NSCLCsurgery

Thoracotomy and major lung resection continue to carry significant morbidity and mortality. Surgery for lung cancer should be carried out in a unit with the appropriate level of experience and expertise. Unnecessary delay may result in a previously operable lung tumour becoming inoperable by progression of disease. In the majority of patients, general anaesthesia with use of double lumen endotracheal tube is desirable to allow one-lung anaesthesia during thoracotomy.

Surgical resection

The essential procedures involved include:

♦ Pneumonectomy

Segmental or wedge resection is generally not advisable because of the risk of incomplete resection due to the presence of satellite tumour foci within the surrounding lung. In a few patients with poor lung function, segmental or wedge resection may be appropriate.

In addition to the removal of all primary tumour with clear margins, regional lymph node sampling is essential to guide the planning of any adjuvant therapy. In cases where histological proof of malignancy is not available pre-operatively, every effort should be made to obtain histology at operation by frozen section before resection is undertaken.

In a minority of cases where the tumour is sited at the origin of the upper lobe bronchus, and is essentially confined to it, an upper lob-ectomy with sleeve resection of the main bronchus, followed by reconstruction by end-to-end anastomosis, will be possible, thus preserving the remainder of functioning lung.

Involvement of the chest wall (T3) or pericardium, including the phrenic nerve, in the absence of significant mediastinal lymph node involvement, does not necessarily constitute inoperability. Resection of the involved chest wall should be considered. A significant portion of pericardium can be removed en bloc in patients with pericardial involvement. Similarly removal of an involved section of the diaphragm is technically feasible.

Post-operative management

Patients should be nursed in an intensive care or high-dependency unit with adequate monitoring of:

♦ Blood pressure

♦ Central venous pressure

♦ Respiratory rate

♦ Oxygen saturation

Adequate pain control is essential following thoracotomy and can be provided by thoracic epidural anaesthesia, intravenous opiates administered by patient-controlled analgesia (PCA), intercostal nerve block prior to wound closure, or opiates administered by intermittent intra-muscular injection.

Oxygen therapy is required in the early post-operative stage, preferably through a nebulizer, and in patients with significant airways' obstruction, a bronchodilator should be added. Regular chest physiotherapy is essential.

Post-operative complications

Early (within days)

♦ Haemorrhage (particularly when there has been widespread pleural adhesions) that may result in a substantial haemothorax

♦ Respiratory failure due to drug-induced respiratory depression, pneumothorax with or without surgical emphysema, and retained bronchial secretions leading to significant atelectasis

♦ Prolonged air leak following lobectomy

♦ Cardiac arrhythmias, particularly atrial fibrillation

♦ Chest infection

♦ Wound infection

♦ Broncho-pleural fistula (particularly on the right following pneumonectomy)

Late (within weeks to months)

♦ Post-thoracotomy pain

♦ Late broncho-pleural fistula with empyema

♦ Tumour recurrence

Results of lung resection

Post-operative mortality rate should be less than 3% following lobectomy and less than 5% following pneumonectomy. Five-year survival is influenced by a number of factors, the most important of which is pathological staging, post-resection (see Table 16.2). Overall five-year

Table 16.2 Five-year survival by stage

Stage

Five-year survival

I 60-80%

II

25-40%

Ilia

10-30%

IIIb and IV

<5%

survival for patients undergoing resection may be as high as 40%, approaching 70% in cases without nodal involvement (N0). However, when mediastinal nodes are involved (N2) only 15% of patients will survive five years.

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