Thoracic Surgery

Each disease with the image that defines it: what it looks like, what the scan shows, and which operation answers it.

Lung cancer, the surgical disease

Resection cures the early stages; the work is proving the stage and the reserve.

Who it is

Mostly non-small-cell carcinoma in current and former smokers, increasingly found early by screening CT: the incidental nodule is now a common doorway into the specialty.

Staging

TNM built from CT, PET and nodal sampling: the mediastinal nodes are the hinge, because disease that has reached them changes the treatment from knife-first to systemic-first.

Operability versus resectability

Resectable describes the tumour; operable describes the patient. Spirometry and gas transfer predict what breathing remains after a lobe leaves; a cure that leaves no reserve is not a cure.

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The operation

Lobectomy with nodal dissection is the oncologic standard; segmentectomy spares reserve in small peripheral tumours; pneumonectomy is the rare, expensive last resort.

After

Air leaks and atrial fibrillation dominate the early days; the pathology report and the MDT decide what, if anything, follows the operation.

VATS lobectomyCase: A shadow on the chest film

X-ray

Pneumothorax

Air where the vacuum should be.

The types

Primary spontaneous in the young and tall from apical blebs; secondary in diseased lungs, where the same rim of air costs far more; traumatic; and tension, which is not a type but an emergency physiology any of them can develop.

First management

Size and symptoms choose between observation, aspiration and a drain. Secondary pneumothoraces earn drains earlier because their owners have no reserve to lend.

Definitive surgery

Recurrence, persistent leak, high-risk occupations and bilateral disease send patients to VATS: staple the blebs, abrade or strip the pleura so the layers fuse.

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The physics

The pleural space is a potential space held shut by negative pressure. Every drain, every leak and every re-expansion makes sense once that vacuum is understood, and none of it does otherwise.

VATS bullectomy and pleurodesisIntercostal chest drain insertionCase: Sudden pleuritic pain in a tall young man Case: The chest that has no breath sounds

X-ray

• Pleural infection & empyema

  Pus under pressure, in stages, on a clock.

  How it forms

  A pneumonia weeps a simple effusion; bacteria cross into it; fibrin lays loculations; and finally a rind of cortex traps the lung. Three stages, three windows, three different treatments.

  Diagnosis

  Sample any effusion beside a pneumonia that is not improving: pH below 7.2, frank pus or organisms mean drainage. Ultrasound sees loculations the X-ray flattens.

  Treatment by stage

  Exudative stage: drain and antibiotics. Fibrinopurulent: drain plus intrapleural fibrinolytics, or VATS washout. Organised: decortication to peel the rind so the lung can re-expand.

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  Why delay costs

  Each week of maturation converts a bedside procedure into an operation and lengthens the recovery: the empyema pathway rewards the team that samples early and escalates without sentiment.

  Intercostal chest drain insertionCase: The pneumonia that will not settle

• Esophageal cancer

  A two-cavity operation for a disease found late.

  The disease

  Adenocarcinoma at the lower end, grown from reflux and Barrett's change; squamous carcinoma higher up, tied to smoking and alcohol. Both present late because the esophagus stretches before it obstructs.

  Staging and selection

  CT, PET and endoscopic ultrasound assign the stage; most resectable disease receives chemotherapy or chemoradiotherapy first, with the operation as the centrepiece of a longer campaign.

  The operation

  Esophagectomy removes the tumour and rebuilds the gut with a gastric conduit pulled into the chest: an abdominal phase, a thoracic phase, and an anastomosis whose blood supply is the whole game.

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  The recovery

  The feared complication is anastomotic leak, announced quietly by a new tachycardia, a climbing CRP or atrial fibrillation around day five to seven; the rebuilt gut also renegotiates eating for months.

  Esophagectomy (Ivor Lewis)Case: Dysphagia, and then a leak