Topics in Thoracic Surgery Edited by Paulo F. Guerreiro Cardoso TOPICS IN THORACIC SURGERY Edited by Paulo F. Guerreiro Cardoso INTECHOPEN.COM Topics in Thoracic Surgery http://dx.doi.org/10.5772/1505 Edited by Paulo F. Guerreiro Cardoso Contributors Paulo Cardoso, Petre Vlah-Horea Botianu, Alexandru-Mihail Botianu, Reubendra Jeganathan, Thomas Lynch, Jim McGuigan, Alan D. L. Sihoe, Khalid Amer, Andrew Seely, Tim Ramsay, Jelena Ivanovic, Nikolaos Barbetakis, Gordana Taleska, Trajanka Trajkovska, Giuseppe Miserocchi, Egidio Beretta, James Maloney, Joshua Hermsen, Nicole Strieter, Francesco Puma, Jacopo Vannucci, Michele Torre, Patricio Varela, Vincenzo Jasonni, Giovanni Rapuzzi, Akira Masaoka, Satoshi Kondo, Victor E. Laubach, Ashish K. Sharma, Christine L. Lau, Matthew L. Stone, Lucas G. Guillermo Fernandez, David R. Jones, James M. Isbell, Yu-Chung Wu, Jung-Jyh Hung, Seyed Mohammad Reza Hashemian, Paul Bresser, Coen Van Kan, Mart N. Van Der Plas, Jaap J. Kloek, Herre J. Reesink, Sevval Eren, Hidir Esme, Anand Alister Joseph R, Donal Harney, Kuang-Yao Yang, Shao-Jung Hsu, Geesche Somuncuoglu, Stefanie Veit, Takashi Iwata, Govindan Raghuraman, Shanawaz Abdul Rasheed, Dariusz Sagan, Jerzy Tarach, Andrzej Nowakowski, Maria Klatka, Andrzej Drop, Janusz Klatka, Elzbieta Czekajska-Chehab, Beata Chrapko © The Editor(s) and the Author(s) 2012 The moral rights of the and the author(s) have been asserted. All rights to the book as a whole are reserved by INTECH. The book as a whole (compilation) cannot be reproduced, distributed or used for commercial or non-commercial purposes without INTECH’s written permission. Enquiries concerning the use of the book should be directed to INTECH rights and permissions department (permissions@intechopen.com). Violations are liable to prosecution under the governing Copyright Law. 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The publisher assumes no responsibility for any damage or injury to persons or property arising out of the use of any materials, instructions, methods or ideas contained in the book. First published in Croatia, 2012 by INTECH d.o.o. eBook (PDF) Published by IN TECH d.o.o. Place and year of publication of eBook (PDF): Rijeka, 2019. IntechOpen is the global imprint of IN TECH d.o.o. Printed in Croatia Legal deposit, Croatia: National and University Library in Zagreb Additional hard and PDF copies can be obtained from orders@intechopen.com Topics in Thoracic Surgery Edited by Paulo F. Guerreiro Cardoso p. cm. ISBN 978-953-51-0010-2 eBook (PDF) ISBN 978-953-51-6796-9 Selection of our books indexed in the Book Citation Index in Web of Science™ Core Collection (BKCI) Interested in publishing with us? Contact book.department@intechopen.com Numbers displayed above are based on latest data collected. For more information visit www.intechopen.com 4,100+ Open access books available 151 Countries delivered to 12.2% Contributors from top 500 universities Our authors are among the Top 1% most cited scientists 116,000+ International authors and editors 120M+ Downloads We are IntechOpen, the world’s leading publisher of Open Access books Built by scientists, for scientists Meet the editor Graduated in Medicine at the Medical School of Rio de Janeiro of the Gama Filho University, Brazil (1979). Trained in General Surgery and Thoracic Surgery and had a MaSc in Thoracic Surgery at the Federal Universi- ty of Rio de Janeiro, Brazil (1980-87). Research and Clin- ical fellowship in Thoracic Surgery at the University of Toronto, Canada (1987-1992) and a Ph.D. in Pneumology at the Federal University of Rio Grande do Sul, Brazil (2000). Dr. Cardoso is currently an Associate Professor of Thoracic Surgery at the Department of Cardiopneumology, Division of Thoracic Surgery of the Faculty of Med- icine of the University of Sao Paulo, Brazil. He is also an attending thoracic surgeon at the Division of Thoracic Surgery of the Heart Institute (InCor) of the Hospital das Clinicas, Faculty of Medicine of the University of Sao Paulo, Brazil. Contents Preface X III Chapter 1 Preoperative Evaluation of Patients for Thoracic Surgery 1 Shanawaz Abdul Rasheed and Raghuraman Govindan Chapter 2 Pulmonary Resection for Lung Cancer in Patients with Liver Cirrhosis 17 Takashi Iwata Chapter 3 The Effect of One Lung Ventilation on Intrapulmonary Shunt During Different Anesthetic Techniques 33 Gordana Taleska and Trajanka Trajkovska Chapter 4 Thoracic Critical Care 59 Seyed Mohammad Reza Hashemian and Seyed Amir Mohajerani Chapter 5 Standardized Monitoring of Post-Operative Morbidity and Mortality for the Evaluation of Thoracic Surgical Quality 67 Jelena Ivanovic, Tim Ramsay and Andrew J. E. Seely Chapter 6 Post-Thoracotomy Pain Syndrome 81 Anand Alister Joseph R., Anand Puttappa and Donal Harney Chapter 7 Chronic Thromboembolic Pulmonary Hypertension: Effects of Pulmonary Endarterectomy 95 Coen van Kan, Mart N. van der Plas, Jaap J. Kloek, Herre J. Reesink and Paul Bresser Chapter 8 Chest Wall Deformities: An Overview on Classification and Surgical Options 117 Michele Torre, Giovanni Rapuzzi, Vincenzo Jasonni and Patricio Varela Chapter 9 Pectus Excavatum: A Historical Perspective and a New Metal-Free Procedure 137 Akira Masaoka and Satoshi Kondo X Contents Chapter 10 Surgical Management of Primary Upper Limb Hyperhidrosis – A Review 165 Geesche Somuncuoğlu Chapter 11 The Evolution of VATS Lobectomy 181 Alan D. L. Sihoe Chapter 12 The Era of VATS Lobectomy 211 Stefanie Veit Chapter 13 Video-Assisted Thoracic Surgery Major Pulmonary Resections 223 Khalid Amer Chapter 14 Video-Assisted Thoracic Surgery (VATS) Systematic Mediastinal Nodal Dissection 247 Khalid Amer Chapter 15 Pancoast Tumors: Surgical Approaches and Techniques 273 N. Barbetakis Chapter 16 Stage I Non-Small Cell Lung Cancer: Recurrence Patterns, Prognostic Factors and Survival 285 Jung-Jyh Hung and Yu-Chung Wu Chapter 17 Surgical Treatment of Bronchiectasis 293 Hidir Esme and Sevval Eren Chapter 18 Role of Thoracomyoplasty Procedures in Modern Surgery for Intrathoracic Suppurations 309 Petre Vlah-Horea Botianu and Alexandru Mihail Botianu Chapter 19 Lung Volume Reduction Surgery 327 James D. Maloney, Nicole K. Strieter and Joshua L. Hermsen Chapter 20 Endoscopic Lung Volume Reduction for Emphysema 345 Paulo F. Guerreiro Cardoso Chapter 21 Mediastinal Parathyroidectomy: Preoperative Management of Hyperparathyroidism 363 Dariusz Sagan, Jerzy S. Tarach, Andrzej Nowakowski, Maria Klatka, Elżbieta Czekajska-Chehab, Andrzej Drop, Beata Chrapko and Janusz Klatka Chapter 22 Pulmonary Transplantation and Ischemia-Reperfusion Injury 377 Ashish K. Sharma, Matthew L. Stone, Christine L. Lau and Victor E. Laubach Contents X I Chapter 23 Superior Vena Cava Syndrome 401 Francesco Puma and Jacopo Vannucci Chapter 24 Compensatory Lung Growth After Pneumonectomy 415 Lucas G. Fernández, James M. Isbell, David R. Jones and Victor E. Laubach Chapter 25 Pathophysiology of Extravascular Water in the Pleural Cavity and in the Lung Interstitium After Lung Thoracic Surgery 433 Giuseppe Miserocchi and Egidio Beretta Chapter 26 The Role of PET-CT in the Clinical Management of Oesophageal Cancer 447 Reubendra Jeganathan, Jim McGuigan and Tom Lynch Chapter 27 Extracorporeal Membrane Oxygenation in the Transition of Emergent Thoracic Surgery 467 Shao-Jung Hsu and Kuang-Yao Yang Preface Open Access publishing has finally become available to Thoracic Surgery. This is a rather simple publishing concept that removes the charges and the need for compulsory subscription. This therefore enables readers worldwide to broaden their access to scientific publications online and, best of all, for free. The numbers are staggering. As I was writing this Preface, I went to the publisher’s web site and found the following: 3,8 million downloads for all books published, championed by Electrical Engineering (29,2%) whereas Medicine is making its way up (13,9%). This is the reason why I believe that Open Access Publishing has become a powerful educational and research tool on a global level. Thoracic Surgery can now extend this benefit to both their specialists and trainees. Furthermore, it offers a new gateway for authors around the world to convey their information in a less formal frame, in a faster way and with a more international flavor. The end result is an excellent opportunity for authors to share their experiences and for readers to have access to more information. The current Thoracic Surgery book has format that differs radically from the usual surgical textbooks. Instead of organizing the book into a pre-formatted table of contents with chapters, sections and then ask authors to submit their respective chapters based on this frame, the authors were encouraged by the publisher to submit their chapters based on their area of expertise. The editor is then commissioned to examine the reading material and put it together as a book. In Thoracic Surgery, the material was rich and encompassed so many interesting chapters that I elected to put it into a single volume with some sense but with no divisions, thus enabling a wider range of topics to be featured. It starts with a comprehensive and objective “Pre- operative Assessment of patients for Thoracic Surgery” by Drs. Rasheed and Raghuraman and moves on to challenging topics such as “Pulmonary Resection for Lung Cancer in Patients with Liver Cirrhosis” by Dr. Iwata from Japan. It then moves into the more specific articles such as “Post-thoracotomy pain management”, chest wall malformations and a provocative new technique for pectus repair along with a historical overview provided by Dr. Masaoka and as well as a historical overview on chest wall malformations by Dr. Torre. On the lung cancer topics, the reader will enjoy the review and technical aspects of VATS major pulmonary resections along with more traditional topics such as Pancoast tumors and recurrence patterns of stage I lung disease. The book also includes articles on hyperhidrosis, surgery for bronchiectasis, lung transplantation, surgical and endoscopic management of emphysema among many others. X Preface For the reader who seeks information on research applicable to clinical situations, we chose a few interesting topics such as Dr. Laubach’s research on compensatory lung growth and Drs. Miserocchi’s and Beretta’s studies on extravascular water in lung and pleural cavity following lung surgery. This inaugurates a novel method of sharing thoracic surgical information and, above all, accessible to everyone with very good publishing quality. I do hope this will succeed as an alternative surgical information output and encourage authors to embark on Open Access. Paulo F. Guerreiro Cardoso MD, Ph.D. Associate Professor of Thoracic Surgery Faculty of Medicine of the University of Sao Paulo Brazil 1 Preoperative Evaluation of Patients for Thoracic Surgery Shanawaz Abdul Rasheed and Raghuraman Govindan Birmingham Heartlands Hospital NHS Trust, United Kingdom 1. Introduction Lung cancer is the most common cancer in the world with 1.61 million new cases diagnosed every year (1). The vast majority of lung cancers are caused by cigarette smoking. It has been estimated that the lifetime risk of developing lung cancer in 2008 is 1 in 14 for men and 1 in 19 for women in the UK. Approximately 2400 Lobectomies and 500 Pneumonectomies are undertaken in the UK annually, the majority for malignancy. For this group of patients, in-hospital mortality rates are 2-4% and 6-8% respectively in the UK, although world mortality rates as high as 11% have been cited for Pneumonectomy(2) To guide decisions, one must not only consider the extremely poor prognosis for inoperable patients but also be familiar with the operative risks, and understand how surgery impacts on pulmonary function both in short term and long term. The aim of the preoperative pulmonary assessment is to identify patients who are at increased risk of having peri-operative complications and long term disability from surgical resection using the least tests available. The purpose of this preoperative physiologic assessment is to enable adequate counselling of the patient on treatment options and risks so that they can make a truly informed decision (3) Preoperative evaluation of a patient with lung cancer involves answering three questions: 1) is the neoplasm resectable? (Anatomic resectability), 2) Does the patient have adequate pulmonary reserve to tolerate pulmonary resection? (Operability or physiologic resectability); 3) is there any major medical contraindication to the proposed surgery? 2. Anatomical resectability After a tissue diagnosis of lung cancer has been made, the neoplasm should first be assessed for anatomic resectability. A neoplasm is considered resectable if the entire tumour can be removed by surgery. Knowing the extent of tumour both within and outside the thorax is the key in determining resectability. Surgical resection is considered the treatment of choice in physiologically operable patients with up to stage IIIA tumour. (4) 2.1 Operability (physiologic resectability) 2.1.1 Physiologic alterations after thoracotomy and lung resection If, after adequate staging, the tumour is found to be anatomically resectable, the next step is determination of operability or physiological resectability. To understand operability the Topics in Thoracic Surgery 2 physiologic changes due to surgery and the pulmonary reserve require discussion. When thoracic surgery is performed, several physiological effects occur which can be discussed under changes in Lung volume, compliance and pulmonary blood flow. 2.1.1.1 Changes in lung volume Even if no lung is resected, vital capacity declines by approximately 25% in the early postoperative period and slowly returns to baseline in a few weeks. In patients with underlying lung disease, the reduction in vital capacity by lung surgery may result in acute and chronic respiratory failure, or even death. However, it should be noted that while in most circumstances lung resection leads to reduction in lung function; this is not always the case. Patients who undergo resection of large bullae may actually have improvement in lung function postoperatively because of better lung mechanics. On occasion, lung resection only involves removal of non-functioning lung parenchyma and there is little or no change in resultant lung function after recovery. Moreover, in some highly selected cases, in particular upper lobe tumours in patients with centrilobular emphysema, there may be a lung volume reduction surgery (LVRS)-like effect. In these selected circumstances, the resultant lung function after recovery from resection is actually better than the preoperative measurements. This effect is difficult to anticipate given the obvious important differences between lobectomy and LVRS protocols, but it has been noticed in anecdotal cases (8). 2.1.1.2 Changes in lung compliance Chest wall compliance also decreases to less than 50% and work of breathing increases to more than 140% of the preoperative level. The cough pressure is reduced to 30% of the preoperative value and increases to 50% by 1 week (5–7). 2.1.1.3 Changes in pulmonary blood flow Removal of lung parenchyma results in reduction of the pulmonary capillary bed. The decrease in pulmonary capillary bed is well tolerated by patients with otherwise normal lungs but in patients with pulmonary dysfunction this may result in postoperative pulmonary hypertension. Unlike most general surgical procedures where cardiovascular complications are the major cause of perioperative morbidity and mortality, in thoracic surgical population respiratory complications are the predominant cause of perioperative morbidity and mortality (9,10). The principles described will apply to all other types of non-malignant pulmonary resections and to other chest surgery. The major difference is that in patients with malignancy the risk/benefit ratio of cancelling or delaying surgery pending other investigation/therapy is always complicated by the risk of further spread of cancer during any extended interval prior to resection. This is never completely “elective” surgery (10). 3. Assessment of patients for lung resection Each patient’s management requires planning by a multi-disciplinary team (MDT), which includes a respiratory physician, a thoracic surgeon, an oncologist and other staff such as physiotherapists and respiratory nurses. If the MDT feels that surgery is appropriate, then the surgeon will decide if the tumour is technically resectable based on chest X-ray and CT scan images (Figure 1). Preoperative Evaluation of Patients for Thoracic Surgery 3 Fig. 1. Chest X ray and CT scan showing Lung Cancer in Left Lung. 4. General assessment Prevention of postoperative complications requires a detailed medical history and examination. History should address the presence of dyspnoea, exercise tolerance, cough, and expectoration, wheezing, and smoking status. Examination should also focus on respiratory rate, pattern of breathing, wheezing, and body habitus. 4.1 Assessment of risks of the surgery Fig. 2. Tripartite Risk Assessment. Topics in Thoracic Surgery 4 Recent British Thoracic Society guidelines 2010 (BTS) presents a Tripartite risk assessment model that considers risk of operative mortality, risks of perioperative myocardial events and risk of postoperative dyspnoea. This model facilitate the calculation and assessment of individual outcomes that may be discussed by the MDT and enables the patient to make truly informed decision. 4.2 Assessment of risks of the surgery Estimating the risk of in-hospital death is one of the most important considerations for surgeons and patients when they evaluate the option of surgery for lung cancer.The 30 day mortality for lobectomy and pneumonectomy in England from National Lung Cancer Audit is 2.3% and 5.8% respectively. Thoracoscore is currently the largest and most validated global risk score . It is a logistic regression derived model which is based on nine variables like Age, sex, ASA score, performance status, dyspnoea score, priority of suregry, extent of surgery, malignant diagnosis and a composite comorbidity score(11). Table 1. Methods for using the logistic regression model to predict the risk of in-hospital death: 1. Odds are calculated with the patient values and the coefficients are determined from the regression equation: