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European journal of cardio-thoracic surgery. Journal of heart and lung transplantation. Journal of Thoracic and Cardiovascular Surgery. Seminars in thoracic and cardiovascular surgery. Thoracic surgery clinics. Find articles on Thoracic Surgery PubMed. Investigations may include echocardiography, cardiac viability study or angiogram. Patients who are on antiplatelets should have their medications withheld 7 days prior to surgery is possible. If patients are on warfarin then it is stopped 3 days prior to surgery and are covered with heparin. Patients are given a single dose of antibiotics for elective cases and they are continued for infected cased or restarted postoperatively if needed.
If surgical intervention is elective, we advocate a short period of preparation may be beneficial if directed at improving the patient's physical status and specifically at pulmonary preparation, conditioning exercises, and nutrition. Video assisted Thoracoscopic procedures are done with increasing frequency for many indications. Most importantly the incidence of postoperative pain is much less in VATS than open procedures and they have shorter hospital stay. The proponents of VATS have published many series about the feasibility, lesser complication rate, reduced pain, early mobility and discharge [ 18 ], [ 19 ].
There are groups who did not find any statistical benefit in performing VATS and have quoted a higher bleeding and intraoperative complication rate [ 20 ]. In our unit we perform VATS for all kinds of thoracic procedures if patients are suitable for it. VATS lobectomy is a safe procedure, which reduces peri operative pain and improves postoperative physical status.
The results obtained with early stage lung cancer are excellent and may reflect inherent oncologic advantageous consequent upon reduced operative trauma. Detection of early stage lung cancer is potentially rewarding and will become a practical imperative if survival results are to be improved. Thus the scope for VATS resection may increase significantly. In our view VATS lobectomy is the procedure of choice for early stage lung cancer and multicentre prospective randomised trials comparing this therapy against conventional open resection are overdue.
Various procedures like wedge resections, lobectomies, excision of bullae may cause prolonged air leaks especially if patients have COAD. Traditionally diathermy dissection and ligation was used and later staplers were used for parenchymal resections. Although certain studies pointed towards improved results with regards to air leaks using staplers [ 21 ] and reported that surgical morbidity due to air leaks decreased with this technique other studies have not shown any particular reduction in duration of air leaks using staplers alone.
The air leaks caused by the holes of the suture needles are of the same magnitude as that caused by the surface tension between the parallel staple lines when the lung inflates. Nevertheless staplers are quicker to use and they have a big role in minimally invasive Thoracoscopic procedures. Polyglycolic acid fabric, polydioxan ribbon, bovine pericardial strips, bovine collagen, and recently, expanded polytetrafluoroethylene have been employed in an attempt to reinforce the staple lines, especially for resections performed in emphysematous lungs [ 23 ]- [ 27 ].
Other techniques like the electrothermal bipolar sealing have shown good results in lung parenchymal surgery. Air leaks are common after pulmonary resections.
They can be inspiratory, expiratory, continuous and forced expiratory. Most of the leaks are expiratory or forced expiratory. Inspiratory leaks happen on positive pressure ventilation. If there is no pleural space then they are managed by underwater seal. If there is a space negative suctions is applied to the underwater seal. If the leak persists beyond a particular time frame then TALC or reopening should be considered. Pain management is of paramount importance post operatively as it is essential for patients to comply for chest physiotherapy and ambulation and they will be unable to do so if they have severe pain.
There are various ways by which pain is managed. They include epidural catheters preoperatively, paravertebral methods pre or intraoperatively or intravenous patient controlled analgesia. On withdrawing these agents patients will need oral analgesics for duration of time till they are pain free. The catheter is placed approximately with the midpoint of the dermatomal distribution of the skin incision. Epidural local anaesthetics increase segmental bioavailability of opioids in the cerebrospinal fluid and increase the binding of opioids to m receptors and the blocking of the release of substance P in the substantia gelatinosa of the dorsal horn of the spinal cord [ 28 ].
The thoracic segmental effects of local anaesthetic and opioid combinations is the only way to minimize motor and sympathetic blockade maintain conscious level and cough reflex and reliably produce increased analgesia with movement and increased respiratory function after thoracotomy [ 29 ]. Generally the most popular regimens are fentanyl or diamorphine combined with levobupivacaine [ 29 ]. The regimens can be administered as an infusion, patient controlled analgesia or both. Potential issues include failure, technical difficulty and hypotension.
It can also reduce the effectiveness of coughing, especially in patients who already have a low FEV1. It is not offered when there is local or systemic sepsis. Paravertebral block is an effective modality to provide pain relief. It can be done by the anaesthesiologist before the start of surgery or by the surgeon before closure. We prefer placing the catheter under direct vision during thoracic surgery and give pain relief as a continuous infusion.
The chest drain loss of local anaesthetic is four times lower than that of interapleural block [ 30 ]. Opioids remain the mainstay of postoperative analgesia and have demonstrated their efficacy in the management of severe pain. The side effects include nausea, vomiting, ileus, biliary spasms and respiratory depression, Opioids can be administered IM, subcutaneously, or IV. Numerous studies have demonstrated the safety and opioid-sparing effect of PCA. After thoracic surgery PCA is often combined with other modalities to offer adequate pain relief. Intrapleural local anaesthetics produce a multi-level intercostal block.
However, the analgesia is extremely dependent on patient position, infusion volume, and the type of surgery. With the drains insitu most of the anaesthetic is drained out and hence the efficacy of the procedure is less. In spite of occasional successes most clinicians have not found the reliability of intrapleural techniques adequate to justify their use on a routine basis. This can be moderately efficient to decrease post-operative pain, but is associated with an incidence of chronic neuralgia that has lead many centres to abandon the technique [ 32 ]. Transcutaneous electrical nerve stimulation TENS may be useful in mild to moderate pain but is ineffective when pain is severe.
Patients are managed generally in a high dependency unit post surgery or the wards if it is a dedicated thoracic unit. Post thoracic surgery especially in resections intravenous fluids are given in reduced amounts to prevent pulmonary insufficiency. Care is taken not to overhydrate the patient and oral feeding in encouraged as soon as possible. Caution should be exercised with regard to silent hypovolaemia, impaired oxygen delivery and acute kidney injury. A high index of suspicion for pulmonary insufficiency should be adopted if there is volume overload.
Intercostal catheter is watched for drainage and air leak. If the postoperative chest X-ray shows expanded lung fields the no suction is applied even if there is bubbling. If there is airspace the suction is applied. It is preferable to use a balanced drainage system in all patients. In pneumonectomy patients no suction is applied after surgery and the balanced drainage system is filled with 1cm of liquid unlike routine thoracic cases where it is filled with 2 cm of fluid. In pneumonectomy patients the drains are removed the next day and in lobectomy patients as soon as possible.
Suction is also applied in cases of pleurodesis with talc so that the visceral and parietal pleurae are approximated. If the drains have to stay due to persistent minimal bubbling and if the parenchyma is expanded without any suction a Heimlich valve container is attached for earlier complete ambulation or discharge. Postoperative insufficiency occurs because of infection, inability to clear secretions or oedema around day 2 or 3, to prevent these from happening attention should be given to physiotherapy, bronchodilators, restriction of intravenous fluids and tracheal toilet.
Chest physiotherapy includes deep breathing and coughing exercises and incentive spirometry. Pulmonary insufficiency is more common in patients have low FEV1. If there is inability to do so then endotracheal suctioning or mini tracheostomy should be used for clearing secretions.
Diuretics are used if necessary and antibiotics are started if clinically indicated without waiting for radiological deterioration. Early postoperative ambulation and physiotherapy reduces complications like atelectasis, pneumonia, empyema and DVT.
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Aspiration should be prevented postoperatively as it can result in multiorgan dysfunction and sepsis. Patients should be allowed to eat only when they are fully alert and sitting up. If there is a tendency to aspirate patients are kept nil by mouth and nasogastric feeding initiated as required. If there is damage to the vocal cords then a speech pathology is sought for and patients are initially kept on nasogastric feeds and based on recovery are put on graded diet beginning from thickened fluids. The prophylaxis should start when the patients are admitted in the hospital. Everyone should be given a prophylactic dose of heparin subcutaneously if not contraindicated at a dose IU twice daily and this is continued in the postoperative period till discharge.
All patients should have stockings and the high-risk patients should be on compression stockings. If there are signs of DVT then a Doppler in arranged and patients put in treatment dose of heparin infusion and an IVC filter put in if necessary. Immediate postoperative bleeding can be caused due to surgical bleeding or coagulopathy, surgical bleeding being more common. A set of standard coagulation tests are performed and coagulopathy is corrected accordingly.
Depending on the coagulation profile factors like FFP, Platelets, cryoprecipitate or factor 7 is given if the patient is bleeding due to profound coagulopathy. The threshold for taking back a patient for re-exploration should be low, as a surgical cause of bleeding should be ruled out. Bleeding after thoracic surgery is rare. A chest tube output of ml in 1 hour necessitates an immediate return to the operating room with concurrent correction of coagulopathy. Serial drainage exceeding ml per hour for 2 to 4 hours after correction of a coagulopathy also indicates surgical bleeding and dictates re-exploration.
If the patient is hemodynamic ally stable but the chest output is high, checking the haematocrit on the chest tube drainage can be helpful in distinguishing active bleeding from a lymphatic leak. If a patient in the immediate postoperative period is hemodynamically unstable but the chest tube output does not suggest active haemorrhage, a chest radiograph may show radiopacity of the operative side with thrombosed chest tubes.
Several herbs like garlic, ginseng etc. Recommendation for perioperative antiplatelet the current recommendations aim at providing the best option for patients. There are issues regarding continuing or discontinuing these medications. These recommendations are mainly form observational data. In the current era Aspirin is a lifelong therapy and it is not necessary to stop it for surgery when there are specific indications like prevention after stroke, acute coronary syndrome, MI, or coronary revascularization, regardless of the time since the event that led to the recommendation of aspirin.
Dual antiplatelet therapy is recommended during the two weeks after simple dilatation, six weeks after bare-metal stents, and at least 12 months after drug-eluting stents. Even if clopidogrel treatment must be interrupted in high-risk surgical situations, aspirin must be continued without interruption. Ticagrelor is used more often these days and should be stopped 36 to 48 hours prior to a planned procedure. It is reversible P2Y 12 adenosine disphosphate receptor binder with shorter duration of action unlike clopidogrel which is irreversibly binds to it. The perioperative management for it is similar to the clopidogrel.
Warfarin should be discontinued 3 days preoperatively, the INR checked. It should be substituted with heparin and APTT checked. Conversion to an open thoracotomy for control of bleeding is done in case of bleeding due to VATS. Intraoperative bleeding can be massive from injury to the pulmonary artery or vein. Proximal control of the pulmonary artery before dissection of its branches is a safe preventive measure in open lobectomies.
Rarely vascular stapler on a pulmonary vessel can cause bleeding and so can its used in the parenchyma. Suturing of the lung is done to control bleeding.
Bleeding can also happen from peribronchial tissue, parenchyma, adhesions, intercostal vessels, and muscles. In some patients, postoperative bleeding develops that is not hemodynamically significant enough to indicate re-exploration but results in a residual clotted hemothorax. As is true for a posttraumatic clotted hemothorax, treatment options include VATS or open exploration and evacuation of the hematoma to prevent development of a trapped lung, respiratory compromise, and empyema.
Risk factors for tachyarrhythmias include [ 48 ], patient related pre-existing cardiovascular disease, postural change, limited pulmonary reserve , surgery related extensive procedure, intrapericardial pneumonectomy, extra pleural pneumonectomy, anaesthetic agents, major bleeding , treatment related previous thoracic irradiation or older age [ 47 ], [ 49 ]. The most common arrhythmia encountered is supraventricular tachycardia.
If patients have atrial fibrillation with haemodynamic compromise then electrical cardioversion should be carries out immediately. If patients have sympromatic AF chemical cardioversion should be attempted first followed by electrical cardioversion if necessary. New-onset postoperative AF is often transient and self-limiting and it is generally accepted that rate comtrolling agents be given first. Rate control resolves AF in most cases in thoracic surgery.
AF generally resolves within 1 day of hospital discharge with rate control alone. A selective Beta 1-blocking agent is recommended as the initial drug for rate control in the absence of moderate-severe chronic obstructive pulmonary disease or active bronchospasms and Diltiazem should be the first agent used in the presence of moderate-severe chronic obstructive pulmonary disease or active bronchospasm. Digoxin as a single agent should not be used for rate control, although it may be effective in combination with a beta1-blocker or diltiazem. Beta blockers are considered better than calcium channel blockers and digoxin for treating AF in thoracic surgery.
The only concern is COPD where it may cause bronchospasms specific beta 1 blockers such as metoprolol are considered safer in this regard.
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When chemical cardioversion is employed in the setting of continuous or recurrent paroxysmal postoperative AF, the most reasonable initial drugs are intravenous followed by oral amiodarone or oral flecainide. Flecainide is not given if there is organic cardiac disease. Other drugs include disopyramide, ibutilide, procainamide, propafenone, quinidine, and sotalol.
Patients who received flecainide had an approximately doubled rate of mortality or cardiac arrest, likely due to a proarrhythmic effect on the ventricle possibly due to structural heart disease. Side effect of amiodarone relevant to thoracic surgery is its pulmonary toxicity [ 51 ]. Both amiodarone and flecainide are highly effective and relatively safe drugs, but the specific contraindications to their use must be kept in mind antiarrhythmic therapy is given usually from 1 to 6 weeks. The only study that has evaluated optimal length of therapy with antiarrhythmic drugs, once initiated, for postoperative AF after coronary artery bypass graft surgery found that there was no difference in the rate of recurrent AF whether the treatment was continued for 1, 3, or 6 weeks after discharge.
For patients with fewer than two risk factors for stroke and patients considered not suitable for warfarin who have postoperative AF that recurs or persists for more than 48 hours, aspirin, mg daily is recommended. In a large series the incidence of ischemic electrocardiographic changes was 3. According to this study hypotension and abnormal exercise testing were the strongest predictors for ischemic events. Patients are monitored invasively, base line medication was continued, and peri operative fluid administration was minimalized. We recommend continuous monitoring for at least 2 days in high-risk patient.
The American College of Cardiology and the American Heart Association guidelines [ 58 ] for peri operative cardiovascular evaluation for no cardiac surgery remain the best available method for risk assessment in noncardiac thoracic surgery. Thoracic surgery is categorized as a high-risk surgical procedure in this matter. Coronary angiography is advocated in case of major clinical predictors such as unstable angina, decompensated heart failure, significant arrhythmias, or severe valvular disease.
In cases of intermediate or minor clinical predictors the decision whether to perform an angiography is based on non-invasive testing [ 59 ]. As adenosine and dipyridamole should be avoided in patients with clinical bronchospasms, dobutamine stress echocardiography is the evaluation of choice for patients with cardiac ischemia referred for thoracic surgery [ 60 ]. In general the indications for coronary angiography are similar to those in the nonoperative setting. No prospective randomized data exists on the role of prophylactic coronary bypass surgery. Whether percutaneous coronary intervention is superior to bypass surgery is uncertain, but in cases of angioplasty with stenting it is probably safer to postpone surgery for 2 to 4 weeks.
In conclusion, the preoperative cardiac assessment of thoracic surgery patients is of great importance, although prospectively controlled data for this type of surgery are lacking. With the increased right-sided pressures associated with pulmonary resection, these patients can develop a right-to-left shunt with refractory hypoxia in the postoperative period. This shunting increases most dramatically after a right pneumonectomy. In some patients, symptoms may not present until after 1 to 5 months, particularly after a right pneumonectomy.
This is because of nediastinal shift, which modifies the relationship between the right and left atrium and distorts the foramen ovale. Cardiac rotation and compression of the right atrium by pleural fluid causes preferential flow of the inferior caval vein into the left atrium. Hemodynamic factors may also have a role, such as reversal of the interatrial pressure gradient. A decrease in right ventricular compliance and the hydrostatic pressures in the left lateral decubitus or orthostatic positions increase the shunt.
Lastly, factors such as pulmonary emboli, right ventricular infarction, increased intrathoracic pressure, chronic obstructive pulmonary disease, and positive pressure ventilation may drive shunt physiology. The diagnosis is made with arterial blood gas analysis, nuclear lung perfusion scanning, echocardiography, MRI, and cardiac catheterization or a combination thereof.
Standard treatment is surgical repair, although several cases of successful intravascular occlusion of the septal defect have been performed. Other causes of dyspnoea must be evaluated, including but not limited to pulmonary embolism, airway narrowing, and post resection pulmonary oedema. Cardiac herniation is a rare complication and happens in the early postoperative period. Cardiovascular collapse is the presenting feature Jugular pulse is elevated and there can be cyanosis in the drainage area of superior venacava.
Ventricular fibrillation may occur [ 63 ]. Treatment is emergency thoracotomy with reposition of the herniated heart into the pericardial sac and repairing the defect of the pericardium [ 64 ]. Most documented cases of cardiac herniation have occurred through surgically created defects as a result of intrapericardial pneumonectomy or lobectomy with partial pericardectomy [ 65 ].
Combination of a sudden superior vena cava syndrome and heart sounds in the right side of the chest should alert the physician to the possibility of cardiac herniation. Surgical defects of the pericardium as a result of right intrapericardial pneumonectomy should be closed. This can be accomplished either by suturing the cut edges of the pericardium to the epicardium or by patching the defect with bovine pericardial patch, PTFE patch or parietal pleura.
In cases of left pneumonectomy, it may be sufficient to enlarge the pericardial defect in order to prevent strangulation, should herniation occur [ 66 ]. Few studies have addressed the problem of postoperative right ventricular dysfunction, which is because of changes in right ventricular afterload and contractility [ 67 ]- [ 71 ].
Although right ventricular end-diastolic volume remains stable in the early postoperative hours, significant increases may be observed on the first and second postoperative days. Although many authors [ 69 ]- [ 71 ] claim that afterload alteration is the major determinant of RV dysfunction. Pulmonary artery pressure and pulmonary vascular resistance only rose modestly in a study [ 66 ], suggesting that the rise in afterload is not the only causing factor.
Another argument favouring afterload augmentation as the cause of RV dysfunction is the fact that postoperative pulmonary artery pressure, pulmonary vascular resistance, and central venous pressure only change significantly during exercise [ 70 ]. Changes in RV function are able to compensate for the increased RV end-diastolic volume at rest, but not during exercise, with a resultant increase in pulmonary artery pressure and pulmonary vascular resistance. Only pneumonectomy patients had mild postoperative pulmonary hypertension without significant RV systolic dysfunction.
Pulmonary embolism and cardiac herniation are rare mechanisms that may cause RV dysfunction. Left heart failure is generally a consequence of impaired right heart function, either by decreasing left ventricular preload or by shifting the intraventricular septum resulting in a decreased left ventricular volume. Other causes of left ventricular dysfunction are acute myocardial infarction, pre-existing valvular disorders or cardiac herniation. The risk factors include age of the patient, extent of resection, preoperative lung function and other co morbidities.
However, central pressure measurements showed no evidence of left ventricular failure or cardiogenic pulmonary oedema. Its incidence is approximately 2. The mechanisms of injury are that ischaemia—reperfusion injury and [ 84 ] reactive oxygen species. Therapy [ 59 ] consists of administration of diuretics, restriction of fluid, nutritional support, and maintenance of adequate oxygenation, even with mechanical ventilation if necessary.
Nitric oxide ventilation and extracorporeal membrane oxygenation were tried as possible therapies. In the same report early intubation at first signs of ARDS , aspiration, bronchoscopy, and postural changes are also advocated. Pulmonary hypertension is a major concern for patients undergoing general thoracic surgery and often contraindicates pulmonary resection. Multiple aetiologies exist, such as cardiomyopathy or intrinsic cardiac valvular disease, as well as destructive pulmonary parenchymal processes resulting in cor pulmonale.
The presence of pulmonary hypertension puts patients at increased risk for anaesthesia and surgical morbidity. Postpneumonectomy syndrome refers to bronchial compression occurring as a result of massive mediastinal shift following pneumonectomy [ 87 ]- [ 89 ]. Incidence is approximately one in cases [ 90 ]. This syndrome is much more common after right pneumonectomy: the mediastinum undergoes counterclockwise rotation as it shifts toward the pneumonectomy space [ 87 ], [ 88 ], [ 90 ], [ 91 ], [ 92 ]. This results in stretching, distortion, and compression of the left main bronchus between the pulmonary artery anteriorly and the aorta and vertebral column posteriorly.
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The syndrome has also been described after left pneumonectomy, both in patients with and without an aberrant right aortic arch [ 92 ], [ 94 ], [ 95 ], [ 96 ], [ 99 ]. Risk factors include young age and female sex [ 88 ], [ 97 ], [ 98 ].