs with sequential treatment. A disadvantage, however, is the necessary reduction in chemotherapy dosage in order to diminish over-lapping toxicities; this can potentially lead to undertreatment of systemic micrometastases. Randomized trials have shown a modest 5-year survival benefit as compared with chemotherapy. In a systematic review of 47 trials and six meta-analyses, an absolute survival benefit of 4% at 2 years was seen when con-current platinum-based chemoradiation was given compared to sequential radiation.77Definitive radiotherapy is predominantly used for pallia-tion of symptoms in patients with poor performance status; cure rates with radiation as a single modality in patients with N2 or N3 disease is less than 7%. Recent improvement has been seen with three-dimensional conformal radiotherapy and altered frac-tionation. Such poor results for patients with stage III lung cancer reflect the limitations of locoregional treatment in a	Surgery_Schwartz. in administering radiotherapy that occurs with sequential treatment. A disadvantage, however, is the necessary reduction in chemotherapy dosage in order to diminish over-lapping toxicities; this can potentially lead to undertreatment of systemic micrometastases. Randomized trials have shown a modest 5-year survival benefit as compared with chemotherapy. In a systematic review of 47 trials and six meta-analyses, an absolute survival benefit of 4% at 2 years was seen when con-current platinum-based chemoradiation was given compared to sequential radiation.77Definitive radiotherapy is predominantly used for pallia-tion of symptoms in patients with poor performance status; cure rates with radiation as a single modality in patients with N2 or N3 disease is less than 7%. Recent improvement has been seen with three-dimensional conformal radiotherapy and altered frac-tionation. Such poor results for patients with stage III lung cancer reflect the limitations of locoregional treatment in a
Surgery_Schwartz_4713	Surgery_Schwartz	been seen with three-dimensional conformal radiotherapy and altered frac-tionation. Such poor results for patients with stage III lung cancer reflect the limitations of locoregional treatment in a disease where death results from systemic metastatic spread.Options for Thoracic Surgical ApproachesThoracic surgical approaches have changed over recent years with advancements in minimally invasive surgery. A surgeon trained in advanced minimally invasive techniques can now perform pleural-based, pulmonary and mediastinal procedures through multiple thoracoscopic ports without the need for a sub-stantial, rib-spreading incision. Subjective measures of quality of life after VATS, such as pain (Fig. 19-26) and perceived functional recovery, consistently and reproducibly favor VATS OpenVATSNoneMildModerateSeverep<0.001Figure 19-26. Pie chart comparison of pain control at 3 weeks after lobectomy by standard thoracotomy or video-assisted tho-racic surgery (VATS). The pie charts show that	Surgery_Schwartz. been seen with three-dimensional conformal radiotherapy and altered frac-tionation. Such poor results for patients with stage III lung cancer reflect the limitations of locoregional treatment in a disease where death results from systemic metastatic spread.Options for Thoracic Surgical ApproachesThoracic surgical approaches have changed over recent years with advancements in minimally invasive surgery. A surgeon trained in advanced minimally invasive techniques can now perform pleural-based, pulmonary and mediastinal procedures through multiple thoracoscopic ports without the need for a sub-stantial, rib-spreading incision. Subjective measures of quality of life after VATS, such as pain (Fig. 19-26) and perceived functional recovery, consistently and reproducibly favor VATS OpenVATSNoneMildModerateSeverep<0.001Figure 19-26. Pie chart comparison of pain control at 3 weeks after lobectomy by standard thoracotomy or video-assisted tho-racic surgery (VATS). The pie charts show that
Surgery_Schwartz_4714	Surgery_Schwartz	19-26. Pie chart comparison of pain control at 3 weeks after lobectomy by standard thoracotomy or video-assisted tho-racic surgery (VATS). The pie charts show that patients undergo-ing VATS have significantly less pain (P <.01) as measured by the most potent analgesic still required: severe—schedule II nar-cotic; moderate—schedule III or lower narcotic; mild–nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen. (Reproduced with permission from Demmy TL, Nwoque C. Is video-assisted thoracic surgery lobectomy better? Quality of life considerations, Ann Thorac Surg. 2008 Feb;85(2):S719-S728.)over thoracotomy. Objective measures such as functional sta-tus as measured by 6-minute walk, return to work, and ability to tolerate chemotherapy also favor VATS over thoracotomy. Finally, recovery of respiratory function occurs earlier in VATS patients. These findings are pronounced in patients with chronic obstructive pulmonary disease and in the elderly—populations whose quality of life	Surgery_Schwartz. 19-26. Pie chart comparison of pain control at 3 weeks after lobectomy by standard thoracotomy or video-assisted tho-racic surgery (VATS). The pie charts show that patients undergo-ing VATS have significantly less pain (P <.01) as measured by the most potent analgesic still required: severe—schedule II nar-cotic; moderate—schedule III or lower narcotic; mild–nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen. (Reproduced with permission from Demmy TL, Nwoque C. Is video-assisted thoracic surgery lobectomy better? Quality of life considerations, Ann Thorac Surg. 2008 Feb;85(2):S719-S728.)over thoracotomy. Objective measures such as functional sta-tus as measured by 6-minute walk, return to work, and ability to tolerate chemotherapy also favor VATS over thoracotomy. Finally, recovery of respiratory function occurs earlier in VATS patients. These findings are pronounced in patients with chronic obstructive pulmonary disease and in the elderly—populations whose quality of life
Surgery_Schwartz_4715	Surgery_Schwartz	of respiratory function occurs earlier in VATS patients. These findings are pronounced in patients with chronic obstructive pulmonary disease and in the elderly—populations whose quality of life can be dramatically impacted by changes in their respiratory symptoms and function, thoracic pain, and physical performance. Table 19-16 provides a summary of pop-ulations that may benefit from VATS approaches.Video-Assisted (VATS)/Robotic-Assisted Thoraco-scopic Surgery (RATS). VATS/RATS has become the rec-ommended approach to diagnosis and treatment of pleural effusions, recurrent pneumothoraces, lung biopsies, lobec-tomy or segmental resection, resection of bronchogenic and mediastinal cysts, and intrathoracic esophageal mobilization for esophagectomy.78 These approaches are also utilized for pneumonectomy in some centers of excellence with very high Table 19-16Special circumstances under which lobectomy by video-assisted thoracic surgery may be preferableCONDITIONEXAMPLESPulmonary	Surgery_Schwartz. of respiratory function occurs earlier in VATS patients. These findings are pronounced in patients with chronic obstructive pulmonary disease and in the elderly—populations whose quality of life can be dramatically impacted by changes in their respiratory symptoms and function, thoracic pain, and physical performance. Table 19-16 provides a summary of pop-ulations that may benefit from VATS approaches.Video-Assisted (VATS)/Robotic-Assisted Thoraco-scopic Surgery (RATS). VATS/RATS has become the rec-ommended approach to diagnosis and treatment of pleural effusions, recurrent pneumothoraces, lung biopsies, lobec-tomy or segmental resection, resection of bronchogenic and mediastinal cysts, and intrathoracic esophageal mobilization for esophagectomy.78 These approaches are also utilized for pneumonectomy in some centers of excellence with very high Table 19-16Special circumstances under which lobectomy by video-assisted thoracic surgery may be preferableCONDITIONEXAMPLESPulmonary
Surgery_Schwartz_4716	Surgery_Schwartz	for pneumonectomy in some centers of excellence with very high Table 19-16Special circumstances under which lobectomy by video-assisted thoracic surgery may be preferableCONDITIONEXAMPLESPulmonary compromisePoor FEV1/Dlco, heavy smoking, sleep apnea, recent pneumoniaCardiac dysfunctionCongestive heart failure, severe coronary artery disease, recent myocardial infarction, valvular diseaseExtrathoracic malignancySolitary brain metastasis from lung cancer, deep pulmonary metastases requiring lobectomyPoor physical performancePerformance status equivalent to a Zubrod score of 2 or 3, morbid obesityRheumatologic/orthopedic conditionSpinal disease, severe rheumatoid arthritis, severe kyphosis, lupus erythematosus, osteomyelitisAdvanced ageAge >70 yearsVascular problemsAneurysm, severe peripheral vascular diseaseRecent or impending major operationUrgent abdominal operation, joint replacement requiring use of crutches, need for contralateral thoracotomyPsychological/neurologic	Surgery_Schwartz. for pneumonectomy in some centers of excellence with very high Table 19-16Special circumstances under which lobectomy by video-assisted thoracic surgery may be preferableCONDITIONEXAMPLESPulmonary compromisePoor FEV1/Dlco, heavy smoking, sleep apnea, recent pneumoniaCardiac dysfunctionCongestive heart failure, severe coronary artery disease, recent myocardial infarction, valvular diseaseExtrathoracic malignancySolitary brain metastasis from lung cancer, deep pulmonary metastases requiring lobectomyPoor physical performancePerformance status equivalent to a Zubrod score of 2 or 3, morbid obesityRheumatologic/orthopedic conditionSpinal disease, severe rheumatoid arthritis, severe kyphosis, lupus erythematosus, osteomyelitisAdvanced ageAge >70 yearsVascular problemsAneurysm, severe peripheral vascular diseaseRecent or impending major operationUrgent abdominal operation, joint replacement requiring use of crutches, need for contralateral thoracotomyPsychological/neurologic
Surgery_Schwartz_4717	Surgery_Schwartz	peripheral vascular diseaseRecent or impending major operationUrgent abdominal operation, joint replacement requiring use of crutches, need for contralateral thoracotomyPsychological/neurologic conditionsSubstance abuse, poor command following, pain syndromesImmunosuppression/ impaired wound healingRecent transplantation, diabetesAbbreviations: Dlco = carbon monoxide diffusion capacity; FEV1 = forced expiratory volume in 1 second.Reproduced with permission from Demmy TL, Nwoque C. Is video-assisted thoracic surgery lobectomy better? Quality of life considerations, Ann Thorac Surg. 2008 Feb;85(2):S719-S728.Brunicardi_Ch19_p0661-p0750.indd 70101/03/19 7:01 PM 702SPECIFIC CONSIDERATIONSPART IIvolumes of VATS lung resection. VATS is performed via two to four incisions measuring 0.5 to 1.2 cm in length to allow insertion of the thoracoscope and instruments. An access incision, typically in the fourth or fifth intercostal space in the anterior axillary line, is used for dissection of	Surgery_Schwartz. peripheral vascular diseaseRecent or impending major operationUrgent abdominal operation, joint replacement requiring use of crutches, need for contralateral thoracotomyPsychological/neurologic conditionsSubstance abuse, poor command following, pain syndromesImmunosuppression/ impaired wound healingRecent transplantation, diabetesAbbreviations: Dlco = carbon monoxide diffusion capacity; FEV1 = forced expiratory volume in 1 second.Reproduced with permission from Demmy TL, Nwoque C. Is video-assisted thoracic surgery lobectomy better? Quality of life considerations, Ann Thorac Surg. 2008 Feb;85(2):S719-S728.Brunicardi_Ch19_p0661-p0750.indd 70101/03/19 7:01 PM 702SPECIFIC CONSIDERATIONSPART IIvolumes of VATS lung resection. VATS is performed via two to four incisions measuring 0.5 to 1.2 cm in length to allow insertion of the thoracoscope and instruments. An access incision, typically in the fourth or fifth intercostal space in the anterior axillary line, is used for dissection of
Surgery_Schwartz_4718	Surgery_Schwartz	cm in length to allow insertion of the thoracoscope and instruments. An access incision, typically in the fourth or fifth intercostal space in the anterior axillary line, is used for dissection of the hilum during lung resection. The incision location varies accord-ing to the procedure. With respect to VATS lobectomy, port placement varies according to the lobe being resected and is highly variable among surgeons.79 The basic principle is to position the ports high enough on the thoracic cage to have access to the hilar structures. Endoscopic staplers are used to divide the major vascular structures and bronchus (Fig. 19-27). Robotic approaches are similarly tailored to the side and lobe under-going resection, with the entire operation performed using DissectBADCERetractRetractRetractRetractRetractViewViewViewViewHoldViewDissectFigure 19-27. Selected video-assisted thoracic surgery lobectomy maneuvers. All the maneuvers are shown with the patient positioned in the left lateral	Surgery_Schwartz. cm in length to allow insertion of the thoracoscope and instruments. An access incision, typically in the fourth or fifth intercostal space in the anterior axillary line, is used for dissection of the hilum during lung resection. The incision location varies accord-ing to the procedure. With respect to VATS lobectomy, port placement varies according to the lobe being resected and is highly variable among surgeons.79 The basic principle is to position the ports high enough on the thoracic cage to have access to the hilar structures. Endoscopic staplers are used to divide the major vascular structures and bronchus (Fig. 19-27). Robotic approaches are similarly tailored to the side and lobe under-going resection, with the entire operation performed using DissectBADCERetractRetractRetractRetractRetractViewViewViewViewHoldViewDissectFigure 19-27. Selected video-assisted thoracic surgery lobectomy maneuvers. All the maneuvers are shown with the patient positioned in the left lateral
Surgery_Schwartz_4719	Surgery_Schwartz	19-27. Selected video-assisted thoracic surgery lobectomy maneuvers. All the maneuvers are shown with the patient positioned in the left lateral decubitus position. The same maneuvers can be performed in mirror image for left-sided work. A. Medial viewing and inferior holding of lung to allow dissection through the access incision. Example shows dissection of the apical hilum. B. Medial viewing and access holding of lung to allow stapling of hilar structures from below. Example shows division of the apical pulmonary artery trunk to the right upper lobe (upper lobe branch of vein divided and reflected away). C. Standard viewing and use of working port to dissect and divide structures while lung is retracted through access incision. Example shows use of stapler to divide pulmonary artery to right lower lobe. D. Standard viewing and use of working port to retract lung and access incision to dissect structures. This method is commonly used to dis-sect the pulmonary artery in the major	Surgery_Schwartz. 19-27. Selected video-assisted thoracic surgery lobectomy maneuvers. All the maneuvers are shown with the patient positioned in the left lateral decubitus position. The same maneuvers can be performed in mirror image for left-sided work. A. Medial viewing and inferior holding of lung to allow dissection through the access incision. Example shows dissection of the apical hilum. B. Medial viewing and access holding of lung to allow stapling of hilar structures from below. Example shows division of the apical pulmonary artery trunk to the right upper lobe (upper lobe branch of vein divided and reflected away). C. Standard viewing and use of working port to dissect and divide structures while lung is retracted through access incision. Example shows use of stapler to divide pulmonary artery to right lower lobe. D. Standard viewing and use of working port to retract lung and access incision to dissect structures. This method is commonly used to dis-sect the pulmonary artery in the major
Surgery_Schwartz_4720	Surgery_Schwartz	to right lower lobe. D. Standard viewing and use of working port to retract lung and access incision to dissect structures. This method is commonly used to dis-sect the pulmonary artery in the major fissure. Example shows inferior pulmonary vein after the pulmonary ligament was divided using this maneuver. E. Standard viewing and use of access incision to deliver stapler to divide fissures. Example shows division of the posterior fissure between the right lower lobe and the upper lobe.Brunicardi_Ch19_p0661-p0750.indd 70201/03/19 7:01 PM	Surgery_Schwartz. to right lower lobe. D. Standard viewing and use of working port to retract lung and access incision to dissect structures. This method is commonly used to dis-sect the pulmonary artery in the major fissure. Example shows inferior pulmonary vein after the pulmonary ligament was divided using this maneuver. E. Standard viewing and use of access incision to deliver stapler to divide fissures. Example shows division of the posterior fissure between the right lower lobe and the upper lobe.Brunicardi_Ch19_p0661-p0750.indd 70201/03/19 7:01 PM
Surgery_Schwartz_4721	Surgery_Schwartz	CHAPTER 19703CHEST WALL, LUNG, MEDIASTINUM, AND PLEURATrapeziusLatissimus dorsidividedLatissimus dorsiBADCSerratus anterior5th rib6th ribRhomboidmajorScapularetractedIncisionTrapeziusrobotic arms, except for one assistant port through which spec-imens can be removed and suctioning and stapling performed (in early models; the newest robotic models have robotic sta-plers, allowing the surgeon to have complete control of the entire operation).Open Approaches to Thoracic Surgery. When a thoraco-scopic approach is not possible, an open approach, most fre-quently the posterolateral thoracotomy, is used to gain access to the intrathoracic space.80,81 The posterolateral thoracotomy incision can be used for most pulmonary resections, esopha-geal operations, and operations in the posterior mediastinum and vertebral column (Fig. 19-28). The anterolateral thora-cotomy has traditionally been used in trauma victims. This approach allows quick entry into the chest with the patient supine. In the	Surgery_Schwartz. CHAPTER 19703CHEST WALL, LUNG, MEDIASTINUM, AND PLEURATrapeziusLatissimus dorsidividedLatissimus dorsiBADCSerratus anterior5th rib6th ribRhomboidmajorScapularetractedIncisionTrapeziusrobotic arms, except for one assistant port through which spec-imens can be removed and suctioning and stapling performed (in early models; the newest robotic models have robotic sta-plers, allowing the surgeon to have complete control of the entire operation).Open Approaches to Thoracic Surgery. When a thoraco-scopic approach is not possible, an open approach, most fre-quently the posterolateral thoracotomy, is used to gain access to the intrathoracic space.80,81 The posterolateral thoracotomy incision can be used for most pulmonary resections, esopha-geal operations, and operations in the posterior mediastinum and vertebral column (Fig. 19-28). The anterolateral thora-cotomy has traditionally been used in trauma victims. This approach allows quick entry into the chest with the patient supine. In the
Surgery_Schwartz_4722	Surgery_Schwartz	and vertebral column (Fig. 19-28). The anterolateral thora-cotomy has traditionally been used in trauma victims. This approach allows quick entry into the chest with the patient supine. In the face of hemodynamic instability, the lateral decubitus position significantly compromises control over the patient’s cardiopulmonary system and resuscitation efforts, whereas the supine position allows the anesthesiologist full access to the patient. A bilateral anterior thoracotomy incision with a transverse sternotomy (“clamshell” thoracotomy) is a standard operative approach to the heart and mediastinum in certain elective circumstances. It is the preferred incision for double-lung transplantation in many centers. A partial median sternotomy can also be added to an anterior thoracotomy (“trap-door” or “hemiclamshell” thoracotomy) for access to mediastinal structures. A hypesthetic nipple is a frequent com-plication of this approach. The median sternotomy incision allows exposure of anterior	Surgery_Schwartz. and vertebral column (Fig. 19-28). The anterolateral thora-cotomy has traditionally been used in trauma victims. This approach allows quick entry into the chest with the patient supine. In the face of hemodynamic instability, the lateral decubitus position significantly compromises control over the patient’s cardiopulmonary system and resuscitation efforts, whereas the supine position allows the anesthesiologist full access to the patient. A bilateral anterior thoracotomy incision with a transverse sternotomy (“clamshell” thoracotomy) is a standard operative approach to the heart and mediastinum in certain elective circumstances. It is the preferred incision for double-lung transplantation in many centers. A partial median sternotomy can also be added to an anterior thoracotomy (“trap-door” or “hemiclamshell” thoracotomy) for access to mediastinal structures. A hypesthetic nipple is a frequent com-plication of this approach. The median sternotomy incision allows exposure of anterior
Surgery_Schwartz_4723	Surgery_Schwartz	or “hemiclamshell” thoracotomy) for access to mediastinal structures. A hypesthetic nipple is a frequent com-plication of this approach. The median sternotomy incision allows exposure of anterior mediastinal structures and is prin-cipally used for cardiac operations. Although the surgeon has access to both pleural cavities, incision into the pleural cavity can be avoided if entry is unnecessary (Fig. 19-29).Postoperative CareChest Tube Management. At the conclusion of most thoracic operations, the pleural cavity is drained with a chest tube(s). If the visceral pleura has not been violated and there is no concern Figure 19-28. The posterolateral thoracotomy incision. A. Skin incision from the anterior axillary line to the lower extent of the scapula tip. B and C. Division of the latissimus dorsi and shoulder girdle musculature. D. The pleural cavity is entered after dividing the intercostal muscles along the lower margin of the interspace, taking care not to injure the neurovascular	Surgery_Schwartz. or “hemiclamshell” thoracotomy) for access to mediastinal structures. A hypesthetic nipple is a frequent com-plication of this approach. The median sternotomy incision allows exposure of anterior mediastinal structures and is prin-cipally used for cardiac operations. Although the surgeon has access to both pleural cavities, incision into the pleural cavity can be avoided if entry is unnecessary (Fig. 19-29).Postoperative CareChest Tube Management. At the conclusion of most thoracic operations, the pleural cavity is drained with a chest tube(s). If the visceral pleura has not been violated and there is no concern Figure 19-28. The posterolateral thoracotomy incision. A. Skin incision from the anterior axillary line to the lower extent of the scapula tip. B and C. Division of the latissimus dorsi and shoulder girdle musculature. D. The pleural cavity is entered after dividing the intercostal muscles along the lower margin of the interspace, taking care not to injure the neurovascular
Surgery_Schwartz_4724	Surgery_Schwartz	dorsi and shoulder girdle musculature. D. The pleural cavity is entered after dividing the intercostal muscles along the lower margin of the interspace, taking care not to injure the neurovascular bundle lying below each rib.Brunicardi_Ch19_p0661-p0750.indd 70301/03/19 7:01 PM 704SPECIFIC CONSIDERATIONSPART IIABThymusR. atrialappendageR. ventriclePreperitonealfatDiaphragmL. atrialappendageAortic archInnominate v.Pulmonary a.Figure 19-29. The median sternotomy incision. A. Skin incision from the suprasternal notch to the xiphoid process. B. Exposure of the pleural space. a. = artery; v. = vein.for pneumoor hemothorax (e.g., after VATS sympathectomy), a chest tube is unnecessary. After chest tube placement, the lung is reexpanded with positive-pressure ventilation. There are two reasons for the use of pleural tubes in this setting: first, the tube allows evacuation of air if an air leak is present; sec-ond, blood and pleural fluid can be drained, thereby preventing accumulation	Surgery_Schwartz. dorsi and shoulder girdle musculature. D. The pleural cavity is entered after dividing the intercostal muscles along the lower margin of the interspace, taking care not to injure the neurovascular bundle lying below each rib.Brunicardi_Ch19_p0661-p0750.indd 70301/03/19 7:01 PM 704SPECIFIC CONSIDERATIONSPART IIABThymusR. atrialappendageR. ventriclePreperitonealfatDiaphragmL. atrialappendageAortic archInnominate v.Pulmonary a.Figure 19-29. The median sternotomy incision. A. Skin incision from the suprasternal notch to the xiphoid process. B. Exposure of the pleural space. a. = artery; v. = vein.for pneumoor hemothorax (e.g., after VATS sympathectomy), a chest tube is unnecessary. After chest tube placement, the lung is reexpanded with positive-pressure ventilation. There are two reasons for the use of pleural tubes in this setting: first, the tube allows evacuation of air if an air leak is present; sec-ond, blood and pleural fluid can be drained, thereby preventing accumulation
Surgery_Schwartz_4725	Surgery_Schwartz	for the use of pleural tubes in this setting: first, the tube allows evacuation of air if an air leak is present; sec-ond, blood and pleural fluid can be drained, thereby preventing accumulation within the pleural space that would compromise the patient’s respiratory status. The tube is removed when the air leak is resolved and when the volume of drainage decreases below an acceptable level over 24 hours.Historically, many surgeons have somewhat arbitrarily required less than 150 mL of drainage volume over 24 hours prior to removing a chest tube to minimize risk of reaccu-mulation. The pleural lymphatics, however, can absorb up to 0.40 mL/kg per hour in a healthy individual, which may be as much as 500 mL over a 24-hour period. In fact, studies have shown that pleural tubes can be removed after VATS lobec-tomy or thoracotomy with 24-hour drainage volumes as high as 400 mL, without subsequent development of pleural effusions.82 It is our current practice to remove chest tubes with	Surgery_Schwartz. for the use of pleural tubes in this setting: first, the tube allows evacuation of air if an air leak is present; sec-ond, blood and pleural fluid can be drained, thereby preventing accumulation within the pleural space that would compromise the patient’s respiratory status. The tube is removed when the air leak is resolved and when the volume of drainage decreases below an acceptable level over 24 hours.Historically, many surgeons have somewhat arbitrarily required less than 150 mL of drainage volume over 24 hours prior to removing a chest tube to minimize risk of reaccu-mulation. The pleural lymphatics, however, can absorb up to 0.40 mL/kg per hour in a healthy individual, which may be as much as 500 mL over a 24-hour period. In fact, studies have shown that pleural tubes can be removed after VATS lobec-tomy or thoracotomy with 24-hour drainage volumes as high as 400 mL, without subsequent development of pleural effusions.82 It is our current practice to remove chest tubes with
Surgery_Schwartz_4726	Surgery_Schwartz	after VATS lobec-tomy or thoracotomy with 24-hour drainage volumes as high as 400 mL, without subsequent development of pleural effusions.82 It is our current practice to remove chest tubes with 24-hour outputs of 400 mL or less after lobectomy or lesser pulmonary resections. In settings where normal pleural fluid dynamics have been altered, such as malignant pleural effusion, pleural space infections or inflammation, and pleurodesis, strict adherence to a volume requirement before tube removal is appropriate (typi-cally 100 to 150 mL over 24 hours).For operations involving lung resection or parenchymal injury, suction levels of –20 cm H2O are routinely used to eradi-cate residual air spaces and to control postoperative parenchy-mal air leaks for the first 12 to 24 hours. The following day, however, the decision to continue suction or place the patient to water seal (off suction) must be made. Applying suction to an air leak has been shown to prolong the duration of the air leak and	Surgery_Schwartz. after VATS lobec-tomy or thoracotomy with 24-hour drainage volumes as high as 400 mL, without subsequent development of pleural effusions.82 It is our current practice to remove chest tubes with 24-hour outputs of 400 mL or less after lobectomy or lesser pulmonary resections. In settings where normal pleural fluid dynamics have been altered, such as malignant pleural effusion, pleural space infections or inflammation, and pleurodesis, strict adherence to a volume requirement before tube removal is appropriate (typi-cally 100 to 150 mL over 24 hours).For operations involving lung resection or parenchymal injury, suction levels of –20 cm H2O are routinely used to eradi-cate residual air spaces and to control postoperative parenchy-mal air leaks for the first 12 to 24 hours. The following day, however, the decision to continue suction or place the patient to water seal (off suction) must be made. Applying suction to an air leak has been shown to prolong the duration of the air leak and
Surgery_Schwartz_4727	Surgery_Schwartz	however, the decision to continue suction or place the patient to water seal (off suction) must be made. Applying suction to an air leak has been shown to prolong the duration of the air leak and extend the time frame during which tube thoracostomy is needed.83 The main guidelines for the continued use of suction if an air leak is present depend on the expansion of the remain-ing lung as determined by CXR. If the lung is well expanded, the chest tube can remain to water seal drainage. If an und-rained pneumothorax is present on CXR, the chest tube and its attached tubing should be examined to ensure that the chest tube is patent and the attached tubing is not kinked or mechanically obstructed, such as occurs when the patient is lying on the tube. If the tube is a small caliber tube (pigtail catheter), it should be flushed with sterile saline through a three-way stopcock that has been cleaned with alcohol because these tubes tend to become clogged with fibrin. These catheters are also	Surgery_Schwartz. however, the decision to continue suction or place the patient to water seal (off suction) must be made. Applying suction to an air leak has been shown to prolong the duration of the air leak and extend the time frame during which tube thoracostomy is needed.83 The main guidelines for the continued use of suction if an air leak is present depend on the expansion of the remain-ing lung as determined by CXR. If the lung is well expanded, the chest tube can remain to water seal drainage. If an und-rained pneumothorax is present on CXR, the chest tube and its attached tubing should be examined to ensure that the chest tube is patent and the attached tubing is not kinked or mechanically obstructed, such as occurs when the patient is lying on the tube. If the tube is a small caliber tube (pigtail catheter), it should be flushed with sterile saline through a three-way stopcock that has been cleaned with alcohol because these tubes tend to become clogged with fibrin. These catheters are also
Surgery_Schwartz_4728	Surgery_Schwartz	catheter), it should be flushed with sterile saline through a three-way stopcock that has been cleaned with alcohol because these tubes tend to become clogged with fibrin. These catheters are also prone to kinking at the insertion site into the skin. Once the surgeon has con-firmed that the chest tube is patent, the patient is asked to volun-tarily cough or perform the Valsalva maneuver. This maneuver increases the intrathoracic pressure and will push air that is contained within the hemithorax out of the chest tube. During the voluntary cough, the fluid level in the water seal chamber should move up and down with the cough and with deep respira-tion, reflecting the pleural pressure changes occurring with these maneuvers. A stationary fluid level implies either a mechanical blockage (e.g., due to external tube compression or to a clot/debris within the tube) or pleurodesis. If bubbles pass through the water seal chamber, an air leak is presumed. If the leak is significant enough to	Surgery_Schwartz. catheter), it should be flushed with sterile saline through a three-way stopcock that has been cleaned with alcohol because these tubes tend to become clogged with fibrin. These catheters are also prone to kinking at the insertion site into the skin. Once the surgeon has con-firmed that the chest tube is patent, the patient is asked to volun-tarily cough or perform the Valsalva maneuver. This maneuver increases the intrathoracic pressure and will push air that is contained within the hemithorax out of the chest tube. During the voluntary cough, the fluid level in the water seal chamber should move up and down with the cough and with deep respira-tion, reflecting the pleural pressure changes occurring with these maneuvers. A stationary fluid level implies either a mechanical blockage (e.g., due to external tube compression or to a clot/debris within the tube) or pleurodesis. If bubbles pass through the water seal chamber, an air leak is presumed. If the leak is significant enough to
Surgery_Schwartz_4729	Surgery_Schwartz	due to external tube compression or to a clot/debris within the tube) or pleurodesis. If bubbles pass through the water seal chamber, an air leak is presumed. If the leak is significant enough to induce atelectasis or collapse of the lung during use of water seal, suction should be used to achieve lung reexpansion.Pain Control. Good pain control after intrathoracic proce-dures is critical; it permits the patient to actively clear and manage secretions and promotes ambulation and a feeling of well-being. The most common techniques of pain management are epidural, paravertebral, and intravenous. Epidural catheters are commonly used, although we prefer to use paravertebral catheters in our center. Epidural catheters should be inserted at about the T6 level, roughly at the level of the scapular tip. Lower placement risks inadequate pain control, and higher placement may provoke hand and arm numbness. Typically, combinations of fentanyl at 0.3 µg/mL with either bupivacaine (0.125%) or	Surgery_Schwartz. due to external tube compression or to a clot/debris within the tube) or pleurodesis. If bubbles pass through the water seal chamber, an air leak is presumed. If the leak is significant enough to induce atelectasis or collapse of the lung during use of water seal, suction should be used to achieve lung reexpansion.Pain Control. Good pain control after intrathoracic proce-dures is critical; it permits the patient to actively clear and manage secretions and promotes ambulation and a feeling of well-being. The most common techniques of pain management are epidural, paravertebral, and intravenous. Epidural catheters are commonly used, although we prefer to use paravertebral catheters in our center. Epidural catheters should be inserted at about the T6 level, roughly at the level of the scapular tip. Lower placement risks inadequate pain control, and higher placement may provoke hand and arm numbness. Typically, combinations of fentanyl at 0.3 µg/mL with either bupivacaine (0.125%) or
Surgery_Schwartz_4730	Surgery_Schwartz	tip. Lower placement risks inadequate pain control, and higher placement may provoke hand and arm numbness. Typically, combinations of fentanyl at 0.3 µg/mL with either bupivacaine (0.125%) or ropivacaine (0.1%) are used. Ropivacaine has less cardiotoxicity than bupivacaine; thus, in the case of inadver-tent intravenous injection, the potential for refractory complete heart block is significantly less with ropivacaine. Paravertebral blocks can be placed using the same epidural catheter kit 2.5 cm lateral to the spinous process at T4 to T6. Combinations of narcotic and topical analgesia are then infused as with the epi-dural catheter.When properly placed, a well-managed epidural can provide outstanding pain control without significant systemic sedation.84 Thoracic epidurals do not commonly cause urinary retention, although a low thoracic epidural may block the sen-sory fibers to the bladder. Motor function, however, remains intact. In some patients who are having difficulty voiding,	Surgery_Schwartz. tip. Lower placement risks inadequate pain control, and higher placement may provoke hand and arm numbness. Typically, combinations of fentanyl at 0.3 µg/mL with either bupivacaine (0.125%) or ropivacaine (0.1%) are used. Ropivacaine has less cardiotoxicity than bupivacaine; thus, in the case of inadver-tent intravenous injection, the potential for refractory complete heart block is significantly less with ropivacaine. Paravertebral blocks can be placed using the same epidural catheter kit 2.5 cm lateral to the spinous process at T4 to T6. Combinations of narcotic and topical analgesia are then infused as with the epi-dural catheter.When properly placed, a well-managed epidural can provide outstanding pain control without significant systemic sedation.84 Thoracic epidurals do not commonly cause urinary retention, although a low thoracic epidural may block the sen-sory fibers to the bladder. Motor function, however, remains intact. In some patients who are having difficulty voiding,
Surgery_Schwartz_4731	Surgery_Schwartz	cause urinary retention, although a low thoracic epidural may block the sen-sory fibers to the bladder. Motor function, however, remains intact. In some patients who are having difficulty voiding, it Brunicardi_Ch19_p0661-p0750.indd 70401/03/19 7:01 PM	Surgery_Schwartz. cause urinary retention, although a low thoracic epidural may block the sen-sory fibers to the bladder. Motor function, however, remains intact. In some patients who are having difficulty voiding, it Brunicardi_Ch19_p0661-p0750.indd 70401/03/19 7:01 PM
Surgery_Schwartz_4732	Surgery_Schwartz	CHAPTER 19705CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAmay be possible to avoid Foley catheterization by simply reminding the patient to void on a regular basis. In male patients with voiding difficulty prior to surgery, urinary catheterization may be required. In addition, the use of local anesthetics may cause sympathetic outflow blockade, leading to vasodilation and hypotension often requiring intravenous vasoconstrictors (an α-agonist such as phenylephrine) and/or fluid administration. In such circumstances, fluid administration for hypotension may be undesirable in pulmonary surgery patients, particularly after pneumonectomy. Paravertebral catheters provide equivalent pain control with less effect on hemodynamics.85 Recently, lipo-somal bupivacaine was introduced and has become the standard approach to pain management after thoracic surgery in several centers. The formulation allows for slow-release of bupivacaine for up to 72 hours after injection. Injected directly into the	Surgery_Schwartz. CHAPTER 19705CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAmay be possible to avoid Foley catheterization by simply reminding the patient to void on a regular basis. In male patients with voiding difficulty prior to surgery, urinary catheterization may be required. In addition, the use of local anesthetics may cause sympathetic outflow blockade, leading to vasodilation and hypotension often requiring intravenous vasoconstrictors (an α-agonist such as phenylephrine) and/or fluid administration. In such circumstances, fluid administration for hypotension may be undesirable in pulmonary surgery patients, particularly after pneumonectomy. Paravertebral catheters provide equivalent pain control with less effect on hemodynamics.85 Recently, lipo-somal bupivacaine was introduced and has become the standard approach to pain management after thoracic surgery in several centers. The formulation allows for slow-release of bupivacaine for up to 72 hours after injection. Injected directly into the
Surgery_Schwartz_4733	Surgery_Schwartz	standard approach to pain management after thoracic surgery in several centers. The formulation allows for slow-release of bupivacaine for up to 72 hours after injection. Injected directly into the inter-costal spaces immediately prior to chest closure, the formulation has shown great promise in several retrospective reports, with randomized trials not yet completed. One limiting factor in use of the formulation is the cost; future trials are needed, with cost-analysis, to determine whether the benefits in pain, reduction in narcotic use, shorter hospital stay and possibly decreased pul-monary complications justify the cost.Alternatively, intravenous narcotics via patient-controlled analgesia can be used, often in conjunction with ketorolac, gabapentin, and intravenous Tylenol. Dosing must be titrated to balance the degree of pain relief with the degree of seda-tion. Oversedated patients are as ominous as patients without adequate pain control because of the significant risk of	Surgery_Schwartz. standard approach to pain management after thoracic surgery in several centers. The formulation allows for slow-release of bupivacaine for up to 72 hours after injection. Injected directly into the inter-costal spaces immediately prior to chest closure, the formulation has shown great promise in several retrospective reports, with randomized trials not yet completed. One limiting factor in use of the formulation is the cost; future trials are needed, with cost-analysis, to determine whether the benefits in pain, reduction in narcotic use, shorter hospital stay and possibly decreased pul-monary complications justify the cost.Alternatively, intravenous narcotics via patient-controlled analgesia can be used, often in conjunction with ketorolac, gabapentin, and intravenous Tylenol. Dosing must be titrated to balance the degree of pain relief with the degree of seda-tion. Oversedated patients are as ominous as patients without adequate pain control because of the significant risk of
Surgery_Schwartz_4734	Surgery_Schwartz	must be titrated to balance the degree of pain relief with the degree of seda-tion. Oversedated patients are as ominous as patients without adequate pain control because of the significant risk of secre-tion retention, atelectasis/pneumonia, and pulmonary aspiration, especially in elderly patients who should be carefully assessed for aspiration risk when ordered for dietary advancement. Proper pain control with intravenous narcotics requires a care-fully regulated balance of pain relief and sedation to maximize the benefits of pain control while minimizing these very real and potentially life-threatening complications.Whether on epidural, paravertebral, or intravenous pain control, the patient is typically transitioned to oral pain medica-tion on the third or fourth postoperative day. During both the parenteral and oral phase of pain management, a standardized regimen of stool softeners and laxatives is advisable in order to prevent severe constipation.Respiratory Care. The best	Surgery_Schwartz. must be titrated to balance the degree of pain relief with the degree of seda-tion. Oversedated patients are as ominous as patients without adequate pain control because of the significant risk of secre-tion retention, atelectasis/pneumonia, and pulmonary aspiration, especially in elderly patients who should be carefully assessed for aspiration risk when ordered for dietary advancement. Proper pain control with intravenous narcotics requires a care-fully regulated balance of pain relief and sedation to maximize the benefits of pain control while minimizing these very real and potentially life-threatening complications.Whether on epidural, paravertebral, or intravenous pain control, the patient is typically transitioned to oral pain medica-tion on the third or fourth postoperative day. During both the parenteral and oral phase of pain management, a standardized regimen of stool softeners and laxatives is advisable in order to prevent severe constipation.Respiratory Care. The best
Surgery_Schwartz_4735	Surgery_Schwartz	During both the parenteral and oral phase of pain management, a standardized regimen of stool softeners and laxatives is advisable in order to prevent severe constipation.Respiratory Care. The best respiratory care is achieved when the patient is able to deliver an effective cough to clear secre-tions and results from the commitment and proper training of all involved healthcare providers. The process begins preopera-tively, with clear instructions on using pillows (or other support techniques) over the wound and then applying pressure.Postoperatively, proper pain control without oversedation (as outlined earlier) is essential. Daily morning rounds should include a careful assessment of the patient’s pulmonary status, reminders to the patient and family about the importance of coughing and deep breathing, including use of adjunctive respi-ratory equipment if ordered, and mobilization of the patient. Early transition to a chair and to ambulation is the best respira-tory therapy and	Surgery_Schwartz. During both the parenteral and oral phase of pain management, a standardized regimen of stool softeners and laxatives is advisable in order to prevent severe constipation.Respiratory Care. The best respiratory care is achieved when the patient is able to deliver an effective cough to clear secre-tions and results from the commitment and proper training of all involved healthcare providers. The process begins preopera-tively, with clear instructions on using pillows (or other support techniques) over the wound and then applying pressure.Postoperatively, proper pain control without oversedation (as outlined earlier) is essential. Daily morning rounds should include a careful assessment of the patient’s pulmonary status, reminders to the patient and family about the importance of coughing and deep breathing, including use of adjunctive respi-ratory equipment if ordered, and mobilization of the patient. Early transition to a chair and to ambulation is the best respira-tory therapy and
Surgery_Schwartz_4736	Surgery_Schwartz	and deep breathing, including use of adjunctive respi-ratory equipment if ordered, and mobilization of the patient. Early transition to a chair and to ambulation is the best respira-tory therapy and should be strongly encouraged. When avail-able, physical and/or cardiopulmonary rehabilitation services are vital additional members of the care team.Postoperative ComplicationsPostoperative complications after pulmonary resection range from minor to life-threatening. Strict attention to volume sta-tus, early and aggressive pulmonary toilet, and good pain control can reduce the risk of most complications, but does not completely eliminate them, even in centers of excellence. The most devastating complication after pulmonary resection is postpneumonectomy pulmonary edema, which occurs in 1% to 5% of patients undergoing pneumonectomy and more often after right compared to left pneumonectomy. Clinically, symp-toms of respiratory distress manifest hours to days after sur-gery.	Surgery_Schwartz. and deep breathing, including use of adjunctive respi-ratory equipment if ordered, and mobilization of the patient. Early transition to a chair and to ambulation is the best respira-tory therapy and should be strongly encouraged. When avail-able, physical and/or cardiopulmonary rehabilitation services are vital additional members of the care team.Postoperative ComplicationsPostoperative complications after pulmonary resection range from minor to life-threatening. Strict attention to volume sta-tus, early and aggressive pulmonary toilet, and good pain control can reduce the risk of most complications, but does not completely eliminate them, even in centers of excellence. The most devastating complication after pulmonary resection is postpneumonectomy pulmonary edema, which occurs in 1% to 5% of patients undergoing pneumonectomy and more often after right compared to left pneumonectomy. Clinically, symp-toms of respiratory distress manifest hours to days after sur-gery.
Surgery_Schwartz_4737	Surgery_Schwartz	occurs in 1% to 5% of patients undergoing pneumonectomy and more often after right compared to left pneumonectomy. Clinically, symp-toms of respiratory distress manifest hours to days after sur-gery. Radiographically, diffuse interstitial infiltration or frank alveolar edema is seen. The pathophysiologic causes are related increased permeability and filtration pressure and decreased lymphatic drainage from the affected lung. Judicious use of intravenous fluids perioperatively, including use of vasopres-sors rather than fluid boluses for hypotension intraand post-operatively, is critical to minimizing the risk of this syndrome. Treatment consists of ventilatory support, fluid restriction, and diuretics. Extracorporeal membrane oxygenation may be life-saving in centers where this option is available. The syndrome reportedly has a nearly 100% mortality rate despite aggressive therapy.Other postoperative complications include air leak and bronchopleural fistula. Although these are two	Surgery_Schwartz. occurs in 1% to 5% of patients undergoing pneumonectomy and more often after right compared to left pneumonectomy. Clinically, symp-toms of respiratory distress manifest hours to days after sur-gery. Radiographically, diffuse interstitial infiltration or frank alveolar edema is seen. The pathophysiologic causes are related increased permeability and filtration pressure and decreased lymphatic drainage from the affected lung. Judicious use of intravenous fluids perioperatively, including use of vasopres-sors rather than fluid boluses for hypotension intraand post-operatively, is critical to minimizing the risk of this syndrome. Treatment consists of ventilatory support, fluid restriction, and diuretics. Extracorporeal membrane oxygenation may be life-saving in centers where this option is available. The syndrome reportedly has a nearly 100% mortality rate despite aggressive therapy.Other postoperative complications include air leak and bronchopleural fistula. Although these are two
Surgery_Schwartz_4738	Surgery_Schwartz	is available. The syndrome reportedly has a nearly 100% mortality rate despite aggressive therapy.Other postoperative complications include air leak and bronchopleural fistula. Although these are two very differ-ent problems, distinguishing between them may be difficult. Postoperative air leaks are common after pulmonary resection, particularly in patients with emphysematous lung, because the fibrosis and destroyed blood supply impairs healing of surface injuries. Prolonged air leaks (i.e., those lasting >5 days) may be treated by diminishing or discontinuing suction (if used), by continuing chest drainage, or by instilling a pleurodesis agent, usually doxycycline or talcum powder, which will cause pleurodesis of the lung within the chest cavity and minimize the possible collapse of the lung due to persistent air leak. This is useful only in patients in whom full lung expansion is achieved, either with suction or on water seal, as patients with a persistent pneumothorax on CXR will	Surgery_Schwartz. is available. The syndrome reportedly has a nearly 100% mortality rate despite aggressive therapy.Other postoperative complications include air leak and bronchopleural fistula. Although these are two very differ-ent problems, distinguishing between them may be difficult. Postoperative air leaks are common after pulmonary resection, particularly in patients with emphysematous lung, because the fibrosis and destroyed blood supply impairs healing of surface injuries. Prolonged air leaks (i.e., those lasting >5 days) may be treated by diminishing or discontinuing suction (if used), by continuing chest drainage, or by instilling a pleurodesis agent, usually doxycycline or talcum powder, which will cause pleurodesis of the lung within the chest cavity and minimize the possible collapse of the lung due to persistent air leak. This is useful only in patients in whom full lung expansion is achieved, either with suction or on water seal, as patients with a persistent pneumothorax on CXR will
Surgery_Schwartz_4739	Surgery_Schwartz	lung due to persistent air leak. This is useful only in patients in whom full lung expansion is achieved, either with suction or on water seal, as patients with a persistent pneumothorax on CXR will not have adequate lung-to-parietal pleural apposition to achieve adequate pleurodesis.If the leak is moderate to large, a high index of suspicion for bronchopleural fistula from the resected bronchial stump should be maintained, particularly if the patient is immunocom-promised or had induction chemoand/or radiation therapy. If suspected, flexible bronchoscopy is performed to evaluate the bronchial stump. Management options include continued pro-longed chest tube drainage, reoperation, and reclosure (with stump reinforcement with intercostal or pedicled serratus mus-cle flap). If the fistula is very small (<4 mm), bronchoscopic fibrin glue application has been used successfully to seal the hole in some patients. Patients often have concomitant empy-ema, and open drainage may be	Surgery_Schwartz. lung due to persistent air leak. This is useful only in patients in whom full lung expansion is achieved, either with suction or on water seal, as patients with a persistent pneumothorax on CXR will not have adequate lung-to-parietal pleural apposition to achieve adequate pleurodesis.If the leak is moderate to large, a high index of suspicion for bronchopleural fistula from the resected bronchial stump should be maintained, particularly if the patient is immunocom-promised or had induction chemoand/or radiation therapy. If suspected, flexible bronchoscopy is performed to evaluate the bronchial stump. Management options include continued pro-longed chest tube drainage, reoperation, and reclosure (with stump reinforcement with intercostal or pedicled serratus mus-cle flap). If the fistula is very small (<4 mm), bronchoscopic fibrin glue application has been used successfully to seal the hole in some patients. Patients often have concomitant empy-ema, and open drainage may be
Surgery_Schwartz_4740	Surgery_Schwartz	fistula is very small (<4 mm), bronchoscopic fibrin glue application has been used successfully to seal the hole in some patients. Patients often have concomitant empy-ema, and open drainage may be necessary.Spontaneous PneumothoraxSpontaneous pneumothorax is secondary to intrinsic abnormali-ties of the lung and can be classified as primary and secondary. Primary spontaneous pneumothorax is defined as a spontaneous pneumothorax without underlying lung disease. The most com-mon cause is rupture of an apical subpleural bleb. The cause of these blebs is unknown, but they occur more frequently in smokers and males, and they tend to predominate in young postadolescent males with a tall thin body habitus. Treatment is generally chest tube insertion with water seal. If a leak is present and persists for greater than 3 days, thoracoscopic man-agement (i.e., bleb resection with pleurodesis by talc or pleural abrasion) is performed. Recurrences or complete lung collapse with the first episode	Surgery_Schwartz. fistula is very small (<4 mm), bronchoscopic fibrin glue application has been used successfully to seal the hole in some patients. Patients often have concomitant empy-ema, and open drainage may be necessary.Spontaneous PneumothoraxSpontaneous pneumothorax is secondary to intrinsic abnormali-ties of the lung and can be classified as primary and secondary. Primary spontaneous pneumothorax is defined as a spontaneous pneumothorax without underlying lung disease. The most com-mon cause is rupture of an apical subpleural bleb. The cause of these blebs is unknown, but they occur more frequently in smokers and males, and they tend to predominate in young postadolescent males with a tall thin body habitus. Treatment is generally chest tube insertion with water seal. If a leak is present and persists for greater than 3 days, thoracoscopic man-agement (i.e., bleb resection with pleurodesis by talc or pleural abrasion) is performed. Recurrences or complete lung collapse with the first episode
Surgery_Schwartz_4741	Surgery_Schwartz	for greater than 3 days, thoracoscopic man-agement (i.e., bleb resection with pleurodesis by talc or pleural abrasion) is performed. Recurrences or complete lung collapse with the first episode are generally indications for thoracoscopic Brunicardi_Ch19_p0661-p0750.indd 70501/03/19 7:01 PM 706SPECIFIC CONSIDERATIONSPART IIintervention.86 Additional indications for intervention on the first episode include occupational hazards such as air travel, deep-sea diving, or travel to remote locations. CT findings of multiple small bullae or a large bleb are associated with an increased risk of recurrent pneumothorax.87 Many surgeons are now using screening CT scan to recommend VATS bleb resection with pleurodesis for first-episode spontaneous pneumothorax.Secondary spontaneous pneumothorax occurs in the set-ting of underlying lung disease, such as emphysema (rupture of a bleb or bulla), cystic fibrosis, acquired immunodeficiency syndrome (AIDS), metastatic cancer (especially sarcoma),	Surgery_Schwartz. for greater than 3 days, thoracoscopic man-agement (i.e., bleb resection with pleurodesis by talc or pleural abrasion) is performed. Recurrences or complete lung collapse with the first episode are generally indications for thoracoscopic Brunicardi_Ch19_p0661-p0750.indd 70501/03/19 7:01 PM 706SPECIFIC CONSIDERATIONSPART IIintervention.86 Additional indications for intervention on the first episode include occupational hazards such as air travel, deep-sea diving, or travel to remote locations. CT findings of multiple small bullae or a large bleb are associated with an increased risk of recurrent pneumothorax.87 Many surgeons are now using screening CT scan to recommend VATS bleb resection with pleurodesis for first-episode spontaneous pneumothorax.Secondary spontaneous pneumothorax occurs in the set-ting of underlying lung disease, such as emphysema (rupture of a bleb or bulla), cystic fibrosis, acquired immunodeficiency syndrome (AIDS), metastatic cancer (especially sarcoma),