Sydney Cardiothoracic Surgeons

Thoracic Surgery

Thoracic Surgery

Thoracic surgery is a specialty focusing on the diagnosis and treatment of disorders of the chest, excluding the heart.

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Preparing for Lung Surgery

The document below outlines and describes the following areas assocaited with lung surgery:

  • How to prepare for lug surgery
  • Pre operation information
  • Post operation information
  • Post discharge pain relief and bowel care

Simply click on the document below to download. (30 pages)

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Procedures for Emphysema - Endobronchial Valves & Lung Volume Reduction Surgery

What makes a good candidate for lung volume reduction surgery?

The following is a brief list of the most essential elements:

  1. NO SMOKING!!!
  2. The patient should visit his GP who can refer him to a Thoracic Physician in his area. The Thoracic Physician would then assess the patient as follows:
    1. Chest xray and CT scan
    2. Lung ventilation and perfusion scan (showing poor ventilation and perfusion to the target zones which are usually present with apical disease but can be basal disease)
    3. Formal respiratory function testing including: - blood gases (pCO2 >55) - spirometry (FEV1/VC about 30% of predicted)
    4. Weaned or weaning from Prednisolone medication (10mg or less daily).
  3. Upper age limit around 80 years old
  4. Sufficiently motivated to start and complete a pulmonary rehab programme of 6 to 8 weeks.
  5. If the patient fits the above criteria then a consultation with the Surgeon is arranged in Sydney.
  6. Travel to Sydney for a formal pulmonary rehabilitation assessment then referred to a local programme, which continues for 6 to 8 weeks prior to surgery. The aim is to have the patient able to complete a 200metre walk in 6 minutes or a 400metre walk in 12 minutes.
  7. Each patient is then assessed again by the Surgeon for their suitability and fitness for surgery.
  8. Be committed to continue the rehabilitation programme after the surgery.

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Living Life after Pneumonectomy

This information has been written as a result of patients wanting more information about living life after pneumonectomy. We trust the information is helpful rather than frightening. We recognize that what is presented is not in any way a complete account of expectations as each person's experience will always be different. We encourage you to take a positive approach to your recovery, work hard at it, and if you have any questions or concerns please pick up the phone and ask about them. It is a very big operation. Your body will undergo a lot of healing and needs time for this to happen.

Jocelyn McLean Case Manager / Thoracic Surgery Preferred contact (02) 9515 6111 and pager 80356 OR (02) 9550 1933

Simply click on the documents below to download.

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Pulmonary Thromboendarterectomy (PTE) Patient Information

Many people experience blood clots in their lungs (this is known as pulmonary emboli). In some cases, these clots do not dissolve, but stick to the vessel wall and obstruct the blood flow. This is called chronic pulmonary thromboembolic disease. This disease can be improved by surgery.

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Mesothelioma Patient Information

This document covers information and management options for patients with malignant pleural mesothelioma.

Please click on the document below to download.

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Clinical Guidelines for Lung Cancer management

Surgical resection has been shown to result in the best five year disease free survival rates compared to any other form of treatment for non small cell lung cancer. Since the first successful pneumonectomy for non small cell lung cancer in 1933, there have been refinements in patient selection, operative techniques and peri-operative management which have translated into better survival with reduced post operative morbidity and mortality. Much information has been learned with evidence to support the guidelines that follow. In addition there are ongoing investigations into newer areas of pre-operative staging (such as PET scanning) and surgical techniques such as video assessed thoracoscopic lung resection and mediastinal node mapping. Of particular interest is the management of those patients with small pulmonary malignancies found incidently with helical CT scanning performed during screening based programs. In time, the evidence will be forthcoming on these issues.

In looking at historical series of early stage lung cancer survival, it must be remembered that there has been a great variation in the degree of characterisation of metastases and node staging from the techniques used for the evaluation (including CT scanning, PET scanning, routine or selective mediastinoscopy, node sampling or node dissection at operation) as well as the difficulties of naming mediastinal and hilar node disease according to whichever node map was utilised. A recommendation for node classification was revised in 199727 and this is currently used in Australia for description of node locations both anatomically and pathologically.

Lung cancer survival following surgical resection was reviewed by Rubens comparing those patients treated between 1947 to 1969 with those treated between 1981 and 1994. This demonstrated that stage for stage the survival over the 47 year period had not altered but the operative mortality had reduced markedly.

Surgery outperforms radiation therapy in the treatment of early stage non small cell lung cancer in those patients fit enough to tolerate the required resection. Morrison reported a randomised study comparing radical radiation employing 45Gy in four weeks for early stage disease versus surgical resection. At four years there was a reported 7% survival in the radiation group compared to 23% in the surgical group. Gauden reported the largest retrospective study of radiation for early stage lung cancer demonstrating a five year recurrence free survival of 23% with the median survival being 19.5 months, significantly less than that reported in comparable surgical series for non small cell lung cancer.

The Japanese Lung Cancer Screening Research Group studied 69 patients with Stage 1 lung cancer treated non surgically with either chemotherapy or radiotherapy and found the five year survival to be 14.3% in screen detected asymptomatic patients and 3.7% for symptomatic patients. This study emphasised the dismal prognosis for Stage 1 non small cell lung cancer patients treated without surgical resection.

Many reviews have been published supporting surgery as the preferred form of treatment for early stage non small cell lung cancer The overall reported survival for patients with pathological Stage 1 and 2 disease is as follows: Mountain 1995

Five Year Survival for Pathologic Stages:

  • Stage 1
    • T1 N0 76% (68.5 ? 83%)
    • T2 N0 59.5% (53.8 ? 65%)
  • Stage 2
    • T1 N1 51.9% (40 ? 63%)
    • T2 N1 40.3% (39 ? 45%)
    • T3 N0 38% (25 ? 55%)

Extent of Pulmonary Resection

The extent of pulmonary resection required to yield the optimal survival rates has been reviewed since the first successful pneumonectomy in 1933. Pneumonectomy was initially thought necessary for potential cure but survival data reported in the 1950?s indicated that lobectomy was equally effective provided macroscopic and microscopic clearance of tumour was achieved. Lobectomy was associated with lower operative and long term mortality and morbidity compared with pneumonectomy.

Lobectomy with mediastinal lymph node dissection became the gold standard for surgical resection of non small cell lung cancer. Pneumonectomy was appropriately reserved for those patients with centrally placed primary tumours crossing the interlobar fissure, involving the main stem bronchi or main pulmonary arteries or in the presence of malignant hilar nodal disease in Stage 2 non small cell lung cancer. For patients with direct invasion of structures adjacent to the lung (T3 ? parietal pleura, chest wall, pericardium, diaphragm) en bloc resection of lung and involved extra pulmonary structures has been associated with a five year survival in excess of 50% in those patients with parietal pleural/chest wall invasion in whom complete microscopic resection is achieved and the nodal status is NO26a26b.

As with malignancies elsewhere in the body, thoracic surgeons have assessed the role of lesser resections, namely pulmonary segmentectomy or wedge resections for early stage non small cell lung cancers. In a retrospective review by Warren and Faber28 they recorded 173 patients with Stage 1 non small cell lung cancer who had undergone either lobectomy or segmental resection. The five year survival was similar but there was a significant increase of recurrence in the segmental segmentectomy group (23%) compared to those undergoing lobectomy (5%). The Lung Cancer Study Group29 in a prospective, multi-institutional randomised trial compared lobectomy with minimal resection, most commonly segmentectomy.

All patients were assessed as fit for lobectomy and randomised in the operating theatre after frozen section confirmed T1 N0 staging with hilar and mediastinal lymph node sampling. 247 patients were randomised and in those patients randomised to limited resection there was a significantly increased local recurrence rate as well as a significantly increased mortality related to their lung cancer. The study therefore concluded that ?because of the higher death rate and a locoregional recurrence rate associated with limited resection (either segmentectomy or wedge resection), lobectomy still must be the surgical procedure of choice for patients with peripheral T1 N0 non small cell lung cancer.?

Ichenose30 studied the correlation of tumour size and lymphatic invasion in resected peripheral Stage 1 non small cell lung cancer. As the tumour increased in size the chance of lymphatic invasion increased from 25% in tumours less than 1cm in diameter to 57% in tumour greater than 3.1cm in diameter. This study emphasised the benefit of lobectomy over lesser resections in Stage I non small cell lung cancer.

Limited resections are not appropriate for patients with Stage I non small cell lung cancer with adequate pulmonary function for lobectomy. The operative approach for lobectomy has traditionally been via a thoracotomy. Recently video assisted thoracoscopic techniques (VATS) have been utilised successfully for pulmonary resections including regional lymph node assessment. Sugi31 reported 100 consecutive patients with clinical Stage 1A (T1 N0) non small cell lung cancer. 48 patients underwent VATS lobectomy and 52 patients open lobectomy with lymph node dissection performed in both groups. There were no differences in local recurrence rates (6%) or five year survival (90% VATS, 85% open) between the two groups. Further studies are required to provide definitive evidence on the relative effectiveness and safety of lobectomy via VATS as compared with open thoracotomy

Nodal Assessment:

Intra-operative and subsequent pathological regional node examination is, as with most malignancies, is considered important in the management of non small cell lung cancer. There was been controversy regarding the extent of lymph dissection necessary for optimal results.

Asamuri32 demonstrated that if thorough lymph node sampling is performed, 25% of patients are found to have unsuspected positive nodes (N1 10%, N2 15%). In patients with positive mediastinal nodes 25% had no hilar node involvement. In Asamuri?s series, Stage 1 patients had a five year survival of 92% and a ten year survival of 87%.

There has also been debate over whether mediastinal lymphadenectomy has a therapeutic advantage for resected lung cancers.

Izbicki et al33 randomised 182 patients with non small cell lung cancer to either standard mediastinal lymphadectomy (removal of lymph nodes suspected of being involved in the hilar or mediastinal regions) or en bloc radical mediastinal lymphadectomy as described by Naruke et al34 where all tissue containing mediastinal lymph nodes was removed with en bloc skeletonising of the mediastinum. When matched for T and N status, no difference in survival or site of recurrence was shown. Not surprisingly staging was more detailed in the radical lymph node dissection group.

The study by Asamuri32 could not relate the increased survival identified in these Stage 1 patients as due to the lymph node resection as opposed to simply more accurately identifying those patients that were truly Stage 1 disease.

A prospective randomised study by Sugi35 studied 115 patients with peripheral non small cell lung cancer less than 2cm in diameter. They were randomly assigned to lobectomy with lymph node sampling or lobectomy with radical systematic lymph node dissection. There was no difference in the detection of N1 or N2 positive nodes, no difference in the local or distant or recurrent rates nor in the five year survival between the two groups (84% for node sampling group and 81% in the node dissection group).

Regional lymph node dissection should be performed with all lung resections for non small cell lung cancers. Radical mediastinal lymph node dissection whilst more accurately staging the patient provides no significant survival advantage over appropriate mediastinal lymph node sampling. Level 2 32,33,35

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What is a PET scan?

What is PET? Positron Emission Tomography (PET) is a powerful imaging technique that holds great promise in the diagnosis and treatment of many diseases, particularly cancer. A non-invasive test, PET scans accurately image the cellular function of the human body. In a single PET scan your physician can examine your entire body. PET scanning provides a more complete picture, making it easier for your doctor to diagnose problems, determine the extent of disease, prescribe treatment, and track progress.

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The Dust Disease Board - A Patients Guide

The Dust Diseases Board is a statutory authority established under the Workers' Compensation (Dust Diseases) Act 1942 and is subject to the direction of the Attorney General and Minister for Industrial Relations, through whom it reports annually to the New South Wales Parliament.

The Workers' Compensation (Dust Diseases) Act 1942 provides for the payment of compensation to:

  • any person whose disablement for work is reasonably attributable to a dust disease or
  • the dependants and / or spouse of any worker who has contracted a dust disease and has subsequently died from that disease (subject to meeting the requirements of the Act).

The Act also provides for additional payments in respect of expenditure necessarily incurred by a disabled worker for medical treatment as a result of a dust disease. Expenses met by the Board include medical practitioners? fees, home nursing, physiotherapy, oxygen, medicines, hospitalisation, ambulance transport and such other expenses as may be necessary. The dust diseases specified in the Schedule of the Act are:

  • Aluminosis
  • Asbestosis
  • Asbestosis induced carcinoma
  • Asbestosis related pleural disease (ARPD)
  • Bagassosis
  • Berylliosis
  • Byssinosis
  • Coal Dust Pneumoconiosis
  • Farmer?s Lung
  • Hard Metal Pneumoconiosis
  • Mesothelioma
  • Silicosis
  • Silico-tuberculosis
  • Talcosis

The Act applies to all persons whose employment as workers exposes them to the inhalation of dust, which may cause one of the above diseases with the exception of:

  • Workers in or about a mine to which the Coal Mines Regulation Act 1912 applies (these workers are covered by another State Legislation)
  • Employees of the Australian Government
  • Persons whose exposure to the inhalation of dust occurred in the course of their employment outside New South Wales
  • Persons whose exposure to the inhalation of dust occurred whilst self-employed.

How to contact the Dust Disease Board

Contact: The Advisory Officer

Address: 82 Elizabeth Street, SYDNEY NSW 2000

Telephone: 02 8223 6600

Facsimile: 02 8223 6699

Toll Free: 1800 550027

Web Site: www.ddb.nsw.gov.au

What is the Dust Disease Board?

The Dust Diseases Board is a statutory authority established under the Workers? Compensation (Dust Diseases) Act 1942 and is subject to the direction of the Attorney General and Minister for Industrial Relations, through whom it reports annually to the New South Wales Parliament.

Who Does the Dust Diseases Board Cover?

The Act applies to all persons whose employment as workers exposes them to the inhalation of dust, which may cause one of the above diseases with the exception of:

  • Workers in or about a mine to which the Coal Mines Regulation Act 1912 applies (these workers are covered by another State Legislation)
  • Employees of the Australian Government
  • Persons whose exposure to the inhalation of dust occurred in the course of their employment outside New South Wales
  • Persons whose exposure to the inhalation of dust occurred whilst self-employed.

What Does the Dust Diseases Board Pay for?

The Workers? Compensation (Dust Diseases) Act 1942 provides for the payment of compensation to:

  • Any person whose disablement for work is reasonably attributable to a dust disease or
  • The dependants and / or spouse of any worker who has contracted a dust disease and has subsequently died from that disease (subject to meeting the requirements of the Act).

The Act also provides for additional payments in respect of expenditure necessarily incurred by a disabled worker for medical treatment as a result of a dust disease. Expenses met by the Board may include medical practitioners? fees, home nursing, physiotherapy, oxygen, medicines, hospitalisation, ambulance transport and such other expenses as may be necessary.

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