Schwartz's Principles of Surgery
Chapter 19: Chest Wall, Lung, Mediastinum, and Pleura
KEY POINTS
1) Lung Cancer
Highly lethal and extremely common cancer
5-year survival of 15%
Incidence is second only to the incidence of prostate
cancer in men and breast cancer in women.
Most common subtypes
a) Squamous cell carcinoma
b) Adenocarcinoma of the lung
Rarely found in the absence of a smoking history
Nonsmokers who live with smokers have a 24% increased
risk of lung cancer compared to non-smokers who do not
live with smokers.
2) Endoscopic Bronchial Ultrasound
Can enhance the accuracy and safety of transbronchial
biopsies of both the primary tumor (abuts central airways)
and the mediastinal lymph nodes
Should become part of the surgeon's armamentarium for
the diagnosis and treatment of lung cancer.
3) Assessment of patient risk before thoracic resection is based on
clinical judgment and data.
4) Impaired exchange of carbon monoxide
Associated with a significant increase in the risk of
postoperative pulmonary complications, independent of the
patient's smoking history.
Patients undergoing pulmonary resection, the risk of any
pulmonary complication increases by 42% for every 10%
decline in the percent carbon monoxide diffusion capacity
(%DLCO)
This measure may be a useful parameter in risk
stratification of patients for surgery.
5) Maximum Oxygen Consumption ( O2max)
Provide important additional information in those patients
with severely impaired DLCO and forced expiratory volume
in 1 second.
Values of <10 mL/kg per minute generally prohibit any
major pulmonary resection
Mortality is 26% compared with only 8.3% in patients
whose O2 patient's ability to tolerate pneumonectomy.
6) Tumor stage will be further subdivided into T1a and T1b, T2a
and T2b, T3, and T4.
Satellite nodules in the same lobe will be considered T3
Malignant pleural and pericardial effusions will be
considered metastatic disease rather than T4 disease.
7) Gastroesophageal reflux disease
There is a significant role in the pathogenesis of chronic
lung diseases (bronchiectasis and idiopathic pulmonary
fibrosis)
It may also contribute to Bronchiolitis Obliterans Syndrome
in lung transplant patients.
8) Multidrug-resistant tuberculosis (MDRTB) organisms
Present in approximately 10% of new tuberculosis cases
and 40% of recurrent cases.
Extensively Drug-Resistant Tuberculosis
Another rare disease varian
Causative organisms are resistant not only to
Isoniazid and Rifampin, as are the MDRTB
organisms, but also to at least one of the injectable
second-line drugs such as Capreomycin, Amikacin,
and Kanamycin.
9) Pulmonary Aspergilloma
Treatment of is individualized.
Asymptomatic patients can be observed without any
additional therapy.
Mild hemoptysis, which is not life-threatening, can be
managed with medical therapy, including antifungals and
cough suppressant.
Amphotericin B is the drug of choice
Voriconazole has recently been used for treatment of
Aspergillosis
Fewer side effects and equivalent efficacy.
10) Massive Hemoptysis
Traditionally been an indication for urgent or emergent
operative intervention.
With the advancement of endovascular techniques,
Bronchial Artery Embolization has been effective.
11) Candidal Infection
Demonstrated efficacy is similar to that of other classes of
antifungal drugs, the Triazoles and Echinocandins
Fewer side effects and better tolerated than these
other drug classes.
12) Malignant pleural effusion, poor expansion of the lung
(entrapment by tumor or adhesions) generally predicts a poor
result with Pleurodesis
Primary indication for placement of indwelling pleural
catheters.
Substantially shorten the amount of time patients spend in
the hospital during their final weeks of life.
TRACHEA
Anatomy
composed of cartilaginous and