Seminars in thoracic and cardiovascular surgery
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Semin. Thorac. Cardiovasc. Surg. · Jan 2013
ReviewThe state of the art in preventing postthoracotomy pain.
Pain after thoracic surgery can be intense and prolonged. Inadequate pain management can have several detrimental effects, including increased postoperative morbidity and delayed recovery as well as occurrence of postthoracotomy syndrome. Therefore, establishing an adequate analgesic regimen for thoracic surgery is critical. ⋯ When these techniques are either contraindicated or not possible, intercostal analgesia or intrathecal opioids are recommended. These techniques should be combined with nonopioid analgesics, such as acetaminophen, nonsteroidal anti-inflammatory drugs, or cyclooxygenase-2-specific inhibitors, administered on a regular "round-the-clock" basis, with opioids used as "rescue" analgesics. Finally, the integration of multimodal analgesia techniques with multidisciplinary rehabilitation program can enhance recovery, reduce hospital stay, and facilitate early convalescence.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2013
ReviewOpen aortic arch repair: state-of-the-art and future perspectives.
Surgical procedures for the treatment of complex aortic arch pathology remain among the most challenging cardiovascular operations, incurring considerable risk for death and stroke. The purpose of this article is to describe the evolution of our approach to open repair of the aortic arch. ⋯ Modifications in surgical technique, including arch reconstruction with the trifurcated graft, and the classical and frozen elephant trunk techniques have simplified the conduct of the operation. Experimental and clinical research supporting the evolution of our approach is discussed in this paper.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2013
ReviewHow to follow up patients after curative resection of lung cancer.
Survivors of lung cancer surgery are among the highest-risk patients for developing another lung cancer, yet there is no clear consensus on the method of surveillance for patients after curative surgical resection. Surveillance is no longer futile because the emergence of computed tomography screening has allowed the detection of recurrences and new metachronous cancers at an early stage. In selected patients, lung cancer identified recently on routine computed tomography scan is amenable to curative treatment and is associated with longer survival.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2013
ReviewCurrent readings: sublobar resection for non-small-cell lung cancer.
The Lung Cancer Study Group consensus recommending lobectomy for stage I non-small-cell lung cancer (NSCLC) to reduce local recurrence associated with sublobar resections has directed NSCLC care since its 1995 publication. However, enhancements in imaging technology and in our understanding of the molecular biology of NSCLC over the past 2 decades have produced large cohorts of patients with smaller, better staged, and more indolent tumors than evaluated by the Lung Cancer Study Group. Numerous single-institution trials have demonstrated that in well-selected patients, sublobar resection can afford comparable survival and recurrence rates with lobectomy with a more favorable risk profile. This review of recent literature will focus on 2 separate issues with regard to the use of sublobar resections for stage I NSCLC: (1) a comparison to nonoperative ablative therapies in medically unfit patients, and (2) identifying in which subset of the noncompromised standard-risk population, sublobar resections provide equivalent outcome to lobectomy.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2013
ReviewCurrent readings: improvements in intensity-modulated radiation therapy for malignant pleural mesothelioma.
The treatment of malignant pleural mesothelioma with radiation therapy has always been a technical challenge. Early experience with intensity-modulated radiation therapy demonstrated troubling toxicity. Recent reports from institutions have demonstrated that with greater experience, intensity-modulated radiation therapy can be delivered safely, both in the setting of pneumonectomy or pleurectomy. ⋯ In the setting of 2 intact lungs, the mean lung dose can be as high as 20 Gy. Expected rates of grade 3 or worse radiation pneumonitis are 12%-20%. The rates of fatal pneumonitis are approximately 3%-8% in these studies, which demonstrate the considerable toxicity of treatment, even with improved technique.