Thoracic surgery clinics
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Fifty years ago, nearly all significant cardiac injuries were fatal, many were untreatable, and most undiagnosed until the autopsy suite. In the last 20 years, however, dramatic improvements in prehospital trauma management, new diagnostic modalities, and the availability of cardiac surgery in many hospitals have rendered treatable most cardiac injuries. Knowledge of various types of cardiac injuries, the methods available to facilitate rapid diagnosis, and familiarity with techniques for surgical repair are no longer an academic exercise but a life-saving necessity.
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This analysis differentiates the causes of postoperative respiratory failure. Respiratory failure in thoracic patients is broken down into two distinct groups, aspiration and pneumonia, promoting actions to prevent respiratory failure. The goal is to develop different strategies to avoid postoperative respiratory failure using an active approach (what can be done in the management of patients undergoing lung resection to prevent problems) rather than passive approach (what patient factors caused problems after surgery). Before that analysis, the operative risks after lung resections (lobectomies, pneumonectomies, elderly patients) and esophagectomies are reviewed to understand the data.
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Given the discomfort of thoracic surgical incisions, thoracic surgeons must understand and use contemporary multimodality pain treatments. Acute postthoracotomy pain not only causes psychologic distress to the patient but also has detrimental effects on pulmonary function and postoperative mobility, leading to increased morbidity. By choosing the most appropriate and least traumatic surgical incision, adhering to meticulous surgical techniques, and avoiding intercostal nerve injury or rib fractures, surgeons can minimize postoperative pain. ⋯ Alternatively, an infusion system for continuous administration of local anesthetics directly in the subpleural plane, posterior to the intercostal incision, also provides excellent pain control. Again, use of an IV-PCA as adjuvant therapy is recommended. With careful planning, severe pain and its negative impact on thoracic surgical patients can be prevented.
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Chylothorax is a rare complication of pulmonary resection. It requires prompt treatment, which is initially conservative. This treatment consists of drainage, nutritional support, and measures to diminish chyle flow. ⋯ On the other hand, VATS is uniformly effective, is less expensive, and has low morbidity. Indeed, VATS is rapidly becoming the preferred approach for the management of chylothorax complicating pulmonary resection. The need to prevent the occurrence of a chylothorax by careful dissection techniques and liberal clipping of lymphatic vessels particularly in areas of high anatomic risk during the initial operation cannot be overemphasized.
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Thoracic surgery clinics · May 2006
ReviewSurgery for colorectal and sarcomatous pulmonary metastases: history, current management, and future directions.
This article provides a historical review of metastasectomy, reviews current surgical management approaches, and proposes what direction future research must take to determine whether there is a survival advantage associated with pulmonary metastasectomy and how best to integrate metastasectomy with medical therapies, primarily induction, and adjuvant chemotherapy.