Thoracic surgery clinics
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Thoracic surgery clinics · Nov 2004
ReviewPatterns of failure following surgical resection for malignant pleural mesothelioma.
The optimum therapeutic strategy for patients with localized malignant mesothelioma continues to evolve. For patients who are eligible candidates, surgical resection plays an important role. An encouraging 45% 5-year survival rate has been reported for patients with early-stage disease who undergo EPP and have the favorable features of epithelial histology and the absence of mediastinal lymph node involvement. ⋯ Further clinical studies are needed for all patients with mesothelioma to define the optimum surgery and duration and types of adjuvant therapy. The appropriate multimodality approaches most likely will differ based on disease stage, histology, and patient performance status. intrapleural chemotheraphy treatments. These two For Patients who have undergone EPP, the pattern
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Thoracic surgery clinics · Nov 2004
ReviewPain management strategies for patients undergoing extrapleural pneumonectomy.
The role of anesthetic or analgesic technique in outcome remains controversial. The choice of anesthetic and postoperative analgesic plan plays a small, albeit important, role in perioperative care and a multimodal rehabilitation program. Pulmonary complications are the most important cause of morbidity and mortality after EPP. There is increasing evidence that TEA with local anesthetic agents and opioids is superior for the control of dynamic pain, plays a key role in early extubation and mobilization, reduces postoperative pulmonary complications, and has the potential to decrease the incidence of PTPS.
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Postthoracotomy pain syndrome is relatively common and is seen in approximately 50% of patients after thoracotomy. It is a chronic condition, and about 30% of patients might still experience pain 4 to 5 years after surgery. In the majority of patients pain is usually mild and only slightly or moderately interferes with normal daily living. ⋯ Scientific evidence is steadily growing but there is still a need for large, prospective, randomized trials evaluating PTPS. Until more is known about this condition and how to prevent the central and peripheral nervous system changes that produce long-term pain after thoracotomy, patients must be warned preoperatively about the possibility of developing PTPS and how it might affect their quality of life after surgery. In addition, measures such as selecting the least traumatic and painful surgical approach, avoiding intercostal nerve trauma, and adopting an aggressive multimodal perioperative pain management regimen commenced before the surgical incision should be performed to prevent postthoracotomy pain syndrome.
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Thoracic surgery clinics · Aug 2004
Risk acceptance and risk aversion: patients' perspectives on lung surgery.
Patients express risk aversion toward surgery, particularly if surgery can lead to lifelong debility and loss of independence. When faced with a guarantee of progressive lung cancer and no alternatives for cure, however, patients are willing to take extremely high risks of postoperative complications and surgery-related death. This result occurs because risk aversion toward unrelenting cancer death supersedes patients' risk attitudes toward almost all other health states. ⋯ Important areas for future study include the search for methods that most accurately communicate risk information to patients, especially patients with low numeracy skills. Part of this communication effort should involve the exploration and discussion of patients' alternative beliefs and ways of using these belief systems to help them make the best possible decisions for their long-term health and quality of life. Also, clinicians must identify pulmonary and other predictors of mortality rates and the debility states that patients' cite as most important according to their risk preferences and give up the predictors of transient postoperative complications that patients find acceptable.
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There are many challenges in performing carinal resection and, in particular, reconstruction. A better understanding of the safe limits of resection has contributed to the reduced mortality from anastomotic complications. ⋯ With carinal resection for bronchogenic carcinoma, contemporary studies suggest that there are reasonable survival rates in the absence of involved mediastinal lymph nodes or distant metastatic disease. The role of neoadjuvant therapy for bronchogenic carcinoma involving the carina deserves further investigation; this type of therapy should be used with caution because of the deleterious effects on anastomotic healing.