Peter Goldstraw

Left Upper Lobectomy

This resection is indicated whenever the disease process is limited to the left upper lobe. The commonest such indication in the western world is carcinoma of the bronchus. The tumour and involved lymph nodes must be confined to the lobe, and lines of resection through vessels and bronchus should be clear of tumour. When undertaken for pulmonary sepsis, pre-operative physiotherapy may produce a temporary but important improvement in the patient’s condition and help minimise post-operative sputum difficulties. All patients should be instructed pre-operatively in the physiotherapy manoeuvres which will be undertaken post-operatively. Prophylactic antibiotics commenced with the premedication and continued for 24 h have been shown to reduce the incidence of wound infection but will have no influence on the more serious problems of chest infection and infection of the pleural space.

Carcinoma : Substernal Gastric Bypass

This operation is gaining increasing popularity to restore normal swallowing in patients with irresectable tumours of the thoracic portion of the oesophagus or in those not sufficiently fit to permit the extensive resection. It is particularly useful where tumours of the intra-thoracic oesophagus have eroded into adjacent organs such as lung, pleura or the tracheo-bronchial tree. Patients are not suitable if tumour or involved lymph nodes involve the cervical oesophagus or if there is involvement of the proximal stomach.

Carcinoma : Oesophageal Resection from the Right (McKeown Operation)

This is the preferred approach for tumours of the oesophagus at or above the aortic arch. It is a three-stage operation : (a) midline laparotomy to mobilise the stomach and hiatus, allowing assessment of intra-abdominal metastases; (b) right thoracotomy to mobilise the oesophagus and tumour; and (c) a cervical incision to perform the anastomosis. The third step may be omitted and an intra-thoracic anastomosis undertaken (Ivor Lewis operation). However, if the anastomosis is within the chest the consequences of anastomotic leak are disastrous and there is some evidence to suggest that such anastomoses are associated with more troublesome reflux problems.

Carcinoma : Left-Sided Approach for Resection of the Lower Oesophagus and Gastro-oesophageal Junction (Logan Operation)

This extensive operation allows en bloc resection of the oesophagus and adjacent lymph nodes from the level of the carina, extending inferiorly to the coeliac axis. It is undertaken with curative intent and less ambitious resections should be used in patients clearly incurable. The proximal macroscopic extent of tumour as assessed endoscopically and on contrast X-rays must be beyond the lower margin of the aortic arch. At this level sufficient oesophagus can usually be devolved from beneath the aortic arch so as to permit an anastomosis below the aorta, but if additional length is required the oesophagus may be mobilised above the aorta and brought outwith the aortic arch.

Right Upper Lobectomy

Right upper lobectomy is indicated whenever the disease process is limited to the right upper lobe. The commonest such indication in the western world is carcinoma of the bronchus. The tumour and involved lymph nodes must be confined to the lobe, and lines of resection through vessels and bronchus should be clear of tumour. When undertaken for pulmonary sepsis, pre-operative physiotherapy may produce a temporary but important improvement in the patient’s condition and help minimise post-operative sputum difficulties. All patients should be instructed pre-operatively in the physiotherapy manoeuvres which will be undertaken post-operatively. Prophylactic antibiotics started with the premedication and continued for 24 h have been shown to reduce the incidence of wound infection, but will have no influence on the more serious problems of chest infection and infection of the pleural space.

Right Radical Pneumonectomy

Right pneumonectomy should only be performed when a lesser resection will not clear the pathological process. The commonest such indication in the western world is carcinoma of the bronchus. The tumour and involved lymph nodes must be confined to the lung, and lines of resection through vessels and bronchus should be clear of tumour. Radical pneumonectomy permits en bloc resection of the tumour with the superior mediastinal lymph nodes. The right lung is the larger of the two, and careful assessment of respiratory function is necessary pre-operatively. All patients should be instructed pre-operatively in the physiotherapy manoeuvres which will be undertaken post-operatively. When undertaken for pulmonary sepsis, pre-operative physiotherapy may produce a temporary but important improvement in the patient’s condition and help minimise post-operative sputum difficulties. Prophylactic antibiotics commenced with the premedication and continued for 24 h have been shown to reduce the incidence of wound infection but will have no influence on the more serious problems of chest infection and infection of the pleural space.

Right Middle Lobectomy

Right middle lobectomy is indicated whenever the disease process is limited to the right middle lobe. The commonest such indication in the western world is carcinoma of the bronchus. The tumour and involved lymph nodes must be confined to the lobe, and lines of resection through vessels and bronchus should be clear of tumour. When undertaken for pulmonary sepsis, pre-operative physiotherapy may produce a temporary but important improvement in the patient’s condition and help minimise post-operative sputum difficulties. All patients should be instructed pre-operatively in the physiotherapy manoeuvres which will be undertaken post-operatively. Prophylactic antibiotics commenced with the premedication and continued for 24 h have been shown to reduce the incidence of wound infection but will have no influence on the more serious problems of chest infection and infection of the pleural space.

Right Middle and Lower Lobectomy

Right middle and lower lobectomy is indicated whenever the disease process is limited to the right middle and lower lobes. The commonest such indication in the western world is carcinoma of the bronchus. The tumour and involved lymph nodes must be confined to the lobes, and lines of resection through vessels and bronchus should be clear of tumour. When undertaken for pulmonary sepsis, pre-operative physiotherapy may produce a temporary but important improvement in the patient’s condition and help minimise post-operative sputum difficulties. All patients should be instructed pre-operatively in the physiotherapy manoeuvres which will be undertaken post-operatively. Prophylactic antibiotics commenced with the premedication and continued for 24 h have been shown to reduce the incidence of wound infection but will have no influence on the more serious problems of chest infection and infection of the pleural space.

Right Lower Lobectomy

Right lower lobectomy is indicated whenever the disease process is limited to the right lower lobe. The commonest such indication in the western world is carcinoma of the bronchus. The tumour and involved lymph nodes must be confined to the lobe, and lines of resection through vessels and bronchus should be clear of tumour. When undertaken for pulmonary sepsis, pre-operative physiotherapy may produce a temporary but important improvement in the patient’s condition and help minimise post-operative sputum difficulties. All patients should be instructed pre-operatively in the physiotherapy manoeuvres which will be undertaken post-operatively. Prophylactic antibiotics commenced with the premedication and continued for 24 h have been shown to reduce the incidence of wound infection but will have no influence on the more serious problems of chest infection and infection of the pleural space.

Left Radical Pneumonectomy

Left pneumonectomy should only be performed when a lesser resection will not clear the pathological process. The commonest such indication in the western world is carcinoma of the bronchus. The tumour and involved lymph nodes must be confined to the lung, and lines of resection through vessels and bronchus should be clear of tumour. All patients should be instructed pre-operatively in the physiotherapy manoeuvres which will be undertaken post-operatively. When undertaken for pulmonary sepsis pre-operative physiotherapy may produce a temporary but important improvement in the patient’s condition and help minimise post-operative sputum difficulties. Prophylactic antibiotics commenced with the premedication and continued for 24 h have been shown to reduce the incidence of wound infection but will have no influence on the more serious problems of chest infection and infection of the pleural space.