Standards of care
By definition, general thoracic surgery includes the knowledge, technical skill and judgement required to diagnose and treat diseases of the chest. The entire spectrum comprises the chest wall, pleura, lungs, trachea and bronchi, mediastinum, diaphragm and oesophagus, in adults and children. General thoracic surgery requires in-depth knowledge of physiology, imaging, organ function testing, investigation, pre-operative evaluation, post-operative and critical care, trauma, oncology and transplantation. It also includes experience in multidisciplinary treatment protocols. The main competence of a thoracic surgeon is the pre-,intra- and post-operative care of patients with general thoracic surgical diseases. This includes the investigation of patients, decisions on specific treatment, performance of technically correct procedures and provision of expert post-operative care.
|Conservative or lung parenchyma-sparing operations|
|Bronchial or tracheal wedge excision|
|Bronchial or tracheal sleeve resection|
|Extended procedures (lung+other structure)|
|Pericardium (intrapericardial pneumonectomy)|
|Chest wall (ribs, vertebrae)|
|Superior sulcus (Pancoast tumour)|
Table 1 – Types of operative procedures.
Techniques and procedures
Since 1990, less invasive techniques have been developed, with video-assisted surgical procedures replacing the classical thoracotomy for some indications. The percentage of these minimally invasive procedures has gradually increased over recent years: in the UK, approximately one-third of all lung resections are now performed by video-assisted thoracic surgery (VATS). Similar trends are found in other countries. (An example of a subtotal pleurectomy performed by VATS can be seen at the Multimedia Manual of Cardio-Thoracic Surgery, dx.doi.org/10.1093/mmcts/mms008 ). A VATS wedge excision is illustrated in figure 1 . Recently, robotic surgery has also been introduced in thoracic surgery, providing a superb three-dimensional view and allowing precise operative interventions using highly flexible robotic arms. Thymectomy and resection of smaller anterior mediastinal tumours can be easily accomplished by robotic surgery. Lobectomy and, to a lesser extent, pneumonectomy remain the classic surgical procedures for lung cancer (table 1). However, over the past two decades major efforts have been made to develop more lung parenchyma-saving interventions. Sleeve and double-sleeve lobectomies using broncho-/tracheoplastic and vascular reconstructive techniques have been introduced successfully. These techniques avoid the need for pneumonectomy, resulting in lesser impact on pulmonary function and thus better quality of life, or allowing for appropriate resectional surgery in patients who otherwise wouldn’t tolerate pneumonectomy. Increasing attention is also directed towards sublobar resection, i.e . anatomical segmentectomy or wide wedge excision in small peripheral cancers: results so far are promising, with similar survival figures in nonrandomised studies to those obtained after classic lobectomy. Indications for surgical treatment of nonsmall cell lung cancer are listed in table 2.
Lung metastasectomy has become a well-accepted procedure in the treatment of lung metastases originating from some solid-organ tumours.
Although still controversial, radical surgery in malignant pleural mesothelioma consisting of either extrapleural pneumonectomy or extended pleurectomy/decortication with or without resection of the diaphragm and pericardium, is performed by a number of thoracic surgeons in an effort to obtain maximal tumour reduction as part of a multimodal therapeutic strategy.
New developments and multidisciplinary cooperation have increasingly made lung transplantation a valid option for selected patients with end-stage lung disease. Worldwide transplantation activity has increased year on year over the past 25 years.
Within the seven-country Eurotransplant community, 1182 lungs (528 double lung, 89 single lungs and 37 lungs plus other organ) were transplanted in 2011, an increase of 6.6% compared to 2010. The most common indications are end-stage emphysema, cystic fibrosis, idiopathic pulmonary fibrosis and pulmonary hypertension. Double lung transplantation has become the standard. According to the most recent adult lung transplant report of the International Society for Heart & Lung Transplantation (ISHLT), 3519 lung transplantation procedures were performed globally in 2010, the highest number ever reported. Although lung transplantation remains a high-risk procedure, survival results have improved over the past decade. Five-year survival is now about 50% overall, but more experienced centres now regularly report 5-year survival figures in the region of 70% ( figure 3 ). However, long-term survival remains low compared with transplantation of other solid organs, due to chronic infection and rejection leading to bronchiolitis obliterans syndrome (BOS), which remains the Achilles’ heel of lung transplantation.
|Stage IIA||T2bN0, T1a,bN1, T2aN1|
|Stage IIB||T2bN1, T3N0|
|Investigational||Stage IIIA||T1–3N2, T4N0,1|
|Stage IIIB||T4N2, T1–4N3|
|Exceptional||Stage IV – single metastasis|
|Stage IV – multiple metastases|
Table 2 – Indications for surgical treatment of nonsmall cell lung cancer. See chapter 19 for an explanation of lung cancer staging.
Organisation of thoracic surgical centres
To ensure the best possible patient care in thoracic surgery, the EACTS/ESTS working group states that it should be performed within the logistical and economic framework of specialised units. These units should be designed to allow patient care and treatment according to recommended standards, as well as education of surgical trainees, continuous development and research in thoracic surgery.
The working group proposed two types of thoracic surgical centres: highly specialised centres within, or associated with a university, performing at least 250 major thoracic procedures per year, and standard units which are free-standing or combined with cardiac, vascular or general surgery. In a standard unit at least 100 major interventions should be performed annually. Lung transplantation and its alternative procedures should be performed only in centres with special interest and with cardiac surgical facilities.