Advanced therapy in thoracic surgery - part 10 docx

494 / Advanced Therapy in Thoracic Surgery gastroepiploic artery Using double clips, ties, or ultrasonic scalpel, short gastric vessels are taken, larger vessels being clamped and tied with 3-0 silk sutures Elevation of the spleen with one or two moist lap pads may aid in exposure of the short gastric vessels Dissection proximally on the greater curvature extends up to the hiatus Following this, the dissection is carried distally, taking great caution in staying at least cm lateral and inferior to the gastroepiploic artery The greater curvature is lifted anteriorly and adhesions between the pancreas and stomach are divided using electrocautery The left gastric artery is located, and celiac nodal tissue is swept onto the specimen Using a 30 mm vascular stapler the origin of the left gastric artery is clamped After verification of an excellent pulse in the gastroepiploic arcade, the stapler is fired (Figure 41-5) The remaining portion of the gastrohepatic ligament is divided using a combination of cautery and staples Using a combination of careful electrocautery and blunt dissection, a Kocher maneuver is performed mobilizing the duodenum to the midline A pyloromyotomy or Heineke-Mikulicz pyloroplasty is performed If a pyloroplasty is performed it is closed with interrupted 3-0 silk sutures, in one layer, carefully incorporating mucosa and muscular wall A cm left neck incision is made along the anterior border of the sternocleidomastoid muscle starting at the sternal notch Dissection continues medial to the carotid sheath but lateral to the strap muscles and thyroid gland The middle thyroid vein and omohyoid muscles are divided Blunt dissection is directed toward the spine, and the Penrose drain, which had been placed around the cervical esophagus from the chest, is grasped The esophagus is gently and bluntly mobilized The nasogastric tube is withdrawn proximal to a point of division of the esophagus and a linear cutter 75 mm stapler is used to divide the cervical esophagus A #2 silk suture is secured to the distal end of the divided esophagus prior to its division The esophagus is delivered into the abdomen with its attached silk suture The other end of the silk suture remains in the neck to aid in passage of the gastric conduit into the neck A gastric tube is created by resecting the gastroesophageal junction and lesser curve of the stomach with a series of linear 75 mm staplers (Figure 41-6) The tube should be kept relatively narrow to aid in gastric emptying The line of division is directed to a point on the lesser curvature just proximal to the crow’s foot of veins The right gastric artery and associated tissue are ligated and divided at this point on the lesser curve in order to prevent “bow-stringing” of the stomach and aid in converting the gastric tube from a curved structure into a straight conduit A final check for hemostasis in the abdomen is made prior to pulling the conduit into the neck The gastric FIGURE 41-5 After verification of an excellent pulse in the gastroepiploic arcade, the stapler is fired FIGURE 41-4 The second Penrose drain is knotted and left in the abdomen for retrieval during the abdominal phase of the operation FIGURE 41-6 A gastric tube is created by resecting the gastroesophageal junction and lesser curve of the stomach Strategies for Esophageal Replacement and Reconstruction / 495 conduit must be mobilized to the neck with minimal trauma and without twisting One reliable atraumatic method is pulling the conduit up in a plastic endoscopic camera bag The silk tie, which had been brought into the abdomen through the mediastinum from the neck, is tied to the valved end of a 30 mL Foley catheter (Figure 41-7) The balloon is secured in one end of the bag The entire conduit is placed in the bag, and the excess bag is trimmed The valved end of the Foley catheter is brought through to the neck, suction is applied to the catheter and bag, and the gastric conduit is delivered into the neck The assistant must guide and push the conduit into the mediastinum, ensuring that no rotation occurs The bag is then cut away from the conduit in the neck The pylorus should sit at the hiatus The anastomosis may be created in a side-to-side functional end-to-end using a linear 75 mm stapler followed by an endoscopic 30 mm stapler Prior to closure of the anterior wall of the anastomosis using a TA-30 stapler, the nasogastric tube is delivered into the neoesophagus with its tip at the hiatus A hand-sewn anastomosis can be created by using interrupted 3-0 silk sutures in a single layer Care must be taken to incorporate full thickness bites Either a Penrose or Jackson-Pratt drain is placed posterior to the anastomosis It is usually left in for days The platysma is closed using a running 2-0 Vicryl, and the skin is closed with staples A j-tube is inserted at a point 40 cm distal to the ligament of Treitz if one was not placed preoperatively The abdominal fascia is closed with a running #2 synthetic monofilament, and the abdominal skin is closed using staples Transhiatal Esophagectomy The abdominal phase of the procedure is carried out in a manner identical to that described above Placement of an upper hand retractor greatly aids in visualization The use of malleable handheld metal retractors at various FIGURE 41-7 The silk tie is tied to the valved end of a 30 mL Foley catheter points in the operation is also useful The esophagophrenic attachments are divided using cautery, and the distal esophagus is encircled with a Penrose drain The esophageal hiatus is dilated to allow entry of the surgeon’s hand A rim of diaphragmatic muscle is incorporated in cases of lower esophageal tumors Using the Penrose drain as a handle, the esophagus in the lower chest is mobilized bluntly Larger arterial branches directly from the aorta are clipped Keeping the fingertips against the esophagus, the prevertebral plane is developed into the upper chest A key aspect of blunt esophageal dissection is remaining very close to the esophagus, with the palmar aspect of the fingers directly against the esophagus This accomplishes two objectives The first is the avoidance of adjacent structures such as membranous trachea and the azygous vein and its branches The second is to disrupt only smaller branches of the esophageal arterial supply after they have branched approximately l cm off the esophagus At this point a lower cervical incision is made as described in the previous section on tri-incisional esophagectomy Care must be taken in getting around the cervical esophagus not to injure the recurrent laryngeal nerve The right recurrent laryngeal nerve lies some distance from the lower cervical esophagus and should be out of harm’s way if dissection is kept immediately on the esophagus and cautery is avoided Metal self-retaining retractors can also cause injury to the recurrent nerve in the tracheoesophageal groove and should not be used A Penrose drain is used to encircle the cervical esophagus, and blunt dissection is used into the upper chest with two fingertips against the esophagus Care must be taken not to injure the membranous trachea Dissection of the posterior esophagus along the prevertebral fascia is continued using a sponge stick to connect to the surgeon’s other hand inserted through the hiatus (Figure 41-8) Dissection is then carried out anterior to the esophagus in similar fashion, reversing the direction of the hand and keeping the fingertips against the esophagus (Figure 41-9) Extreme care must be taken as the surgeon approaches the carina A combination of anterior dissection from above and below are required until the fingers and sponge stick inserted from above meet The remainder of circumferential dissection of the upper esophagus is performed via the neck That portion of dissection lateral to the esophagus that cannot be directly visualized is performed bluntly The surgeon’s right hand is advanced through the hiatus anteriorly until it reaches that portion of the upper esophagus that has been circumferentially mobilized The first and second fingers surround the esophagus and press against the spine, and the lateral attachments are avulsed as the hand is drawn back into the abdomen Strategies for Esophageal Replacement and Reconstruction / 497 FIGURE 41-11 Anastomosis is typically carried out high in the chest at the level of the azygous vein less well to mechanical dilatation The hand-sewn anastomosis may be one or two layers Whatever the method of anastomosis, the incidence of leakage must be close to zero, as intrathoracic leakage carries a near 50% mortality Lack of adherence to surgical principles of lack of tension on the anastomosis, preservation of blood supply, meticulous suture placement and tying, and gentle handling of tissues will become apparent in an increased leak and mortality rate Left Thoracoabdominal Approach The left thoracoabdominal approach is most useful for benign strictures involving the distal esophagus or for proximal gastric cancers where a small margin of normal esophagus is needed It has limited utility in management of distal esophageal cancers, because of the need for adequate margins It is more difficult, though possible, to resect the esophagus high in the left chest than in the right because of the heart and aortic arch The patient is placed in the right lateral decubitus position, and the abdomen, chest, and, if total esophagectomy is contemplated, left neck are prepped and draped in the field A left anterolateral thoracotomy is made and the chest is typically entered in the sixth or seventh interspace for a distal esophagectomy If exposure of the upper esophagus is needed, then the incision can be extended posterior to the tip of the scapula midway between the scapula and the spine, and a separate entrance into the chest in the fourth interspace may be made The distal esophagus is encircled with a Penrose drain and dissected free as described in the previous sections Although the abdomen can be explored through the chest across the diaphragm, better exposure can be obtained by extending the thoracotomy incision across the costal margin and obliquely into the abdominal wall In both instances the diaphragm is taken down radially cm from the chest wall so that adequate tissue remains for diaphragmatic closure Mobilization of the stomach and a Kocher maneuver can easily be performed with this exposure Exposure of the short gastrics and spleen is excellent through this incision If only a limited segment of distal esophagus is resected, it may not be necessary to completely mobilize the gastric conduit One must not sacrifice a tension-free anastomosis, however, in order to save time on gastric conduit mobilization The esophagus should not be dissected more than a few centimeters proximal to the proposed site of division, in order to preserve blood supply to the esophagus If additional proximal margin is needed, the esophagus may be dissected behind and above the aortic arch Great care must be taken in this area to avoid injury to the left recurrent laryngeal nerve and thoracic duct The thoracic duct crosses from the right chest to the left chest at approximately the level of the carina Dissection may be continued to the neck and total esophagectomy may be completed by a counterincision in the left neck as described in the section on tri-incisional esophagectomy The anastomosis may be performed in hand-sewn, two-layered manner,6 or in a single layer.9 The anastomosis may also be stapled, although use of the EEA stapler may result in a higher incidence of stricture Omentum may be placed over the anastomosis Some anchor the proximal gastric conduit to pleura with several interrupted sutures, although it is questionable whether these sutures placed in pleura in fact take tension off the anastomosis The abdomen is closed in layers and the costal incision is carefully and securely secured by either wire or a heavy nonabsorbable monofilament figure of eight suture The chest incision is closed in standard fashion Colon as Esophageal Replacement Left Colon As stated previously, the stomach is the preferred conduit for esophageal replacement Its advantages over colon include a reliable blood supply infrequently affected by atherosclerosis, low level of bacterial colonization, need for only a single anastomosis, and a mucosa that is relatively resistant to ulceration At times, because of intrinsic peptic ulcer disease, previous gastric surgery, or involvement with tumor, the stomach may not be suitable for use as esophageal replacement In this instance, colon becomes the preferred conduit, with left colon preferred over the right The arterial anatomy is more consistent, the diameter smaller, and usable length is 498 / Advanced Therapy in Thoracic Surgery usually greater with the left colon If colon is to be used, preoperative angiography is important in individuals over 40 years of age and in anyone at risk for atherosclerotic disease A barium enema or colonoscopy is performed to rule out neoplasia or extensive diverticular disease A mechanical and antibiotic bowel preparation is required Colon interposition may be used after any of the methods of esophageal resection The length of colon needed may be estimated by placing an umbilical tape between the proposed lines of colon transection and along the margin of the colon This tape is then placed from the gastric remnant or jejunal loop along the skin of the chest to the proposed point of anastomosis in the neck or chest This approximates the length of colon needed for a subcutaneous conduit and is always sufficient length for conduit placed in the posterior mediastinum The peritoneal attachments of the left colon are mobilized along the white line of Toldt Using transillumination, the left colic artery, marginal artery of Drummond, and middle colic artery are inspected and palpated Clamping of the middle colic artery should leave the proximal portion of conduit with a palpable pulse in the marginal artery of Drummond After determining that the conduit is of good quality, the esophageal resection is completed The greater omentum is separated off the transverse colon The middle colic artery is divided and the mesocolon is divided using electrocautery, a safe distance parallel to the marginal artery (Figure 41-12) The colocolonic anastomosis is performed, and the mesocolonic defect is closed The left colon is then mobilized to the neck or chest in the same atraumatic method as used for a gastric conduit in an isoperistaltic orientation The posterior mediastinal route is preferred over substernal placement It is a more direct route to the neck and requires less length and results in less conduit angulation and a lower risk of obstruction FIGURE 41-12 The middle colic artery is divided and the mesocolon is divided using electrocautery Substernal placement may be required in cases of severe scarring of the posterior mediastinum as occurs after gastric conduit leak or prior esophageal resection We believe that performing the distal anastomosis first is better for determining the necessary length of colon The distal anastomosis can be constructed using a large EEA stapler or in a functional end-to-end manner using a linear stapler The conduit is draw up through the chest, and necessary length is determined prior to performing the proximal anastomosis The esophagocolonic anastomosis may be constructed by a one- or two-layered hand-sewn method with the end of the esophagus to the side of the antimesenteric tenia It may also be stapled using an EEA stapler or functional endto-end stapling techniques The conduit should be inspected for arterial insufficiency or venous engorgement The crus should be sutured to the conduit to prevent migration of excess colon conduit into the chest or herniation of abdominal viscera into the chest The anastomoses should be constructed over a nasogastric tube positioned in the distal stomach to allow for postoperative decompression of the conduit (Figure 41-13) Right Colon If the left colon is deemed unacceptable owing to extensive diverticular disease or previous surgery, the right colon may be used The right colon is first inspected for any pathology of the colon or mesentery The greater omentum is removed from the proximal two-thirds of the transverse colon The right colon conduit will be supplied by the middle colic artery via the marginal artery, and the ileocolic and right colic artery are clamped with a soft clamp to assess for adequate collateral circulation through the marginal artery If perfusion is deemed adequate, the right colon is harvested and an appendectomy is performed Harvesting of a short segment of distal ileum for use in the proximal conduit is FIGURE 41-13 Anastomoses are constructed over a nasogastric tube positioned in the distal stomach to allow for postoperative decompression of the conduit Strategies for Esophageal Replacement and Reconstruction / 499 controversial Proponents argue that the size match of the ileum is better for the esophagus, and the presence of the ileocecal valve may help prevent reflex esophagitis Opponents note that reflux high in the neck is rare, and the ileocecal valve adds bulk to the conduit and may contribute to antegrade obstruction After mobilizing the right colon, adequate length is confirmed by placing the conduit on the skin of the chest wall and bringing it to the neck From the surgeon’s perspective the right colon is swung counterclockwise around the axis of the middle colic artery and rotated to the neck to preserve an isoperistaltic orientation The colon ideally is brought to the neck through the esophageal hiatus and posterior mediastinum in the orthotopic if it is being used for primary esophageal replacement It should be brought to the neck in atraumatic fashion as described in the section on triincisional esophagectomy In certain situations the posterior mediastinum may be scarred, usually because of esophageal or gastric conduit leak and mediastinitis In this instance the substernal route should be used This distal anastomosis is performed first, the necessary length of conduit is confirmed, and the proximal anastomosis is then performed Jejunum as Esophageal Replacement Jejunum is generally considered the third alternative for esophageal replacement, because it generally cannot reach the cervical esophagus and thus cannot be used as a total esophageal substitute except as a free graft Jejunum may be used as a Roux-en-Y loop, a pedicled graft, or as a free jejunal graft A Roux-en-Y loop of jejunum will reach the lower esophagus easily but not the upper esophagus A point of division is chosen at a comfortable distance from the ligament of Treitz and several proximal jejunal branches of the superior mesenteric artery are divided close to the base of the mesentery Test clamping with a soft, noncrushing vascular clamp may aid in assessment of the extent of arterial branches that may be sacrificed The Roux-en-Y loop is tunneled through the retrocolic mesentery For distal esophageal replacement, the midline abdominal incision is taken across the left costal margin The anastomosis between the esophagus and jejunum is constructed in end-to-side fashion near the end of the Roux limb, either stapled or hand-sewn The distal anastomosis may be performed end-to-side hand-sewn or side-to-side with a stapler (Figure 41-14) Jejunum may also be used as a substitute for a short segment of esophagus in the treatment of benign stricture Because of the limit on the length of jejunum that can be mobilized to the chest or neck, jejunum has a limited role in esophageal replacement for malignant disease For distal esophageal strictures, pedicled proxi- mal jejunum can be swung behind the colon and stomach and into the lower chest for replacement of the distal esophagus (Figure 41-15) The best application may be in the treatment of peptic distal esophageal strictures that have failed antireflux measures and repeated dilations Distal esophageal excision with gastric pull-up may predispose one to gastroesophageal reflux as disruption of the hiatus and negative intrathoracic pressure draws gastric secretions into the chest Resection of the stricture, leaving the stomach in the abdomen and interposing a short segment of isoperistaltic jejunum, may be the best method of preventing recurrent gastroesophageal reflux disease and stricture For isolated benign cervical esophageal disease, free jejunal interposition is an option (Figure 41-16) The diameter of jejunum closely approximates the diameter of the esophagus, and its lack of bulk is optimally suited to the neck This technique, first described by Jurkiewicz involves harvesting a short segment of jejunum including its vascularized pedicle in atraumatic fashion 16 After dissection of the cervical esophagus and jugular and carotid vessels, the abdomen is explored and a section of jejunum at least 20 cm past the ligament of Treitz is harvested This segment of free jejunum is brought to the neck and the proximal and distal esophageal anastomoses are completed An operating microscope is then used to FIGURE 41-14 Distal anastomosis may be performed end-to-side hand-sewn or side-to-side with a stapler FIGURE 41-15 Pedicled proximal jejunum are swung behind the colon and stomach and into the lower chest for replacement of the distal esophagus Strategies for Esophageal Replacement and Reconstruction / 501 the esophagus They found that 20% of patients with margins less than cm and 8% of patients with margins less than 10 cm developed local recurrence No patients with margins greater than 10 cm developed local recurrence.22 A 10 cm margin is optimal in esophageal resection Wong points out that the average tumor is 6.3 cm in length, and thus even if a near-total esophagectomy is performed, a 10 cm margin is possible only with mid or distal esophageal tumors 23 The additional proximal margin gained from a cervical versus intrathoracic anastomosis has been estimated to be about to cm A longer margin can be obtained if the anastomosis is made in the apex of the right chest using an EEA stapler than with a hand-sewn anastomosis in the mid-high right chest Using an EEA stapler smaller than 33 mm, however, is associated with the development of strictures.23 Thus, use of a cervical anastomosis in mid and upper esophageal cancers is useful in obtaining optimal proximal margins Proponents of an intrathoracic anastomosis argue that intraoperative confirmation of margins using frozen section and the ability to convert from an Ivor Lewis to cervical anastomosis if needed makes their approach equally as sound The importance of the lymph node dissection, and the extent of lymph node dissection required, is debated Skinner has long been a proponent of radical esophagectomy with en-bloc resection of pleura, pericardium, thoracic duct, and all regional nodes His group reported an overall 4-year survival of 37% with en-bloc resection versus no survivors after standard resection in stage III esophageal cancer patients.24 This study was retrospective, nonrandomized, and subject to selection bias but nonetheless shows a dramatic difference in equally staged patients To date, no prospective, randomized US studies have shown a survival advantage to lymphadenectomy in esophageal cancer patients The study by Goldminc mentioned previously, which randomized patients to transhiatal versus transthoracic resection, did not show a significant difference in survival, although there was a trend favoring survival in patients undergoing transthoracic resection with lymph node dissection It is clearly difficult to assemble a large randomized prospective trial comparing more radical with conservative resections of the esophagus, and the issue may never be resolved completely The incidence of certain complications and their severity varies between techniques of esophageal resection The most dreaded complication in esophagectomy is an intrathoracic leak An intrathoracic leak carries a high mortality rate, and even when survived, it carries a tremendous burden in intensive care unit and hospital stay and delayed recovery The incidence of intrathoracic leak varies greatly but is generally considered to be in the range of to 10% Early reports described a 70 to 90% mortality from an intrathoracic leak 10 More recent reports describe a mortality rate of 20 to 44%.25–27 With earlier diagnosis and improved treatment in high-volume centers, survival from an intrathoracic leak continues to improve The one thing that is clear regarding an intrathoracic anastomosis is that it must be done with a low incidence of leak The incidence of leak from a cervical anastomosis is generally higher than with an intrathoracic anastomosis, typically in the 10 to 15% range.8 The mortality from a leak in the cervical position is much lower than an intrathoracic leak and is in the range of to 6% A leak in the neck can be diagnosed radiographically on barium swallow or clinically by fever, elevated white blood cell count, localized redness, and tenderness Treatment requires opening the incision at the bedside with local anesthesia, with or without sedation The platysma is opened, and a finger is passed deep to the anastomosis in order to break up any loculated collections The patient is maintained on jejunal feeds, nothing by mouth, until the fistula is closed If the leak is large, placement of a T-tube stent may help control drainage and allow for stenting of the anastomosis Rarely, leakage from a cervical esophageal anastomosis may enter the thorax This may result from either retraction of the gastroesophageal anastomosis into the high thorax or leak of enteric contents in dependent fashion into the mediastinum This leak must be treated like any life-threatening intrathoracic leak, with thoracotomy, drainage, and diversion, if necessary Provided there is no leakage into the mediastinum, the main sequelae of a cervical esophageal leak are limited to patient inconvenience and a higher incidence of stricture associated with leak The stricture rate associated with a gastroesophageal anastomosis is higher in the cervical region than in the intrathoracic position and may be almost double (28% vs 16%).28 This is commonly attributed to increased tension on the anastomosis, decreased arterial perfusion in the long conduit, and increased venous congestion of the conduit possibly owing to swelling in a tight cervical compartment Honkoop and colleagues studied the risk factors for late stricture and compared a single-layer continuous synthetic anastomosis to a circular EEA cervical anastomosis 29 They found that previous cardiac disease, EEA stapler, and postoperative leak increased the risk for stricture These strictures can usually be treated by bougienage dilation, although repeat dilations may be necessary Dilation of an anastomosis made with an EEA stapler may not be possible In our series, using a combination of hand-sewn and stapled cervical anastomoses, the stricture rate requiring more than two dilations was 9%.9 Recurrent laryngeal nerve injury is also higher with an anastomosis in the cervical position versus the intratho- 502 / Advanced Therapy in Thoracic Surgery racic position A review of 5,483 esophagectomy patients showed a recurrent nerve palsy rate of 4.8% with the Ivor Lewis approach versus 11.2% with the transhiatal approach.28 Initially, the Brigham and Women’s Hospital rate of recurrent laryngeal nerve injury following triincisional esophagectomy with radical mediastinal lymph node dissection was 17% After modification of surgical technique including isolation of the cervical esophagus from within the vagus nerve high in the mediastinum the rate of recurrent nerve injury dropped to 7%.9 Recurrent nerve palsy may affect quality of life and result in aspiration pneumonia and sepsis Recognized early and treated aggressively, however, the risk of aspiration pneumonia and sepsis may be minimized At the Brigham and Women’s Hospital, any patient who is noted postoperatively to have hoarseness or an ineffective cough undergoes immediate laryngoscopy If a vocal cord paralysis is noted, it is injected and medialized This aggressive mode of treatment has limited the incidence of postesophagectomy pneumonia at that institution to 5%.9 The effect of the thoracotomy incision itself is manifested in patient discomfort and splinting Surprisingly, the incidence of pulmonary complications has not been shown to be any lower with a transhiatal esophagectomy than when a thoracotomy is used This may be because of several factors The widespread use of epidurals, limited thoracotomy incisions, and muscle-sparing approaches all aid in limiting post-thoracotomy discomfort and splinting The increased incidence of recurrent nerve injury with cervical as opposed to intrathoracic anastomosis with its attendant risk of aspiration may account for the significant incidence of pulmonary complications seen with transhiatal esophagectomy, despite the absence of a thoracotomy incision Although both vagus nerves are divided during esophagectomy, reflux esophagitis in the remaining portion of esophagus can be a major problem This may be a result of continued acid production and reflux or reflux of bile into the conduit It is theorized that negative intrathoracic pressure draws bile or acid into the chest Construction of a narrow gastric conduit is also believed to aid in emptying of the conduit and minimization of reflux While it is unclear whether construction of a cervical anastomosis carries a lower risk of reflux esophagitis than with a high intrathoracic anastomosis, most believe that a distal esophagectomy with low intrathoracic anastomosis is at high risk for complications from reflux esophagitis Turnball and Ginsberg found that 20% of patients undergoing distal esophagectomy needed repeat surgical procedures to relieve symptoms from reflux or stricture.30 Conclusion In summary, the esophageal surgeon must be skilled in a variety of techniques of esophageal resection and reconstruction A surgeon skilled in only a single technique of esophageal resection cannot adequately care for the wide spectrum of patients presenting with esophageal cancer Although in esophageal surgery, as in medicine in general, there are no absolutes, there are general guidelines that should be followed A 10 cm proximal margin is desirable, and thus cancers of the middle and upper esophagus should undergo complete resection with anastomosis in the neck If an Ivor Lewis resection is used for middle-third lesions, the surgeon must be prepared to convert to a tri-incisional esophagectomy if the initial frozen margin is close or positive In locally advanced middle-third tumors, thoracotomy and dissection under direct vision is desirable and improves the safety of the operation The same may apply to middle-third tumors receiving neoadjuvant therapy For tumors of the distal esophagus, transhiatal, tri-incisional, and Ivor Lewis resection are probably equally as safe and probably result in equivalent long-term survival An intrathoracic anastomotic leak is disastrous, carrying a mortality rate of up to 50% Any surgeon that performs esophagectomy with an intrathoracic anastomosis must so with a low incidence of leakage, certainly under 5% The use of an EEA stapler smaller than 33 mm in performing this anastomosis is associated with a higher rate of stricture and should probably be avoided Finally, a skilled esophageal surgeon must be prepared to employ jejunal and colonic conduits if stomach is not available for replacement and should use these conduits primarily if a distal esophageal resection is performed for peptic stricture References Earlam R, Cunha-Melo JR Oesophageal squamous cell carcinoma: I A critical review of surgery Br J Surg 1980;67:381 Ellis FH Carcinoma of the esophagus Cancer 1983;33:264 Posthlethwait RW Complications and deaths after operations for esophageal carcinoma J Thorac Cardiovasc Surg 1983;85:827 Giuli R, Gignoux M Treatment of carcinoma of the esophagus Retrospective study of 2400 patients Ann Surg 1980;192:44 Muller TM Surgical therapy of oesophageal carcinoma Br J Surg 1990;77:845m Mathisen DJ Transthoracic esophagectomy: a safe approach to carcinoma of the esophagus Ann Thorac Surg 1988;45:137 Strategies for Esophageal Replacement and Reconstruction / 503 Mitchell RL Abdominal and right thoracotomy approach as standard procedure for esophagogastrectomy with low morbidity J Thorac Cardiovasc Surg 1987;93:205 20 Goldminc M, Launois B, et al Oesophagectomy by a transhiatal approach or thoracotomy: a prospective randomized trial Br J Surg 1993;80:367–76 Orringer MB, Marshall R, Iannettoni MD Transhiatal esophagectomy: clinical experience and refinements Ann Surg 1999;230:392–403 21 Chu KM, Wong J, et al A prospective randomized comparison of transhiatal and transthoracic resection for lowerthird esophageal carcinoma Am J Surg 1997;174:320–4 Swanson SJ, et al Transthoracic esophagectomy with radical mediastinal and abdominal lymph node dissection and cervical esophagogastrostomy for esophageal carcinoma Ann Thorac Surg 2001;72:1918–25 22 Tam PC, Cheung TIC, Ma L, et al Local recurrences after subtotal esophagectomy for squamous cell carcinoma Ann Surg 1987;205:189–94 10 Urschel J Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review Am J Surg 1995;169:634–9 23 Wong J Esophageal resection for cancer: the rationale of current practice Am J Surg 1987;153:18–24 11 McKeown K Total three-stage oesophagectomy for cancer of the oesophagus Br J Surg 1976;63:259 24 Altorki NK, Girardi T, Skinner DB En bloc esophagectomy improves survival for stage III esophageal cancer J Thorac Cardiovasc Surg 1997;114:948–56 12 Swanson S, Sugarbaker D The tri-incisional esophagectomy—the Brigham and Women’s Hospital Approach Chest Surg Clin N Am 2000;10:531–52 13 Orringer MB Technical aids in performing transhiatal esophagectomy without thoracotomy Ann Thorac Surg 1984;38:128–32 14 Lewis I The surgical treatment of carcinoma of the esophagus with special reference to a new operation for growths of the middle third Br J Surg 1946;34:18–31 15 Law S, Fok M, Chu KM, Wong J Comparison of hand-sewn and stapled esophagogastric anastomosis after esophageal resection for cancer — a prospective randomized controlled trial Ann Surg 1997;776:169–73 16 Jurkiewicz MJ Vascularizcd intestinal graft for reconstruction of the cervical esophagus and pharynx Plast Reconstr Surg 1965;36:509–17 17 Stark SP, Delcore R, et al Transhiatal versus transthoracic esophagectomy for adenocarcinoma of the distal esophagus and cardia Am J Surg 1996;172:478–82 25 Sauvanet A Diagnosis and conservative management of intrathoracic leakage after oesophagectomy Br J Surg 1998;85:1446–9 26 Ellis HF, Krasna MJ Esophagogastrectomy for carcinoma of the esophagus and cardia: a comparison of findings and insults after standard resection in three consecutive eightyear intervals with improved staging criteria J Thorac Cardiovasc Surg 1997;113:836–46 27 Fahn HJ, Wang LS Leakage of intrathoracic oesophagovisceral anastomoses in adenocarcinoma of the gastric cardia: changes in APACHE III scores and their prognostic significance Eur J Surg 1997;163:345–50 28 Rindani R, Martin C, Cox M Transhiatal versus Ivor Lewis oesophagectomy: is there a difference? Aust N Z J Surg 1999;69:187–94 18 Pac M, Keles M, et al Transhiatal versus transthoracic esophagectomy for esophageal cancer J Thorac Cardiovasc Surg 1993;106:205–9 29 Honkoop P, et al Benign anastomotic strictures after transhiatal esophagectomy and cervical esophagogastrostomy: risk factors and management J Thorac Cardiovasc Surg 1996;111:1141 19 Hankins JR, McLaughlin JS, et al Carcinoma of the esophagus: a comparison of the results of transhiatal vs transthoracic resection Ann Thorac Surg 1989;47:700–5 30 Turnball AM, Ginsberg RJ Options in the surgical treatment of esophageal carcinoma Chest Surg Clin N Am 1994;4:315–29 CHAPTER 42 MINIMALLY INVASIVE ESOPHAGECTOMY YARON PERRY, MD ANTHONY T PETRICK, MD JAMES D LUKETICH, MD Modern esophageal surgery dates to 1913, when Torek was the first to successfully remove the thoracic esophagus Torek made no attempt to reestablish cervical esophageal continuity with the gastrointestinal tract Since that time numerous approaches to esophageal resection and reconstruction have been described The most commonly performed procedures today are the transhiatal esophagectomy popularized by Orringer and the combined thoracic and abdominal esophageal resection.1 Although the transhiatal approach is believed by some to be associated with fewer pulmonary complications, regardless of the surgical approach, esophagectomy remains one of the most physiologically stressful surgical procedures performed today Open esophagectomy is associated with high rates of morbidity (60 to 84%) and mortality rates ranging from to 4% in specialized centers—mortality increases to over 10% in less experienced hands.2 The transhiatal approach to esophagectomy may limit the pulmonary morbidity of the procedure but has been criticized as violating the surgical oncologic principles of en bloc resection Recent studies have shown that the most important issue regarding morbidity and mortality for either approach is that it can be reduced in high-volume centers.3 In an effort to limit the physiologic stress of esophagectomy while preserving the principle of en bloc resection, our group at the University of Pittsburgh Medical Center (UPMC) has developed a minimally invasive approach to esophageal resection Minimally invasive approaches to gastrointestinal surgery have been shown to protect the patient to some degree from the physiologic impact of the procedure In general, most patients experience less pain, fewer wound complications, less blood loss, and a quicker return to normal activity However, some complications have been reported to be more common with minimally invasive procedures, including iatrogenic bowel and vascular injuries In addition, the cost of disposable minimally invasive equipment and longer operative times needs to be considered Since the introduction of the laparoscopic Nissen fundoplication for reflux disease4 there has been a dramatic increase in the types of esophageal disease approached using minimally invasive techniques and in the number of centers performing these procedures Minimally invasive approaches have been described for the treatment of achalasia,5 paraesophageal hernia,6 and reflux associated with a shortened esophagus7 and for the staging and treatment of esophageal cancer.8 Our investigations in animal and cadaver models documented the feasibility of laparoscopic and thoracoscopic esophageal resection Numerous clinical reports have also confirmed the feasibility and potential advantages of minimally invasive esophagectomy (MIE) DePaula and colleagues, and Swanstrom and Hansen10 were the first to report a total minimally invasive approach to esophagectomy Their procedure included a laparoscopic transhiatal esophagectomy operation similar to the open transhiatal technique described by Orringer Subsequently, our UPMC group reported the totally MIE,11 which consisted of a thoracoscopic esophageal mobilization procedure as described by Law and colleagues12 and laparoscopic gastric mobilization with a cervical anastomosis as described by De Paula and coworkers and Swanstrom and Hansen The rationale for thoracoscopic esophagectomy was to allow a better view to facilitate accurate dissection of the esophagus, perform en bloc lymphadenectomy, and provide hemostasis without the morbidity of a thoracotomy Although total Minimally Invasive Esophagectomy / 505 minimally invasive esophagectomy has been shown to be feasible and safe in experienced hands, controversy still exists concerning indications, optimal approach, and clinical benefits This chapter addresses these issues and summarizes our own experience Indications The indications for the laparoscopic or thoracoscopic esophagectomy in our early experience were stricture (1%), lymphoma (0.5%), perforation (0.5%), tracheoesophageal fistula (1%), Barrett’s syndrome with highgrade dysplasia (18%), and carcinoma (79%) In our initial experience we avoided large bulky tumors and patients with extensive lymph node metastases As we gained experience and confidence in the minimally invasive approach, we included patients who had received neoadjuvant chemotherapy and, in some cases, radiation Surgical Approach In August 1996 we performed our first MIE at UPMC using an approach similar to that described by DePaula and Swanstrom using a laparoscopic transhiatal esophagectomy 9,10 The advantages of the transhiatal approach include no repositioning of the patient or single-lung ventilation The limitations of this approach include the small working space through the esophageal hiatus Laparoscopy provides only limited access to thoracic lymph nodes, and there is significant difficulty gaining mobilization of the middle and upper thirds of the esophagus Because of these limitations our standard approach evolved to include thoracoscopy to facilitate esophageal mobilization and lymph node dissection.8 Initially, patients primarily with Barrett’s high-grade dysplasia 13 were offered MIE As our experience has increased, most patients with resectable lesions are now included The approach now most commonly used at UPMC is the combined laparoscopic and thoracoscopic esophagectomy posterior axillar y line and the eighth interspace Additional ports are placed posterior to the tip of the scapula and another at the anterior axillary line and fourth intercostal space The final port is for retraction of the lung and countertraction during the esophageal dissection The patient’s body habitus will determine optimal port placement and the surgeon’s flexibility in placement greatly influences the ease of the operation An elevated diaphragm sometimes obscures exposure of the distal esophagus In this case, a single retracting suture (O-Surgitek, US Surgical, Norwalk CT) is placed near the central tendon of the diaphragm and brought out of the inferior anterior chest wall through a mm skin incision This will provide downward traction on the diaphragm to allow good exposure of the distal esophagus Dissection of the thoracic esophagus is primarily accomplished with the ultrasonic scalpel Mobilization begins with division of the inferior pulmonary ligament and incision of the mediastinal pleura up to the level of the inferior pulmonary vein Paraesophageal lymph nodes are swept toward the specimen and the subcarinal lymph nodes are dissected with the specimen exposing the left and right main stem bronchi The azygos vein is divided using the endo-GIA stapler (US Surgical) The pleura is then incised lateral to the esophagus Aortoesophageal vessels are divided, and clips are used liberally in the area of the thoracic duct To facilitate exposure a Penrose drain is placed around the esophagus (Figure 42-2) and used as a traction device Following mobilization of the esophagus from the thoracic inlet to the diaphragmatic reflection, a single 28 F chest tube is inserted through the camera port, and an intercostal block using 0.5% Marcaine is administered Ports are closed, and the patient is turned to the supine position Video-Assisted Thoracic Surgery Mobilization The patient is prepared with a double-lumen endotracheal tube for single-lung ventilation and then placed in the left lateral decubitus position The operating surgeon is positioned on the patient’s right with the assistant on the left Port placement is crucial to facilitate a minimally invasive approach to any complex procedure Four thoracoscopic ports are placed (Figure 42-1) Initially, the camera port is placed at the anterior axillary line and seventh intercostal space The second port (10 mm) is the working port for the operating surgeon and is in the FIGURE 42-1 Video-assisted thoracoscopic surgical port sites 534 / Advanced Therapy in Thoracic Surgery ultrasound of, 166 Broncholithiasis, 252f, 274–275 bacteriology of, 274 diagnosis of, 274 management of, 274–275 pathogenesis of, 274 surgery indications of, 274 surgical treatment of, 266–276 Bronchopleural fistula development of, 209 Bronchoscopy See also Laser bronchoscopy; Rigid bronchoscopy operative strategy of, 219 surveillance, 372 techniques of, 219 therapeutic role of, 275 Bronchus carcinoma survival, 101f dissection and division of, 360, 361 stapler placement of, 70f Bupivacaine for postthoracotomy blocks, Bystander effects, 116–117, 116f C Cadaveric organ transplantation recipient survival of, 367f Caffey hyperostosis, 179 Calcified granuloma CT scan of, 43f Calcium channel blockers for PPH, 289 Calcium overload ischemia-reperfusion lung injury, 330 Camelot sign, 245 cAMP See Cyclic adenosine monophosphate (cAMP) Cancer solitary metastatic, 143 Candida albicans, 253 Carbon dioxide lasers, 91 Carbon monoxide diffusing capacity (DLCO) with nonseminomatous GCT, 423 Carboplatin for nonseminomatous GCT, 422 Carboplatin for, 422 Cardiac anomalies with Barrett’s esophagus, 480 Cardiac sympathetic fibers blockade of, 14 Cardiopulmonary bypass, 303 comparison of, 310f Cardiopulmonary perfusion standard flow of, 303 Carinal reconstruction postresection, 224f resections, 222–225 Carolina rinse solution, 329 Carotid sheath, 442 Casoni skin test, 247 Catastrophic hemodynamic deterioration with ECMO, 315 Cavitation, 253 CCAM See Congenital cystic adenomatoid malformations (CCAM) Cell death lung transplantation, 331–332 Cell injury of membrane lipids, 332 Celsior, 326 Central alveolar hypoventilation, 450 Cervical leaks, 515f, 516 complications, 516–517 fulminant leaks, 516 CGF See Chronic graft failure (CGF) Chest deformities classification of, 146f Chest pain with esophageal stents, 526 Chest radiography, 33–34 Chest wall benign soft tissue tumors of, 136–137 deformities management of, 145–162 pectus excavatum, 145–150 malignant soft tissue tumors of, 137–142 metastatic tumors of, 142–143 primary tumors of, 125t tuberculosis, 261 tumors benign bony tumors, 128–130 benign soft tissue, 136–137 clinical presentation of, 126 desmoid, 141–142 diagnosis of, 126–127 malignant bony tumors, 130–136 malignant soft tissue tumors, 137–142 primary and secondary, 125–144 secondary, 142–143 treatment of, 127 Children bronchogenic cyst, 164 ECMO, 309 with evidence of hyperinflation, 173 with pulmonary sequestration, 171–172 Chondromanubrial prominence with chondrosternal depression, 153 Chondromas, 129 clinical diagnosis of, 127 Chondrosarcoma, 126 of the anterior chest wall, 131f, 132f CT scan of, 126f Chondrosternal depression, 145 and chondromanubrial prominence, 153 Chondrosternal prominence, 151 Choriocarcinomas, 420, 423 Chronic graft failure (CGF) survival after transplantation, 381 Chronic lung rejection pathogenesis of, 369 Chronic obstructive pulmonary disease (COPD), 398 with pulmonary hypertension, 293 Chronic postoperative pain dysfunction definition of, less than one year after VATS, 3t more than one year after VATS, 3t Chronic pulmonary thromboembolism modern management of, 297–307 Chronic respiratory failure representation of, 398 Chronic thromboembolic pulmonary hypertension (CTPH), 291–292 with acute pulmonary embolism, 291 angioscopy, 291–292 causes of, 291 CT angiography, 291 duplex scanning, 291 patient evaluation, 291 presentation of, 291 right heart catheterization, 291 Chylothorax, 180 Chylous effusions, 179 Ciliary defects, 270t Circumferential dissection, 228f Cisapride for GERD, 467 Cisplatin adverse effects, 424 for nonseminomatous GCT, 422 CLE See Congenital lobar emphysema (CLE) Cleft sternum, 158–161 clinical features of, 158–159 clinical symptoms of, 159–160 results and complications of, 161 sternal foramen, 161 Clinical allotransplantation success of, 386 Clinical lung transplantation, 329 Clotting cascade activation of, 404 Clubbing with PAVM, 235 CMV See Cytomegalovirus (CMV) Coagulation cascade final steps of, 50f Coagulation pathway adhesive interaction of, 393–394 Coastal cartilage mechanical model of, 146f Coccidioidomycosis, 252, 255f Codeine administration of, Coherent Laser, 92f Coil embolization chest radiograph of, 237f pulmonary angiogram, 237f Cold abscesses Index / 535 of chest wall, 261 Collar incision, 227 Collis gastroplasty for GERD, 473–474, 475f Colon as esophageal replacement, 497–499 Complement activation prevention of, 393 Complement fixation test, 247 Complement system ischemia-reperfusion injury, 336 Complete vascular rings treatment of, 190–192 Computed tomography (CT) angiography effectiveness of, 38 characteristics of, 78 enhancement, 43–44 helical, 34, 36 improvements of, 39 spiral, 34 techniques of, 40 Congenital cystic adenomatoid malformations (CCAM), 163, 174–179, 175f classification of, 175 CT, 176, 176f, 177f expansion of, 167 intraoperative photo, 177f prenatal diagnosis of, 178 radiograph of, 176f resection of, 178 specimen of, 177f survival of, 179 ultrasound of, 176f Congenital diaphragmatic hernia ECMO, 316 Congenital Diaphragmatic Hernia Study Group, 316 Congenital lesions CT scan of, 163 Congenital lobar emphysema (CLE), 171–174 from CCAM, 172 CT scan of, 173 degree of hyperinflation, 171 elective resections of, 173 intrinsic obstruction of, 171 outcome for babies, 174 pathology specimen of, 171f prenatal diagnosis, 172 pulmonary tests of, 172 surgical specimen of, 174f treatment strategy for, 172 Congenital lung lesions investigation of, 184 Congenital pulmonary lymphangiectasis, 179, 180–181 Congestive heart failure, 238 Constitutive promoters, 114 COPD See Chronic obstructive pulmonary disease (COPD) Copper ischemia-reperfusion lung injury, 334 Corticosteroids (CS) dosing and administration of, 352 immune system, 351–352 for lung transplantation, 351–352 mechanism of action, 351–352 CoSeal, 48 clinical trials of, 52 types of, 53f CoStasis, 48, 49, 52 Costoclavicular test military position, 197 Cough with bronchiectasis, 271 C3 protein diffuse deposition of, 389f C-reactive protein, 394 Crescent sign, 245 Cryptococcal infection, 256, 256f Cryptococcus neoformans, 255 CS See Corticosteroids (CS) CsA See Cyclosporine A (CsA) CT See Computed tomography (CT) CTPH See Chronic thromboembolic pulmonary hypertension (CTPH) Cuff stenosis, 216, 218f Currarino-Silverman syndrome, 153 Cyanosis with PAVM, 235 Cyclic adenosine monophosphate (cAMP), 334 nitrous oxide (NO), 334 NO, 334 Cyclin D1 with Barrett’s esophagus, 486 Cyclooxygenase NSAIDs inhibitions of, Cyclophosphamide for Ewing’s sarcoma, 133 for sarcoma, 141 Cyclosporine A (CsA), 347–349 chemical structure of, 347 dosage and administration of, 348–349 drugs that may cause decrease of, 348t drugs that may cause increase of, 348t for lung transplantation, 347–349 administration, 348–349 dosage, 348–349 drugs decreasing, 348t drugs increasing, 348t mechanism of action, 347 pharmacology of, 347–348 mechanism of action, 347 pharmacology, 347–348 structure of, 347 Cylindrical bronchiectasis bronchogram, 270 Cystic bronchiectasis, 269f Cystic fibrosis, 270t of pleural cavity, 362 Cytokines ischemic-reperfusion injury source and function of, 332t network, 33 Cytomegalovirus (CMV), 270, 369 commonality of, 353 management schemes of, 372 pneumonia, 370 D Daclizumab (Zenapax), 354 studies of, 354 Dactinomycin for Ewing’s sarcoma, 133 Da Vinci Surgical System, 194 DCLHb See Diaspirin cross-linked hemoglobin (DCLHb) Decortication indications of, 212–213 Dermoid cyst, 420 Descending necrotizing mediastinitis (DNM), 441–446, 445f anatomy of, 441–442 clinical manifestations of, 443–444 diagnosis of, 444–445 pathophysiology of, 443 treatment of, 445–446 results, 446 Desmoid tumor chest wall, 141f CT, 141 doxorubicin for, 142 shoulder MRI, 127f Dextran, 326 erythrocyte deformability of, 326 low-potassium, 326 Diagnostic imaging advance technology applications of, 35–43 Diaphragmatic pacing, 449–453 apparatus, 449–450, 450f failures, 452 outcome, 452 patient selection, 450–451 preoperative screening, 451 schedule, 452 surgical technique for, 451–452 trends, 452–453 Diaspirin cross-linked hemoglobin (DCLHb), 278 Diazepam with thymectomy, 409 Diffuse esophageal spasm preoperative evaluation, 460–461 Digoxin for PPH, 290 Diomed laser, 93f Direct endoscopic therapy role of, 97 Disaccharide Galactosyl alpha 1, 389 chemical structure, 389f Disaggregated pain treatment of, 21 Disaggregation 536 / Advanced Therapy in Thoracic Surgery definition of, Discordant xenogeneic grafts fate of, 387 Ditzels, 42–43 DLCO See Carbon monoxide diffusing capacity (DLCO) DNM See Descending necrotizing mediastinitis (DNM) Dominant suppression, 117 Donor lobectomy, 358–365 lower left, 360–361 postoperative pain control, 258 Donor lungs deflation of, 359 shortage of, 386 Dor fundoplication for GERD, 472–473, 474f Double aortic arch formation of, 190f intraoperative view, 191f MRI, 190f repair of, 191 treatment of, 190–191 Down syndrome, 179, 180 Doxorubicin for desmoid tumor, 142 for Ewing’s sarcoma, 133 for sarcoma, 141 Dual-energy radiographs, 33f Ductus arteriosum formation of, 186 Dysphagia with GERD, 474–475 Dysphagia lusoria, 188 Dyspnea with CTPH, 291 with PAVM, 234–235 E Early Lung Cancer Action Project, 40 Early stage lung cancer multimodality management of, 61–65 Early stage nonsmall cell lung cancer, 61 adjuvant therapy, 61–63 chemotherapy, 62, 64 platin-based regimens, 62–63 postoperative chemotherapy meta-analysis of, 62t postoperative UFT meta-analysis of, 63 radiation, 61–62 survival rates of, 61t UFT regimens, 63 Echinococcosis, 241 Echinococcus granulosus, 241, 437 Echinococcus multilocularis, 241 ECLS See Extracorporeal life support (ECLS) ECMO See Extracorporeal membrane oxygenation (ECMO) EEA See End to end anastomosis (EEA) EER See Extraesophageal reflux (EER) Effort thrombosis of axillary-subclavian vein, 201 Eisenmenger’s syndrome, 301 Elastofibroma dorsi, 137 CT scan of, 138f Electrode delivery systems, 83 Electronic radiology, 32 Electrophrenic respiration, 449 ELISA See Enzyme-linked immunosorbent assay (ELISA) ELSO See Extracorporeal Life Support Organization (ELSO) Embolic pulmonary hypertension, 298–300 medical therapy of, 302 Embryonal carcinoma, 420 Emphysema See Congenital lobar emphysema (CLE) Empyema classification of, 210t therapy of, 210t VATS, 212 Enchondroma, 129f Endodermal sinus tumors, 420 Endogenous nitric oxide, 327 Endo-GIA stapler, 514f Endoscopic techniques, 166 Endoscopy for Barrett’s esophagus, 480 for GERD, 456–457, 469–470 for pseudoachalasia, 463 Endothelial-epithelial barrier, 326 Endothelins, 334 End to end anastomosis (EEA) stapling device, 474, 475f, 513f Enteric cysts, 430 Enzyme-linked immunosorbent assay (ELISA), 246, 247 Eosinophilic granuloma, 129–130, 129f Epidermal growth factors with Barrett’s esophagus, 485–486 Epidural abscess, 16 Epidural analgesia, 11–20 adjuvants of, 14 advantages and disadvantages of, 14–15 contraindications of, 18–19 decrease risks of, 15 definition of, 11–12 dosing examples of, 12t drug classes of, 11 duration of, 19 efficacy of, 13–14 mechanism of action, 12–13 technique of, 11–12 Epidural anesthesia, 21 Epidural clonidine, 20 Epidural hematomas, 16 association of, 16 Epidural infections effects of, 16–17 Epidural local anesthetic-opioid combination injections, 17–18 Epidural medication requirements of, 19 Epidural morphine, 20 efficacy of, 13 Epidural nalbuphine, 20 Epidural needle complications of, 16 punctures of, 14 Epidural opioids therapeutic effects of, 13 Epidural space needle insertion effects of, 15 thoracic region, 12 Epiglottis exposure of, 95f Epinephrine for postthoracotomy blocks, Epoprostenol for PPH, 289, 290 ERBB2 gene with Barrett’s esophagus, 486 Esophagacoil stent, 522–523 Esophageal anastomotic leaks, 513–518 diagnosis of, 515–516 Esophageal anastomotic techniques, 509–513, 510t anastomosis location of, 509–510 conduit selection, 509 hand-sewn, 510–511, 512f stapled anastomoses, 511 vs hand-sewn, 511–513 Esophageal atresia, 179 Esophageal cysts, 433–434, 433f diagnosis of, 433–434 treatment of, 434 Esophageal defect, 228f Esophageal manometry for achalasia, 462, 463f for diffuse esophageal spasms, 462 for GERD, 457–458, 470 Esophageal neuromotor diseases preoperative evaluation of, 455–460, 455–464 Esophageal resection, 492–497, 500–501 left thoracoabdominal approach, 497 Esophageal stents, 520–528 bleeding, 526 chemoradiation, 527 chest pain with, 526 complications of, 524–527 custom made, 521 efficacy, 527 erosions, 526 future, 528 history of, 520–521 insertion technique, 523 malposition, 525 migration, 525 perforation, 524–525 placement of, 521, 524t plastic, 521 pressure necrosis, 526 with recurrent dysphagia, 525–526 reflux and aspiration, 526 results, 524 Index / 537 selection of, 528 self-expandable metal, 521–523 self-expandable plastic, 523 self-expanding metal stents, 527–528 sizes of, 522t types of, 521–523 Esophageal stricture with esophageal stents, 522f with GERD, 468 Esophagectomy See Minimally invasive esophagectomy Esophagogastric junction with Barrett’s esophagus, 480 Esophagram for GERD, 469 timed barium, 462f upper air hiatal hernia, 458f Esophagus replacement and reconstruction, 492–502 Etoposide adverse effects, 424 for Ewing’s sarcoma, 133 for nonseminomatous GCT, 422 Euro-Collins solutions of preservation, 326 Ewing’s Sarcoma, 126, 132–133, 133f cyclophosphamide for, 133 dactinomycin for, 133 doxorubicin for, 133 ifosfamide for, 133 radiographs of, 132 treatment of, 127 vincristine for, 133 Expiratory volume, 409 Extracorporeal carbon dioxide removal, 312 and ECMO, 308–323 with LFPPV, 312 comparison of, 310f Extracorporeal gas exchange, 308, 309–314 formats of, 313 techniques of, 310 Extracorporeal life support (ECLS), 399 operations, 317t Extracorporeal Life Support Organization (ELSO), 308 Extracorporeal membrane oxygenation (ECMO), 308 airway management, 314 arteriovenous carbon dioxide removal, 308–323 bacterial patterns of, 315 cannulation, 313–314 cannulation of, 317 catastrophic hemodynamic deterioration, 315 children, 309 circuit, 308f comparison of, 310f complications of, 314–315 flow of, 315–316 lung transplantation of, 318 patent ductus arteriosus, 315 postcardiotomy, 314 major complications, 314 preoperative supportive, 317–318 preoperative use of, 314 systemic oxygenation of, 316 techniques and management of, 312 trauma, 318 venoarterial, 310 current practice of, 311 survival of, 316 venovenous, 310 current practice of, 311 superior vena cava, 311f survival of, 316 weaning and decannulation of, 315 Extracorporeal support future of, 318 problems of, 404 Extracorporeal systems flow impediments, 403–404 Extraesophageal reflux (EER), 468 Extralobar sequestrations, 179, 239 communication of, 170 F FDA See Food and Drug Administration (FDA) FDG See Fludeoxyglucose F 18 (FDG) Fentanyl, 3–4 for direct skin transfer, 3–4 Fentanyl citrate oral transmucosal, Fertility with mediastinal GCT, 424 Fiberoptic bronchoscope induction of anesthesia, 358 insertion of, 96f Fibrin glues study of, 47 Fibrinolytic agents intrapleural for pleural space infection, 211–212 Fibrin sealants, 51f complications of, 51 HIV transmission, 51 study of, 47 viral hepatitis transmission, 51 Fibrosing interstitial lung disease with pulmonary hypertension, 293–294 Fibrotic stricture, 219 Fibrous dysplasia, 128, 128f resected rib, 128f First rib transmaxillary resection of, 200–201 Fistulas See also Tracheoesophageal fistulas arteriovenous, 234 bronchopleural development of, 209 nonmalignant tracheoesophageal, 226 pulmonary arteriovenous, 183 tracheobronchial with esophageal stents, 522f tracheoinnominate, 226 repair of, 226–227 FK506, 349–350 clinical trials of, 349 dosage and administration of, 349=350 for lung transplantation blood levels drugs decreasing, 350t blood levels drugs increasing, 350t mechanisms of action, 349 Flamingo stent, 522 Flexible scopes research of, 92 FloSeal, 48, 53f clinical trials of, 52 Fludeoxyglucose F 18 (FDG), 43 Flush solution temperature, 327 volume, pressure, and temperature, 327–328 FocalSeal, 55f clinical trials, 55 FocalSeal-L, 48, 53, 54, 54f Follicular bronchiectasis, 269 Food and Drug Administration (FDA) approved tissue adhesives, 48t Forced expiratory volume, Forced vital capacity, Foregut cysts, 429 frequency of, 430t Fourier transformation of pulmonary artery pressure waveform, 402f Fragile histidine triad gene with Barrett’s esophagus, 485 French glue, 48 French trial, 65, 65t Functional capillary density, 280f Fundoplication Dor (anterior) for GERD, 472–473, 474f laparoscopic room setup, 471f Nissen for GERD, 473f–474f, 474f Rosetti-Nissen for GERD, 476 Toupet (posterior) for GERD, 472 Fungal diseases, 251–263 Fungal lung disease thoracic surgical intervention, 255–256 indications for, 255–256 Funnel chest, 145 538 / Advanced Therapy in Thoracic Surgery G Galactosyl alpha 1, 389 chemical structure, 389f Gas bloat with GERD, 476 Gastric emptying studies for GERD, 460 Gastric tumors with mediastinal GCT, 424 Gastroesophageal reflux disease (GERD), 455, 466–477 barium esophagography, 457 Barrett’s esophagus, 467–468, 470 with Barrett’s esophagus, 483 cisapride for, 467 complications of, 467–470 dysphagia with, 474–475 extraesophageal symptoms, 468–469 gas bloat, 476 gastric emptying studies, 460 with heartburn, 457f herniation, 476 24-hours pH monitoring, 459–560, 470 preoperative evaluation of, 455–460, 460t recurrent, 476 reoperative surgery, 477 surgery of complications, 475–476 contraindications for, 471 indications for, 471 trocar insertion sites, 472f treatment failure reasons for, 456t treatment of, 467 Gastrointestinal anastomosis (GIA) stapler, 474, 475, 475f GCT See Germ cell tumors (GCT) Gelatin-resorcinol-formaldehyde (GRF) glue, 48, 56, 56f Gelfoam-Thrombin hemostatic effectiveness, 52 Gemcitabine for GCT, 423 Gene therapy, 113–122 intrathoracic with thoracic surgical problems, 117–120 lung cancer preclinical studies of, 117 lung transplantation, 120, 330 nonviral vector systems, 116 strategies for lung cancer, 117t thoracic surgery, 113–122 transgene components of, 113f vectors, 115f vector systems limitations of, 116 GERD See Gastroesophageal reflux disease (GERD) Germ cell tumors (GCT) See also Mediastinal germ cell tumors classification of, 418t gemcitabine for, 423 seminomatous treatment, 421–422 testicular, 417 GIA See Gastrointestinal anastomosis (GIA) stapler Glues BioGlue, 48, 53, 57 applicator of, 57f avoiding intracoronary contamination, 57f photomicrograph, 57f biologic glue, 55–58 variations of, 57 fibrin glues study of, 47 French glue, 48 GRF glue, 48, 56, 56f Granulomas with tracheal resection, 230 GRF See Gelatin-resorcinol-formaldehyde (GRF) glue H Hamartomatous angioma, 234 Hannover Thoracic Transplant Program, 381 HAR See Hyperacute rejection (HAR) Heat gradient vectors, 77f Helical computed tomography, 34, 36 Hemangioma, 130 benign cavernous, 234 Hematologic compatibility, 403–405 Heme Assist, 278 Hemithorax opacification of, 213f Hemoglobin diffusion constant of, 281 molecular structure of, 278 research model of, 278–280 Hemoglobin solution administration of, 278f Hemoptysis, 253 occurrence of, 258 Hemorrhage with ECMO, 314 Hemorrhagic telangiectasia (HHT), 234 Hemostasis, 50 Hemostatic agents, 49–53 Heparin-bonded oxygenators, 318 Hepatic cyst CT scan, 244 Heredity Barrett’s esophagus, 483 Hernia See also Hiatal hernia Bochdalek diaphragmatic, 168 congenital diaphragmatic ECMO, 316 Herniation with GERD, 476 Heroin administration of, Herpes simplex virus thymidine kinase (HSTVK), 114 mesothelioma, 119 plus ganciclovir mesothelioma, 119 Hexacanth embryo, 241, 242 HHT See Hemorrhagic telangiectasia (HHT) Hiatal hernia, 456, 459f with GERD, 467–468 upper air esophagram, 458f Hilar adhesions distinction of tissue layers, 380f Hilar vessels control of resection, 263 Histoplasma capsulatum, 274 HIV See Human immunodeficiency virus (HIV) Horner syndrome, 203 24-hours pH monitoring for GERD, 459–560, 470 HSTVK See Herpes simplex virus thymidine kinase (HSTVK) Human immunodeficiency virus (HIV), 270 fibrin sealants, 51 Human leukocyte antigen, 325, 388 Hydatid cysts, 241–249, 245f, 246f, 437–438, 437f acute rupture stages of, 249 cause of, 241 clinical features of, 243–244 components of, 242, 242f CT scan of, 244f delivery of, 248–249 diagnosis of, 244 dissection of, 248f excision of, 243f infection of, 243 lung surgical treatment of, 247–248 management of, 241–249 mebendazole for, 247 medical treatment of, 247 MRI of, 246 parasite, 241–242 pathology of, 241 pulmonary clinical symptoms of, 244t ruptured, 245f, 246f treatment of, 247 Hydatid disease, 241 pulmonary, 247 bronchoscopy of, 246 mimicry of, 247 Hydatid hydropneumothorax, 244 Hydatid pyopneumothorax, 244 Hydatid vesicle, 243 Hydromorphone administration of, Hyoid bone dividing, 225f Hyperabduction test, 198 Hyperacute rejection (HAR), 387, 388 presumptive mechanism of, 389 prevention of, 393 Index / 539 strategies to overcome, 391–394, 392f Hyperinflation children with evidence of, 173 Hypoalbuminemia, 514 Hypoventilation central alveolar, 450 I ICAM See Intracellular adhesion molecule (ICAM) Idiopathic laryngotracheal stenosis, 217 Ifosfamide adverse effects, 424 for Ewing’s sarcoma, 133 Imaging technologies advances of, 44 Immunoelectrophoresis, 247 Immunosuppressant therapy, 231 Immunosuppression lung transplantation, 347–366 Incomplete vascular rings, 192–193 Indirect hemagglutination test, 247 Inducible nitrous oxide (iNOS), 335 Ineffective esophageal peristalsis, 458f, 459f Inferior sternal cleft, 159 Inferior thyroid artery, 215 Inflammatory lung disease, 262 preoperative preparation of, 262 technical approach of, 262–263 Infrasternal mediastinoscopic thymectomy, 412 Innominate artery compression, 192–193 embryological origin of, 192f symptoms of, 192 iNOS See Inducible nitrous oxide (iNOS) INR See International normalized ratio (INR) Intensive care unit, 335 Intercostal nerve block, 6–7 advantages and disadvantages of, contraindications of, definition and technique of, 6–7 efficacy of, mechanism of action, International normalized ratio (INR), 290 International Society for Heart and Lung Transplantation, 378 International Society of Chemotherapy Lung Cancer Study Group, 105 Interpleural analgesia, 8–11 advantages and disadvantages of, adverse effects of, contraindications of, definition of, dosing regimen of, 8t efficacy of, 8–9 mechanism of actions, technique of, Interstitial thermal therapy (ITT), 75 See also Radio frequency interstitial thermal therapies (RF-ITT) success and limitations of, 75 tissue effects of, 76 Intracellular adhesion molecule (ICAM), 333 Intralobar sequestrations, 238, 238f, 239 representations of, 168 resection of, 170 Intrapericardial hilar release technique, 226f Intrapleural fibrinolytic agents for pleural space infection, 211–212 Intrathoracic gene therapy with thoracic surgical problems, 117–120 Intrathoracic leaks, 516 Intravascular oxygenation clinical trials of, 399 Invasive aspergillus, 253f Invasive pulmonary aspergillosis (IPA), 256 surgical resection of, 256 IPA See Invasive pulmonary aspergillosis (IPA) Iron ischemia-reperfusion lung injury, 334 Ischemia-reperfusion lung injury complement system, 336 degree of, 337 iron, 334 macrophages, 336 mechanisms of, 330–334 calcium overload of, 330 metals and metalloenzymes, 334 neutrophils, 336–337 oxidative stress, 330–331 prostaglandins, 335–336 prothrombotic and antifibrinolytic agents, 334 study of, 334 vasomodulators, 334–335 ITT See Interstitial thermal therapy (ITT) Ivor Lewis esophagectomy, 496–497, 496f J Jejunum as esophageal replacement, 499–500, 499f K Kartagener syndrome, 268f, 270 Kasabach-Merritt syndrome, 181 Keel chest classification of, 151 repair of, 152f surgical correction of, 151–152 Ketamine, 20 definition of, Ketorolac tromethamine incidence of nonincisional pain, Kidney ischemia-reperfusion injury of, 331 transplantation, 329 Killian, Gustav, 91 Klinefelter’s syndrome with mediastinal germ cell tumors, 417–418 Klippel-Feil syndrome with Poland’s syndrome, 153 Kommerell’s diverticulum, 191 Kovalesky canal, 434 L Laparoscopic fundoplication room setup, 471f Laryngeal edema with tracheal resection, 230 Laryngeal nerves position of, 217f Laryngoscope, 95f anchoring, 94f Laryngotracheal resection, 222 Laser(s) injuries from, 99–100 types of, 92–93 Laser bronchoscopy, 91–100 advantages and disadvantages of, 93 in benign disease, 98 bleeding, 99 chemotherapy, 97–98 clinical applicability, 98 complications and treatment of, 99 effectiveness of, 100 history of, 92 mechanism of action, 93 patient selection, 96–98 photodynamic therapy, 96, 97 radiation therapy, 97–98 results, 98 stents, 98 Laserscope Laser, 92f Lateral pectus carinatum, 151 surgical correction of, 153 Lateral pharyngeal space, 443 Late reflush, 329 LCSG See Lung Cancer Study Group (LCSG) Left aortic arch with aberrant right subclavian artery, 193 Left lower lobectomy techniques of, 72 Left pulmonary artery, 193 intraoperative photograph, 360f Left upper lobectomy techniques of, 71–72 Left ventricular failure with pulmonary hypertension, 294 Leiomyosarcoma, 138 LES See Lower esophageal sphincter (LES) 540 / Advanced Therapy in Thoracic Surgery Leukocyte depletion beneficial effect of, 336 Leukotrienes, 333 LFPPV See Low-flow positive-pressure ventilation (LFPPV) Linear B antigen, 389 chemical structure, 389f Lipid mediated network, 332–333 Lipiodol bronchography bronchiectasis, 271 Lipoma chest wall, 136 CT of, 137f Liposarcoma, 141 Liver cells light microscopy, 79f Living donor lung transplantation, 357–366 allograft implantation, 362–363 allograft preservation, 361 bronchiolitis obliterans, 364 donor left lobectomy, 360 lobectomy, 358–365 outcome, 364–365 relationship to recipient, 364t right lower lobectomy, 359–360 screening, 358t selection, 357–358 postoperative donor management, 361 morbidity, 364 pulmonary function, 364 recipient management, 363 quality of life, 365 recipient outcome, 364 recipient pneumonectomy, 361–362 donor outcome of, 364–365 postoperative pulmonary function of, 364 recipient outcome of, 364 recipient pneumonectomy, 361–362 rejection and bronchiolitis obliterans, 364 space problems of, 364 recipient selection, 357 recipient surgical technique, 361–363 rejection, 364 space problems, 364 surgical procedure of, 358 Lobar lung transplantation alternative, 365 Lobectomy donor, 358–365 postoperative pain control, 258 donor lower left, 360–361 lower complete fissure, 71 incomplete fissure, 71 middle, 61 simultaneous stapling, 71 techniques of left lower, 72 left upper, 71–72 right upper, 71 Low-density lipoprotein receptor, 347 Lower esophageal sphincter (LES), 455 Lower left lobectomy donor, 360–361 Lower lobectomy complete fissure, 71 incomplete fissure, 71 Lower tracheal resections, 222–225 Low-flow positive-pressure ventilation (LFPPV), 312 with extracorporeal carbon dioxide removal, 312 comparison of, 310f Low potassium dextran (LPD), 326 beneficial effect PF, 326 EC, 327 glucose, 326 effect of, 326 studies in vitro, 327 LPD See Low potassium dextran (LPD) Lung(s) See also Artificial lungs expansion of, 328 fungal infections of, 251, 256 histology of, 388f HIV and AIDS, 253–255 LPD solution, 326 non-HIV associated immune suppression, 252–253 primary infections of, 251 rejection of vector, 120 restricted disease of, 133 secondary infections of, 251–252 Lung allograft, 120 rejection classification of, 369t Lung cancer, 142 clinical studies, 118–119 early-stage multimodality management of, 61–65 gene therapy preclinical studies of, 117 screening, 38–40 study group trial, 107–109 Lung Cancer Study Group (LCSG), 62, 107 results of, 110 Lung congenital lesions See Pulmonary congenital lesions Lung disease inflammatory, 262 preoperative preparation of, 262 technical approach of, 262–263 Lung dysfunction prediction of, 324 Lung inflation optimal state of, 328 Lung oncology results of, 64t Lung parenchyma preservation of, 249 Lung preservation current recommendations, 337 donor assessment, 325 solutions of, 326–327 techniques of, 324 transplantation for, 324–346 Lung rejection chronic pathogenesis of, 369 Lung retransplantation, 378–384 procedures, 382f survival of, 382f technical aspects of, 379–381 Lung transplantation anti-CD25 monoclonal antibodies, 354–355 azathioprine for, 350 biologic agents, 353 bronchial healing of, 384 causes of death after, 367f cell death, 331–332 chest, 370f clinical, 329 corticosteroids for, 351–352 cyclosporine A (CsA), 347–349 of end-stage lung disease, 383 gene therapy of, 120, 330 inflation, oxygenation, and storage temperature, 328–329 living donors of, 357–366 modern concepts of immunosuppression, 347–366 mycophenolate mofetil for, 350–351 polyclonal antibodies, 353 for PPH, 290 problem of, 405 Lung transplant recipients survival rates for, 367 Lung xenotransplantation accommodation, 391 cellular rejection, 391 chronic rejection, 391 genetically engineered donor pigs, 394 history of, 386–387 immunobiology of, 388–391 lessons learned and future perspectives, 386–394 lung HAR, 388 survival of, 394 vascular rejection, 390–391 Lymphangioma, 438 M Macrophages ischemia-reperfusion lung injury, 336 Index / 541 Magnetic resonance imaging (MRI), 34–35, 75 cardiac gating of, 35 characteristics of, 78 of chest wall tumors, 126 of pathologic fractures, 132 variations of, 34 Major hemoptysis, 256 Major histocompatibility complex (MHC), 231, 325 antigens, 231 Malignant bony tumors, 130–136 chondrosarcoma, 130–132 Malignant fibrous histiocytoma, 140f CT scan of, 140 patterns of, 140 Malignant lymphoma fungal infections of, 253 Malignant pleural effusion, 205–208 etiology of, 206t pleurodesis, 207 shunts and catheters, 208 thoracostomy, 207 treatment of, 207 VATS, 207–208 Malignant soft tissue tumors of chest wall, 137–142 Marlex mesh pectus excavatum, 148, 149f Maximal thymectomy, 410–411, 411f Mebendazole for hydatid cysts, 247 Mechanical cardiac support success of, 398 Mechanical ventilation, 329 causing tracheoesophageal fistula, 216 Mechanical ventilatory support, 370 Median sternotomy, 411–413, 411f Mediastinal cysts, 429–438 bronchogenic cysts, 431–433 embryology of, 430–431 esophageal cysts, 433–434 foregut cysts, 429 frequency of, 429t hydatid cysts, 437–438 lymphangioma, 438 neurenteric cysts, 434–435 nonneoplastic, 430t parathyroid cysts, 436 pericardial cysts, 435 pleural cysts, 435 thoracic duct cysts, 435 thymic cysts, 436–437 Mediastinal germ cell tumors, 417–425 bleomycin-associated pulmonary toxicity, 424 clinical presentation, 418–419 cytogenic abnormalities, 420–421 epidemiology, 417–418 histologic classification, 419–420, 419t immunohistochemical markers, 421 incidence, 417–418 midline tumors of uncertain histogenesis, 424–425 radiographic and imaging studies, 419 tissue sampling, 421 treatment, 421–424 toxicity, 424 tumor markers, 420 Mediastinoscopy, 222 for bronchogenic cysts, 433 Mediastinum anterior, 411f anterior superior operative, 413f Medical Research Council of Great Britain, 101 Membrane cofactor protein, 394 Meperidine administration of, Mesothelioma, 119–120 Metoclopramide for GERD, 467 MHC See Major histocompatibility complex (MHC) Microcomplement fixation procedure reactivity in, 387f Midazolam with thymectomy, 409 Middle lobectomy, 61 Middle lobe syndrome, 267 Middle lobe vein stapler placement of, 70f Midtracheal stenosis resection of, 221f Minimally invasive esophagectomy, 504–508, 507f indications for, 505 jejunostomy, 506–507 laparoscopy, 506, 506f neck dissection, 507 oncological perspectives, 507–508 surgical approach to, 505 technical considerations, 507 video-assisted, 505, 505f Mitochondrial dysfunction clinical importance of, 325 Mitral valve stenosis with pulmonary hypertension, 294 MMF See Mycophenolate mofetil (MMF) Mobius’ syndrome with Poland’s syndrome, 153 Monoclonal antibody administration of, 333 Moon sign, 245 Mounier-Kuhn syndrome, 270 MRI See Magnetic resonance imaging (MRI) Mucormycosis, 252, 253, 254f, 255f tracheal involvement, 257 Multidrug resistant tuberculosis, 259f Multiple echinococcal cysts, 248f Multiple myeloma, 135–136 Murine tracheal allografts studies of, 369 Myasthenia gravis, 407–415 diagnosis of, 407 staging of, 407t surgery of, 407–415 anesthetic management of, 409 intraoperative management, 409–410 postoperative pain relief, 410 preoperative preparation of, 409 results, 414f survival, 408f technique of, 410–413 Mycetoma, 251, 252f Mycobacterial infection, 251–263 atypical, 261–262 Mycobacterium avium-intracellulare, 261 Mycobacterium fortuitum, 261 Mycobacterium kansasii, 261 Mycobacterium tuberculosis, 257 Mycophenolate mofetil (MMF) for lung transplantation, 350–351 clinical trials of, 351 dosing and administration of, 351 mechanism of action, 350–351 pharmacokinetics of, 351 Myeloma, 126 Myocardial infarction, 324 N National Cancer Institute, 40, 140 National Cancer Institute of Canada (NCIC), 63 Nausea with GERD, 470 NCIC See National Cancer Institute of Canada (NCIC) Neck anatomy of, 442–443 fascial planes of, 442, 442f Nenerow sign, 245 Neocarina method, 224–225 Neostigmine for thymectomy, 410 Nerve compression differential diagnosis of, 200t Neurenteric cysts, 430, 434–435 diagnosis of, 434 treatment of, 434–435 Neurilemmoma, 136 Neurofibroma of chest wall, 136–137 radiograph of, 137f Neurovascular compression, 203 Neutropenic fever with mediastinal GCT, 424 Neutrophils ischemia-reperfusion lung injury, 542 / Advanced Therapy in Thoracic Surgery 336–337 New York Heart Association, 306 Nicotra, Brooke, 269 Nissen fundoplication for GERD, 473f–474f, 474f Nitrous oxide, 334, 335 cAMP, 334 developmental strategies of, 335 Nodule stability radiologic assessment of, 42 Nonincisional pain, incidence of ketorolac tromethamine, Nonmalignant tracheoesophageal fistulas, 226 Nonneoplastic mediastinal cysts, 430t Nonsmall cell lung cancer (NSCLC), 65 See also Early stage nonsmall cell lung cancer early-stages of, 64 genet therapy for, 117 preoperative chemotherapy of, 65 survival rates for, 61t TP53 functions of, 118 Nonsteroidal anti-inflammatory drugs (NSAID) chronic pain, investigations of, 22 for postoperative pain, 4–5 Nontuberculous mycobacterium infection, 262f Noonan syndrome, 180 Notch sign, 245 NSAID See Nonsteroidal anti-inflammatory drugs (NSAID) NSCLC See Nonsmall cell lung cancer (NSCLC) Nuclear factor of activated T cells, 347 Nutcracker esophagus, 462–463 O Odontogenic infection with descending necrotizing mediastinitis, 443 OKT3, 354 Opioid(s) conversion table of, 3t epidural injections of, 17 Opioid-local anesthetic combinations of, 13 Opioid-naive patients apnea, Opioid receptors location of, 13 Opitz-Frias syndrome, 179 Oral transmucosal fentanyl citrate, Osteochondroma, 128 Osteogenic sarcoma radiograph of, 134f of sternum CT scan, 135f Osteoid osteoma, 130 Osteosarcoma, 134–135 sunburst appearance, 134 Oxidative stress ischemia-reperfusion lung injury, 330–331 Oxycodone administration of, P P16 with Barrett’s esophagus, 485 P53 with Barrett’s esophagus, 485 PA See Plasminogen activator (PA) Paclitaxel adverse effects, 424 PACS See Picture archiving and communication system (PACS) PAF See Platelet activating factor (PAF) Paget, James, 200 Paget-Schroetter syndrome, 201–202 evaluation of, 202 long-term results, 202 natural history of, 202 recurrent symptoms of, 201–202 PAH See Pulmonary arterial hypertension (PAH) PAI-1 See Plasminogen activator inhibitor (PAI-1) Pain See also Postoperative pain disaggregated treatment of, 21 management of, 20–22 NSAID, postthoracotomy forms of, research, surgical interval frequencies of, 2t referred with thoracic outlet syndrome, 198 VAS, 3f decrease of, 22 rating, visceral, PAI-STK cells mesothelioma, 119 Palliative treatment strategy effectiveness of, 97 Pancoast’s tumor chest radiograph of, 36f Parapharyngeal space, 443 Parapneumonic effusion, 208 classification and therapy of, 210t drainage of, 210 therapy of, 210t Parathyroid cysts, 436, 436f Parietal pleura, 205 Partial pressure of carbon dioxide, Partial sternotomy with or without cervical incision, 412–413 Patent ductus arteriosus (PDA), 315 with ECMO, 315 with pulmonary hypertension, 294 Patient-controlled analgesia, Patient-controlled epidural analgesia (PCEA), addition of Ketorolac, Patient percentages, 55f PAVM See Pulmonary arteriovenous malformations (PAVM) PCD See Primary ciliary dyskinesia (PCD) PCEA See Patient-controlled epidural analgesia (PCEA) PCNA See Proliferating cell nuclear antigen (PCNA) PDA See Patent ductus arteriosus (PDA) Peak expiratory flow rate, Pectus carinatum, 150–155 clinical features of, 151 physiological effects of, 151 treatment of, 151 Pectus elevatum repair of, 152, 152f Pectus excavatum, 145–150 asymmetric repair of, 150f circulatory involvement of, 146–147 classification and assessment of, 145 complications of, 149–150 etiology, 145 Marfan syndrome, 147 operative indications of, 148 operative techniques of, 148–149 psychological effects of, 147–148 repair of, 149f respiratory involvement, 147 scoliosis, 147 simultaneous repair with cardiac surgery, 149 surgical correction of, 148 timing of surgery, 148 PEEP See Positive end-expiratory pressure (PEEP) PEG-Hb See Polyethylene glycol hemoglobin (PEG-Hb) Perfadex solution composition and tonic concentrations of, 326f Perfusion isotopic scans bronchiectasis, 271 Peribronchial inflammation CT scanning of, 272 Pericardial cysts, 435, 435f Pericardium, 370f Pericystic cavity, 249 Peripheral neuroectodermal tumor (PNET), 133–134 vs Ewing’s sarcoma, 133 PET See Positron emission tomography (PET) PGE See Prostaglandin E (PGE) pH monitoring Index / 543 24-hours for GERD, 459–560, 470 Photodynamic therapy laser bronchoscopy, 96, 97 types of, 92 Physiotherapy for neurovascular compression, 203 Picture archiving and communication system (PACS) advancements of, 32 Pig donor genetic engineering, 392f lung xenotransplantation, 394 Placental alkaline phosphatase (PLAP), 424–425 PLAP See Placental alkaline phosphatase (PLAP) Plasma cell tumor definition of, 135 Plasmacytoma, 135–136 Plasmapheresis with thymectomy, 409 Plasminogen activator (PA) urinary, 334 Plasminogen activator inhibitor (PAI1), 334 Platelet activating factor (PAF), 332–333 Platyhelminthes, 241 Pleura level 10 nodes of, 71f Pleural adhesions infective processes of, 263 Pleural cysts, 435 Pleural effusions, 179–180 See also Malignant pleural effusion expansion of, 167 Pleural space infections, 208–212 anesthetic management, 212 clinical presentation of, 208–209 decortication, 212–213 definition of, 208 operative management, 212–213 thoracotomy, 212 VATS, 212 Pleural space problems anatomy of, 205 antibiotics, 209–210 CT of, 209 management of, 205–214 pathophysiology, 205–208 PNET See Peripheral neuroectodermal tumor (PNET) Pneumocystis carinii, 270 Pneumonectomy, 72 Pneumonia associated with pleural effusion chest radiograph of, 211f cytomegalovirus, 370 Pneumothorax with GERD, 474 Poland’s syndrome, 153, 155–158, 155f anesthesia, 156 aplasia, 157, 157f clinical features of, 156 complications of, 158 etiology, 155–156 operative indications of, 156 repair of, 158f treatment of, 156–157 Polyethylene glycol hemoglobin (PEGHb) molecular weight of, 281 Positive airway pressure bilevel, 363 Positive end-expiratory pressure (PEEP), 328 TV of, 328 Positive-pressure ventilation low-frequency, 312 Positron emission tomography (PET), 43–44, 75 Postcardiotomy extracorporeal membrane oxygenation major complications, 314 Postdural puncture headache, 15 Posterior fundoplication for GERD, 472 Posterior lamina, 154 Posterior membranous tracheal wall flap, 224f techniques of, 224f Postoperative analgesia with postthoracotomy pain, 1–3 for thoracotomy, 1–22 Postoperative arrhythmias with epidural analgesia, 15 Postoperative care, 413 Postoperative pain chronic dysfunction definition of, less than one year after VATS, 3t more than one year after VATS, 3t control donor lobectomy, 258 lobectomy donor, 258 management of, 20 NSAID, 4–5 relief myasthenia gravis surgery, 410 VATS lobectomies, 73 Postoperative radiotherapy effect examination of, 61 Postoperative respiratory failure risk factors of, 409 Postoperative therapy, 64–65 Postoperative thoracic pain management organization of, 21f Postthoracotomy pain forms of, research, surgical interval frequencies of, 2t Post-transplant lung transplantation, 383 Posttuberculous bronchiectasis, 260f with massive hemoptysis, 260f Pouter pigeon breast, 153 cardiac abnormalities, 153 classification of, 153–154, 154f clinical features of, 153 operative indications of, 154 psychological effects of, 153 repair of, 155f respiratory disorders of, 153 surgical correction of, 154–155 PPH See Primary pulmonary hypertension (PPH) PPI See Proton pump inhibitor (PPI) Preemptive analgesia, 22 Premedication with thymectomy, 409 Pretracheal space, 442 Primary ciliary dyskinesia (PCD), 270 Primary esophageal motility disorder preoperative evaluation, 460–461 Primary lung cancer invading lateral chest wall CT scan, 142f Primary pulmonary hypertension (PPH), 285, 287–291, 398 bosentan for, 289, 290 chest radiograph of, 288 clinical signs and symptoms of, 288t complicating feature, 290 diagnosis of, 288 lung transplantation, 290 physiological evaluation of, 289 pregnancy, 290 symptoms of, 288t time of survival, 290 of a young woman, 288f Primary pulmonary hypoplasia and agenesis, 181–182 degrees of, 181 Primary tracheal tumors tracheal resection results, 229 Prograf, 349–350 clinical trials of, 349 dosage and administration of, 349=350 for lung transplantation blood levels drugs decreasing, 350t blood levels drugs increasing, 350t mechanisms of action, 349 Proliferating cell nuclear antigen (PCNA) Barrett’s esophagus, 484 Propofol for tracheal resection, 220 Prostaglandin E (PGE), 329 administration of, 335–336 beneficial effect of, 335 ischemia-reperfusion injury, 335–336 544 / Advanced Therapy in Thoracic Surgery ischemia-reperfusion lung injury, 335–336 vasodilative property, 336 Prosthetic tracheal replacements lack of success, 231 Protective ventilation, 329–330 Proton pump inhibitor (PPI), 466 for GERD, 467 Prototype artificial lung, 400f Prototype compliance chamber schematics of, 404f Proximal trachea, 95f P-selectin, 333 antagonist, 334 Pseudoaneurysms CT, 37 MRI, 37 Pseudoangina with thoracic outlet syndrome, 198 PTE See Pulmonary thromboendarterectomy (PTE) Pulmonary and systemic vascular resistance, 401 Pulmonary angiography cardiac investigations of, 301 PAVM, 235 Pulmonary arterial hypertension (PAH) causes of, 294 examples of pathogenic factors, 287t pulmonary edema, 292 radiographic features of, 292 Pulmonary arteriovenous angiomatosis, 234 Pulmonary arteriovenous fistula, 183 Pulmonary arteriovenous malformations (PAVM), 234–240 angiographic balloon placement, 236 angiographic embolization, 236 chest radiograph of, 235f clinical features of, 234 with clubbing, 235 complications of, 236 CT, 235 cyanosis with, 235 with dyspnea, 234–235 management of, 234–240 neurologic events of, 235 pulmonary angiogram of, 235, 236f with seizures, 235 Pulmonary artery, 218f, 299f, 400 dissection and division of, 360 flow vs time, 403f formation of, 186 left, 193 intraoperative photograph, 360f normal development of, 187f placement of, 359f pressure waveform Fourier transformation of, 402f sling, 186, 193–194 formation of, 193f intraoperative, 194f Pulmonary congenital lesions alveolar capillary dysplasia, 183 bronchogenic cysts, 164–167 congenital cystic adenomatoid malformation, 174–179 congenital lobar emphysema, 171–174 pleural effusion, 179–180 primary pulmonary hypoplasia and agenesis, 181–182 pulmonary arteriovenous fistula, 183 pulmonary hemangiomatosis, 181 pulmonary lymphangiomatosis, 181 pulmonary sequestration, 167–171 surgical management of, 163–185 Pulmonary cryptococcosis with AIDS, 254 Pulmonary cyst rupture of, 243 Pulmonary embolism acute special circumstances of, 298 surgical operation of, 302 Pulmonary embolus, 39f Pulmonary fibrosis clinical studies of, 133 Pulmonary function studies for bronchiectasis, 272 Pulmonary hemangiomatosis, 181 Pulmonary hydatid cyst clinical symptoms of, 244t Pulmonary hydatid disease, 247 mimicry of, 247 Pulmonary hydatidosis bronchoscopy of, 246 conservative surgery, 249 Pulmonary hypertension angiograms specimens of, 304f associated with lung disease, 293–294 cardiac diseases associated with, 294 causes, 293 chronic thromboembolic, 291–292 classification of, 285, 286t coronary arteriography, 301 CT, 301 diagnosis of, 300–302 diagnostic tests of, 301–302 Doppler echocardiography, 301 etiology of, 299 fibrosing interstitial lung disease with, 293–294 functional assessment of, 286t history of, 300 majority of deaths, 305 management of, 285–296 operation of, 303–305 perfusion scan, 301 physical examination of, 301 physiology and pathobiology, 285–286 postoperative care, 305 prognosis of, 297 pulmonary angiography, 301, 302f pulmonary arteriogram, 299f radiographic signs of, 301 restrictive lung diseases, 293 result of, 297, 301 surgical implications of, 295 surgical specimen, 299f treatment of, 294, 302–303 Pulmonary infection causes of, 261 Pulmonary lesions CT evaluation of, 43 Pulmonary lymphangiectasis congenital, 179, 180–181 Pulmonary lymphangiomatosis, 181 Pulmonary occlusive disease types of, 304 Pulmonary replacement achievement of, 402 Pulmonary retransplantation, 384 evidence of, 383 indications of, 378–379 special aspects of, 378–381 Pulmonary sealants, 53–55 Pulmonary sequestration, 167–171, 170f, 237 common features of, 238t CT scan of, 169 diagnostic imaging of, 169 locations of, 167 magnification of, 167f MRI of, 169 outcome of children with, 171–172 radiograph of, 169f treatment of, 170 types of, 168 ultrasound of, 169, 169f Pulmonary surfactant dysfunction of, 331–332 Pulmonary thromboendarterectomy (PTE), 292, 297 effective therapy of, 297 pulmonary artery planes, 306 therapeutic alternative, 306 Pulmonary values hemodynamics, 286t Pulmonary vascular resistance, 388 Pulmonary veno-occlusive disease (PVOD), 292–293 definitive diagnosis of, 292–293 subcategory of, 292 Pulmonary vessels division of, 359 Pumpless artificial lung schematics of, 401f PVOD See Pulmonary veno-occlusive disease (PVOD) Pyothorax, 246f Index / 545 Q Quality of life issues following donation, 365 R Rabbit antithymocyte globulin (RATG), 354 Radio frequency ablation of thoracic malignancies, 75–88 configuration of, 76f Radio frequency interstitial thermal therapies (RF-ITT) acute thermal lesions, 83f anatomic and pathologic considerations of, 81–83 cancer palliation and debulking, 83 chronic pneumonia, 86f clinical instruments of, 78–81 delivery probes, 81 electric impedance of tissues, 82 electrode design, 76–79 fibrous scar tissue, 88f kissing lesions, 85f lung lesion of, 76 lung tumors, 78–79 microscopic evaluations of, 82 necrosis of segmented blood vessel wall, 82 paraneoplastic syndromes, 79 pathologic and imaging studies of, 81 preclinical studies of, 81 predictability of, 83 pulmonary infarction, 87f seven days after, 85f, 86f, 87f studies of, 80t thermal lesions comparisons, 82 three days after, 84f tissue effects of, 76 tissue heating mechanisms, 76–79 treatment for, 75–76 twenty-eight days after, 88f Radiography techniques of, 32 Raffinose, 327 ras oncogene with Barrett’s esophagus, 486 RATG See Rabbit antithymocyte globulin (RATG) Raynaud’s phenomenon with thoracic outlet syndrome, 199 Recipient right pneumonectomy, 362f Recombinant viruses gene therapy studies, 115t Recurrent gastroesophageal reflux disease, 476 Recurrent laryngeal nerves, 215 Recurrent thoracic outlet syndrome, 202–204 elements of reoperation, 203 Referred pain with thoracic outlet syndrome, 198 Regional analgesia, 5t techniques appropriateness of, techniques of, 5–20 use in thoracotomies, Registry of the International Society for the Heart and Lung Transplantation, 369 Remifentanil for tracheal resection, 220 Renal cell cancer metastatic to sternum, 143f Rendu-Osler-Weber syndrome, 234 Reoperation for recurrent thoracic outlet syndrome, 203 Reperfusion response, 305 Respiration muscles disorders, 294 Respiratory complications, 413 Respiratory depression, 17 Respiratory failure, 312 acute, 209 chronic representation of, 398 postoperative risk factors of, 409 severe, 310 treatment history of, 399 Retinoblastoma with Barrett’s esophagus, 485 Retransplant cohort causes of death, 382f Retrograde flush, 329 Retropharyngeal space, 442 Retrovirus, 115 disadvantages, 115 Retrovisceral space, 442 RF-ITT See Radio frequency interstitial thermal therapies (RF-ITT) Rhabdomyosarcoma, 138, 141 Rib fracture bone cyst, 130f Rib hemangioma bone scan, 131f Right-angled clamp, 69f Right aortic arch with left ligamentum arteriosum, 191–192, 191f with mirror-image branching, 191f, 192f Right hilum, 370f Right lower lobe implantation, 362f, 363f Right pulmonary artery, 193 Right subclavian artery MRI, 190f Right upper lobectomy techniques of, 71 Rigid bronchoscopy, 94 advantages and disadvantages of, 93–94 fear of, 99 history of, 91–92 perception of, 95 technique of, 94–96 Rosetti-Nissen fundoplication for GERD, 476 Roth, Jack, 118 S Saccular bronchiectasis, 269 Sarcoidosis with mediastinal germ cell tumors, 418 with pulmonary hypertension, 294 Sarcomas See also Desmoid tumor; Liposarcoma; Malignant fibrous histiocytoma; Osteogenic sarcoma; Rhabdomyosarcoma doxorubicin for, 141 with mediastinal GCT, 424 MRI, 139f, 140f soft tissue classifications of, 140–141 Schwann cell tumor, 136 CT, 138f SCLC See Small cell lung cancer (SCLC) Sealants See also Fibrin sealants pulmonary, 53–55 vascular, 49–53 Seizures with PAVM, 235 Selective spinal analgesia, 13 Sellheim, Hugo, Seminomatous germ cell tumors treatment, 421–422 Sepsis with ECMO, 315 Severe respiratory failure, 310 Short esophagus with GERD, 468 Side-to-side anastomosis, 515f Simple midtracheal stenosis resection of, 221f Simple tracheal resection, 220–222 technique of, 220–221 Simulect, 354 Simultaneous stapling lobectomy, 71 Sirolimus for lung transplantation, 352 clinical trials of, 352 dosing and administration of, 352 mechanism of action, 352 SIRS See Systemic inflammatory response syndrome (SIRS) Slipped Nissen with GERD, 476 Slow reperfusion, 329–330 Small cell lung cancer (SCLC) adjuvant chemotherapy comparison of, 105f following surgery, 104–106, 104t relapse patterns, 106t 546 / Advanced Therapy in Thoracic Surgery chemotherapy, 104, 105 followed by surgical resection, 106–110 Phase II trials of induction, 106t recommendations for, 110 clinical trials of, 117 comparison of survival, 107f induction chemotherapy, 107t late recurrence after successful treatment, 104 mixed histology tumors, 103–104 pretreatment clinical stage comparison of survival, 108t salvage surgery, 109–110 treatment options of, 109 subpopulation, 102 with super venal caval obstruction, 105 surgery rationale, 103–104 surgical management, 101–112 survival, 109f thoracotomy patients comparison of survival, 108t TNM classification, 103 TNM stages after chemotherapy, 108 TNM subgroups, 110 Soft tissue sarcomas, 137–138 classifications of, 140–141 Solitary plasmacytoma, 126, 136f radiation of, 136 Solitary pulmonary nodule, 255f calcification of, 42 edge characteristics of, 41 evaluation of, 40–43 rate of growth, 42 size of, 41, 401 Southwest Oncology Group (SWOG), 64 Spermatocytic seminoma, 420 Spiral computed tomography, 34 scan, 40f Spirometry with nonseminomatous GCT, 423 Split notochord syndrome, 430 Sporotrichosis, 253f chest wall invasion, 257 Squamous cell carcinoma CT scan of, 41f multislice CT scan of, 41 trachea, 217, 218f Stapler, 69t Endo-GIA, 514f GIA, 474, 475, 475f placement of bronchus, 70f middle lobe vein, 70f Starling forces, 205 Stenosis anterolateral operative repair of, 223f with tracheal resection, 230 Stents laser bronchoscopy, 98 Sternal clefts classification of, 159f operative indications of, 160–161 types of, 159 Sternal foramen, 161 CT scan of, 161 radiographs of, 161 Sternum See also Cleft sternum angulated synostosis of the, 153 Sternum elevatum, 151 repair of, 152f Strap muscle, 228f Streptokinase for pleural space infection, 211 Streptomyces hygroscopicus, 352 Streptomyces tsukubaensis, 349 Stridor with esophageal stents, 526 Subclavian artery aberrant right left aortic arch, 193 MRI, 190f Subclavian vein effort thrombosis, 201 Submandibular space, 443 Subtotal sternal cleft, 159 Sufentanil administration of, Sunset sign, 245 Superior sternal cleft, 159 repair of, 160f surgical correction of, 160f Suture line separation with tracheal resection, 230 SWOG See Southwest Oncology Group (SWOG) Sympathectomy, 203 Systemic analgesia, 3–5 opioids, 3–4 Systemic inflammatory response syndrome (SIRS), 393, 444 Systemic pulmonary shunt, 238 T Tacrolimus (FK506, Prograf), 349–350 clinical trials of, 349 dosage and administration of, 349=350 for lung transplantation blood levels drugs decreasing, 350t blood levels drugs increasing, 350t mechanisms of action, 349 Taenia echinococcus, 241 Taenia saginata, 247 Taenia solium, 247 Talc insufflation for malignant pleural effusion, 208 Targetable injectable vectors, 114 Taxol for GCT, 423 Tegafur, 63 Teratomas, 420 treatment, 421 Testicular germ cell tumors, 417 Thematic gene therapy approaches of, 114 Therapeutic armamentarium, 209 Therapeutic bronchoscopy role of, 275 Therapeutic gene choice and engineering of, 113 Thermal damage zones, 77t heat damage zones, 77f Thoracic aortic aneurysms, 36–37 Thoracic cage disorders, 294 soft tissue of, 125 Thoracic duct cysts, 435 Thoracic fungal infections with HIV and AIDS, 254–255 Thoracic imaging progress of, 44 Thoracic malignancies radio frequency ablation of, 75–88 Thoracic outlet forces compressing neurovascular structure, 197f Thoracic outlet syndrome, 196–204 anatomic considerations of, 196 angiography of, 199 atypical manifestation of, 198 compression factors, 196–198 diagnosis of, 199 differential diagnosis of, 199 etiologic factors, 197f nerve conduction velocity, 199 results, 201 signs and symptoms, 198–199 therapy, 199–200 Thoracic paravertebral nerve blocks (TPVB), 9–11 advantages and disadvantages of, adverse effects of, 11 characteristics of, 5, 5t combinations of, 14 contraindications of, 11 definition of, 9–10 dosage examples of, 10t efficacy of, 10–11 mechanism of action, 10 studies of, 10 technique of, 9–10 Thoracic paravertebral space anatomy, Thoracic surgical procedures results of, 53 Thoracoscope, 206f Thoracotomy for bronchogenic cysts, 432–433 Thorax development of, 181 diagnostic imaging advances, 32–44 Index / 547 emergency evaluation of, 36–38 Thrombocytopenia with ECMO, 315 use of ECMO, 315 Thromboembolic disease, 289 Thromboembolic pulmonary hypertension prognosis of, 306 Thromboembolism chronic pulmonary modern management of, 297–307 Thromboxanes, 333 Thymectomy benzodiazepine, 409 maximal, 410–411, 411f for myasthenia gravis, 408 combined cervical exploration and transsternal, 410–411, 411f comparison of remission rates, 414f indications of, 408 results of, 413–415, 414f Thymic cysts, 436–437, 436f, 437f Thymoma with transcervical thymectomy, 412 Thymus gland anatomy of, 408–409 Thyroid cancer tracheal resection, 229 Timed barium esophagram, 462f Timed barium swallow, 461 Tisseel-VH Duploject applicator, 49f Tissue adhesives enhancement of, 47 FDA-approved, 48t investigations of, 58 in thoracic and cardiovascular surgery, 47–58 historical perspective of, 47–49 Tissue invasive cytomegalovirus, 351 TIVA See Total intravenous anesthesia (TIVA) TNM See Tumor, nodes, and metastases (TNM) Tolypocladium inflatum, 347 Tooth guard placement of, 95f Toronto group, 108 Total intravenous anesthesia, 220 Total intravenous anesthesia (TIVA) for tracheal resection, 220 Total lung bronchiectasis, 261f Total sternal cleft, 159 Toupet fundoplication for GERD, 472 Tovell tube, 221 TP53 gene therapy, 118, 119 TPVB See Thoracic paravertebral nerve blocks (TPVB) Trachea, 257 anatomy of, 215 blood supply of, 215, 216f microscopic blood supply of, 216f resection and reconstruction, 215–231 anesthesia, 220 bronchoscopy of, 219–220 conditions treated by, 215–217 irradiated field, 225–226 lower, 222–225 postoperative issues, 227–229 release procedures, 225 remifentanil for, 220 results and complications of, 229 surgical anatomy, 215 techniques of, 215–231 substitutes and substitutions, 230–231 Tracheal stenosis clinical presentation of, 218 radiologic assessment, 218–219 Tracheobronchial fistula with esophageal stents, 522f Tracheoesophageal fistulas endoscopic, 227f exposure of, 227f nonmalignant, 226 prolonged mechanical ventilation, tracheal resection, 229–230 Tracheoinnominate fistulas, 226 repair of, 226–227 Tracheostomy stoma, 217f Transbronchial biopsy diagnosing of thoracic surgical intervention, 255–256 Transcervical thymectomy, 412 surgeon’s view, 412f Transcription targeting, 114 Transhiatal esophagectomy, 495–496, 495f Transplantation See also Living donor lung transplantation; Lung transplantation advantages of, 387 cadaveric organ recipient survival of, 367f clinical allotransplantation success of, 386 clinical lung, 329 history of, 386–387 lobar lung alternative, 365 post-transplant lung, 383 xenotransplantation acute problems of lung allograft, 394 published reports of, 387f Transsternal thymectomy, 411–413, 411f Transthoracic echocardiography for PPH, 289 Tuberculosis, 257f active pulmonary, 258–260 bulla secondary to, 261f chest wall, 261 complications of treatment of, 258, 260–261 multidrug resistant, 259f progression, 258f resection of lung parenchyma, 257 rib destruction, 262f surgery of indications for, 257t, 258 Tuberculous adenopathy airway obstruction, 261f Tuberculous pyopneumothorax, 259f Tube thoracostomy, 210–211 Tumor, nodes, and metastases (TNM), 106 importance of, 102 SCLC classification, 103 stages after chemotherapy, 108 subgroups, 110 Tumors, 102 See also Desmoid tumor; Germ cell tumors (GCT); Mediastinal germ cell tumors; Peripheral neuroectodermal tumor (PNET) of apical and posterior chest wall, 134f Askin’s, 133–134, 134f benign soft tissue of chest wall, 136–137 endodermal sinus, 420 gastric with mediastinal GCT, 424 malignant bony, 130–136 chondrosarcoma, 130–132 malignant soft tissue of chest wall, 137–142 Pancoast’s chest radiograph of, 36f plasma cell definition of, 135 primary tracheal tracheal resection results, 229 Schwann cell, 136 CT, 138f of secondary chest wall, 142–143 seminomatous germ cell treatment, 421–422 testicular germ cell, 417 yolk-sac, 420 Turner syndrome, 179 24-hours pH monitoring for GERD, 459–560, 470 U UFT regimens NSCLC, 63 Ullrich-Turner syndrome, 180 Ulnar nerve conduction velocity (UNCV), 196 Ultaflex stent, 522 Ultrasonography, 75 characteristics of, 78 548 / Advanced Therapy in Thoracic Surgery UNCV See Ulnar nerve conduction velocity (UNCV) Undifferentiated small cell carcinoma survival, 102 f Unilateral recurrent laryngeal nerve injury with tracheal resection, 230 United Network for Organ Sharing, 369, 386 University of Toronto Lung Oncology Group, 103, 110 Upper airway stenosis, 223f Urinary plasminogen activator (u-PA), 334 Urokinase for pleural space infection, 211 US Food and Drug Administration, 48 V VAS See Visual analog scale (VAS) Vascular camp placement of, 359 Vascular compression differential diagnosis of, 200t Vascular rejection, 390–391, 391 binding of XNA, 390 Vascular rings and slings, 186–195 bronchoscopy, 190 cardiac anomalies, 187t chest radiograph of, 188 clinical presentation of, 187–188 complete treatment of, 190–192 CT of, 189 diagnosis of, 188 echocardiography, 190 embryology of, 186–187 incidence and classification of, 187 incomplete, 192–193 minimally invasive surgery, 194 MRI of, 189 postoperative management of, 195 right thoracotomy, 194 treatment of, 190–94 vascular anomalies, 187t Vascular sealants, 49–53 Vasoconstriction alternative explanations of, 282 new theory of, 281 physiological basis of, 280 Vasodilator test, 289 Vasodilator therapy for PPH, 289 VASOG See Veterans Administration Surgical Adjuvant Group (VASOG) Vasomodulators ischemia-reperfusion lung injury, 334–335 VATS See Video-assisted thoracic surgery (VATS) Vectors, 114 Vecuronium for thymectomy, 410 Venoarterial extracorporeal membrane oxygenation, 310 current practice of, 311 survival of, 316 Venovenous double lumen, 313 Venovenous extracorporeal membrane oxygenation, 310 current practice of, 311 superior vena cava, 311f survival of, 316 Ventilation perfusion scan, 172, 289 Ventilator-induced lung injury, 312 Ventricular failure left with pulmonary hypertension, 294 Ventricular septal defect with pulmonary hypertension, 294 Verapamil, 20 Veterans Administration Surgical Adjuvant Group (VASOG), 102 study of, 105 Video-assisted thoracic surgery (VATS), 207–209 anatomic pulmonary resections, 68–73 indications and contraindications of, 68 concerns of, 72–73 lobectomies, 72t cancer operation, 73 cardiothoracic surgery robotics, 73 contraindications of, 68t conversion to thoracotomy, 72 fissure, 70 general techniques of, 69–71 hilar dissection, 69 incision tumor seeding, 73 indications of, 68t intraoperative hemorrhage, 72–73 lymph node dissection, 70 postoperative pain, 73 results of, 72–73 specimen removal, 70 stapling devices, 69–70 lung nodules localization of, 69 operative deaths of, 194 parietal pleurectomy for malignant pleural effusion, 208 pleural effusion, 206 pneumonectomies, 72t procedures general approach for, 68–69 incisions of, 68–69 survival comparison, 73 Video thoracoscopic thymectomy, 413 Vinblastine adverse effects, 424 Vincristine for Ewing’s sarcoma, 133 Viral hepatitis fibrin sealants, 51 Viral vector systems, 114–116 Visceral injury with GERD, 474 Visceral pain, Visceral pleura, 205 Visual analog scale (VAS) pain, 3f decrease of, 22 pain rating, Von Recklinghausen’s disease, 136 W Walk test, 289 Wanderer cyst, 245 Wanderer sign, 245 Water lily sign, 245 Weinberg reaction test, 247 White blood count, 209 Wild-type adenoviruses, 115 Williams-Campbell syndrome, 270 Wood, Alexander, X Xenograft development of hyperacute rejection, 390 discordant fate of, 387 Xenograft endothelium interaction and XNA interference, 392 prevention, 391–393 Xenoreactive natural antibodies (XNA) of humans, 389 pretransplant removal of, 391 prevention of EIA, 392 prevention of HAR, 392 and xenograft endothelium interaction of, 391–393 interference of, 392 Xenotransplantation acute problems of lung allograft, 394 published reports of, 387f Y Yolk-sac tumors, 420 Young’s syndrome, 270, 270t Yttrium-aluminum-garnet (YAG) laser, 91 description of, 96 tumors associated with, 99 Z Zenapax, 354 Zero harmonic impedance, 401 Zinc ischemia-reperfusion lung injury, 334 Z stent, 522 ... Ultraflex-uc Z stent-c Z stent-c Wallstent-c Wallstent-uc Ultraflex-uc Wallstent-c Ultraflex Wallstent-c Song-c Ultraflex-c Wallstent-c Z stent-c 100 100 100 100 100 100 100 100 100 86 100 97 94 100 ... chemotherapy comparison of, 105 f following surgery, 104 ? ?106 , 104 t relapse patterns, 106 t 546 / Advanced Therapy in Thoracic Surgery chemotherapy, 104 , 105 followed by surgical resection, 106 – 110. .. Wallstent-uc Z stent-c Wallstent-uc Wallstent-uc Wallstent-uc Ultraflex-uc Wallstent-uc/c Song-c Z stent-c Ultraflex-uc Wallstent-c Wallstent-uc Ultraflex-uc Ultraflex-uc Ultraflex-uc Z stent-c Ultraflex-uc