SurgSpace / Specialties / Thoracic Surgery
Thoracic Surgery
Lungs, pleura, esophagus and mediastinum: lobectomy planned on the bronchial tree, pleural disease from pneumothorax to empyema, and esophageal surgery that crosses two body cavities in one operation. Much of it now through keyhole (VATS) approaches.
Backdrop: Chest X-ray showing the signs of pneumothorax · Karthik Easvur · CC BY-SA 3.0
After, and when it goes wrong
Post-op & Emergencies
The expected course, the ward reads, and the calls that cannot wait.
The expected course and the ward reads, then the complications and the calls that cannot wait.
On the ward
Three boards, three reads
POD 1 · VATS lobectomy
Drain bubbling on cough
Lung up on CXR
Sats 94% on air
Walking to the door
Does the bubbling drain change the plan?
The read
Not yet: an air leak on coughing in the first days after lobectomy is common and most seal spontaneously. The management is mobilisation and patience, not clamping. It earns escalation if it persists beyond about five days, or if the lung will not stay up, at which point the options conversation starts with the surgical team.
POD 6 · esophagectomy
New AF at 132
CRP 260 from 140
Temp 37.8
Drains serous, feeds running
Rate control and recheck tomorrow?
The read
No. New atrial fibrillation at day six after an esophagectomy is a leak announcing itself until proven otherwise: the arrhythmia gets treated, and simultaneously the leak gets hunted, with a septic screen, imaging of the anastomosis, and the operating team informed now. The mistake on this board is treating the rhythm and stopping there.
Day 2 · empyema on a drain
Drain: 450 mL turbid then slowing
Temp settling
CRP 180 from 290
Ultrasound booked
What decides whether this plan is working?
The read
The pairing of output and inflammation: falling CRP with a draining tube and a defervescing patient means the space is emptying. If the drain slows while the CRP plateaus, the fluid has loculated beyond the tube's reach, and the answer is escalation to fibrinolytics or VATS, not a bigger tube and a longer wait.
Emergencies
The calls that cannot wait
Tension pneumothorax
Recognise: Escalating distress, silent hyperresonant hemithorax, distended neck veins and falling pressure: physiology, not imaging.
First move: Immediate decompression, then a drain. In the thoracic ward this hides behind a blocked or clamped drain: unkink and unclamp before anything else.
Anastomotic leak after esophagectomy
Recognise: Day 5 to 7: new atrial fibrillation, unexplained tachycardia, a climbing CRP, or turbid drain fluid. Subtle first, septic later.
First move: Treat new AF after esophagectomy as a leak until proven otherwise: septic screen, contrast study or CT, and the surgical team told tonight, not at handover.
Massive haemoptysis
Recognise: Hundreds of millilitres of blood from the airway: patients die of asphyxiation, not exsanguination, and the flooding lung drowns its neighbour.
First move: Bleeding side down if known, secure the airway (intubate the good side if needed), and mobilise bronchoscopy and interventional radiology at once.
The crashing post-lobectomy patient
Recognise: Sudden hypotension or desaturation in the first days: the short list is haemorrhage into the chest, lobar torsion, tension physiology and a massive air leak.
First move: Look at the drain first: what is coming out, and what has stopped coming out, usually names the diagnosis. Then the film, then the call to theatre.
Hub shaped by the Surgical Specialties Lead with the Thoracic surgery reviewer (open seat). Images and videos carry their source; educational use for supervised learning, not clinical guidance.