Seminars in thoracic and cardiovascular surgery
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Semin. Thorac. Cardiovasc. Surg. · Jan 2013
ReviewArtificial lung and novel devices for respiratory support.
There is a growing demand for new technology that can take over the function of the human lung, whether it is to assist an injured or recently transplanted lung or to completely replace the native lung. The use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation was reported for the first time more than 3 decades ago; nevertheless, its use in lung transplantation was largely abandoned owing to poor patient survival and frequent complications. ⋯ The use of ECMO is now being considered in awake and nonintubated patients so as to improve oxygenation, facilitate ambulation, and improve physical conditioning before transplant. Several programs have developed ambulatory capability of most forms of ECMO, and ambulatory ECMO is now often referred to as the "artificial lung." We present a brief description of the evolution of the use of ECMO in lung transplantation and summarize the available technology and current approaches to provide ECMO support.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2013
ReviewThe state of the art in the technical performance of lung-sparing operations for malignant pleural mesothelioma.
Malignant pleural mesothelioma remains an incurable disease for which the role of surgery remains controversial. Though not yet clearly defined there does appear to be a subset of patients who benefit from a surgery-based multimodal treatment plan, beyond what would be expected with current nonoperative therapies. As with other pleural cancers it is probably not possible to achieve a microscopic complete resection with any operation. ⋯ Many of these cases involved bulky cancers, some exceeding two liters in volume, and often with extensive invasion of the pulmonary fissures. With the described technique there has not yet been an instance where conversion to extrapleural pneumonectomy would have contributed to the ability to achieve a macroscopic complete resection. Whether or not radical pleurectomy is the optimal approach for any or all patients undergoing surgery-based multimodal treatment for malignant pleural mesothelioma is not known, but the described technique does offer an operation that can serve as a consistent foundation for any surgery-based treatment strategy where achieving a macroscopic complete resection, while sparing the lung, is desired.
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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.
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Modern cardiac practice in the United States is conservative when it comes to using bilateral internal mammary or radial artery grafts in coronary artery bypass surgery. Here, we examine the evidence regarding using other arterial grafts instead of veins as a complement to left internal mammary artery in surgical revascularization. In addition, we put our report in perspective relative to prevailing practice, professional societal guidelines, and future directions in coronary artery bypass grafting.