1. Thoracic SurgeryInnovations

2. Innovations • VATS • LVRS • Chemotherapy • Radiotherapy • PET • Small Cell • N2 • Stents & Lasers • Stapler In Oesophagogastrectomy • Epidural • SVC stents

3. VATS • Sympathectomy • Pleurectomy • Lobectomy • Biopsy • mass • lung

6. Pneumothorax

7. Pleurectomy • VAT • Muscle sparing • Mini • Full Thoracotomy

8. VAT Lobectomy

9. Biopsy Lung / Pleura

11. LVRS

12. LVRS

14. LVRS • Criteria • Dyspnoeic on daily activities • Age < 75 • No bullae > 5cm • Generalised emphysema with regional heterogeneity • TLC > 125% • FEV1 < 30 % • PaCO2 < 50 mmHg, PaO2 > 40 mmHg on air • No CAD or Pulmonary hypertension • Steroid < 15 mg/day

15. LVRS • Unilateral / Bilateral • Thoracotomy / Sternotomy / VAT • Role of Physio

17. Chemotherapy and Radiotherapy • Preoperative Neoadjuvant • Operative • Postoperative Adjuvant

18. Chemotherapy • Numerous agents • Adjuvant • Stage II (T2N0) • ? Role in N2 disease • All oat cell • Neoadjuvant • Stage IIIA (N2) • If respond are resected • No residual tumour at surgery means prolonged survival • Experimental

19. Radiotherapy • External beam external rays • Single / multiple beam / Fraction No • Brachy local ie intra bronchial • Interstitial directly into tumour • Intra cavity in bronchus • Adjuvant Postoperative • Neoadjuvant Preoperative

20. Radiotherapy • Primary treatment • Stage 1 and 2 • Refuse or unfit for surgery • Failure 30 % stage 1 (T1N0), 70% stage 2 (T2N0) • 5 year survival 5 to 40% • Adjuvant for N1 / N2 • Reduces rate local recurrence • Survival unchanged • ? Role in +Ve resection margins

21. Radiotherapy • Neoadjuvant • T3 Pancoast prior to surgery • Palliative • Symptomatic relief • Pain, haemoptysis, bronchial, SVC obstruction • Bone met pain • Brachytherapy • Local application high local dose

22. Chemotherapy and Radiotherapy • Adjuvant • Neoadjuvant • Sequential / concurrent / alternating • Good performance status • Not standard practice • May increase risk surgery

23. PET • 2-(fluorine-18) fluo-2-deoxy-D-glucose (18-FDG) • 18-FDG competes with glucose for facilitated transport into tumour cells and also competes with glucose for phosphorylation by hexokinase • Positive and negative predictive power

26. Small Cell Lung Cancer

27. Small Cell All need : Mediasteinoscopy CT head Bone scan

28. Pre operative N2 • Young patients • Pre op chemo downstage • No evidence

29. Stents & Lasers Malignant terminal conditions that are inoperable Benign inoperable conditions

30. Tracheal obstruction-malignant - Pre and post Nd:Yag laser

31. Left main bronchus extensive squamous cell carcinoma Metal stent in left main

32. Stapler In Oesophagogastrectomy

33. Epidural • Pain • Poor PFTs • Cardiac history • Contraindications • Low risk • On anticoagulants • Consent • Anatomical • Infective

36. SVC Stents

38. Any Questions ?

39. Next Week2nd MarchInotropesITU seminar room