the 3/3 rule for segmentectomy/wedge resection

tumors located at outer 1/3 of the lung parenchyma,
and < 3 cm in diameter

GGO

GGOs are frequently BACs and may be best treated by sublobar resections because they have a low malignant potential by traditional criteria, yet may need additional pulmonary resections in the future due to the natural history of BAC.

pneumonectomy

elective pneumonectomy for NSCLC operative mortality 3~12%, higher than CABG !


right pneumonectomy has higher operative risk than left pneumonectomy

Left upper lobe

lymphatics commonly drain to AP window (Gr 5) or para-aortic node (Gr 6)


thus, when performing LULobectomy, Gr 5 and 6 must be removed to obtain complete staging information.

left pulmonary resection

contralateral mediastinal LN involvement is much more common with left-sided lesions, particularly lesions of LLL. 


for this reason mediastinoscopy is critically important when assessing lesions of the LLL.

recurrent laryngeal nerve

It descends into the thorax before rising up between the trachea and esophagus to reach the neck


The left laryngeal nerve is longer, branches from the vagus nerve to loop under the arch of the aorta, posterior to the ligamentum arteriosum before ascending


The right branch loops around the right subclavian artery

食道破裂可以置放支架來短期治療

在急性期的食道破裂
如果病患已經經過開胸的手術
重複的開胸探查尋找食道破裂處被認為是困難不可行
則可以先放置食道內支架以得到暫時性的緩解

待急性期過後
食道癒合
可把支架移除
此時多半會伴有食道的局部窄縮(stricture)
可再以食道鏡/胃鏡作食道的氣球擴張術

後縱膈腔腫瘤術後可能的併發症

後縱膈腔腫瘤,是指長在脊椎體兩旁的腫瘤.
因地緣性的關係,最常是神經性來源的腫瘤.
若腫瘤大小還不算太大,一般以胸腔鏡手術就可以處理了

也因為地緣性的關係,離得近
食道有可能會受到傷害
如上圖食道攝影便可看到兩個明顯滲漏的地方

食道滲漏有時很難修補
如上圖
雖然上面的洞以肋間肌補好了
但下面的洞卻還是存在


因食道內的食物是髒的(相對上來講胸腔是很乾淨的)
未及時發現的滲漏可能造成縱膈腔炎
重者甚至敗血症而危及生命!

Proceed further mediastinal staging or not

A CT scan without mediastinal lymph nodes > 1.5 cm in size and a negative PET scan obviate the need for further mediastinal staging.

A PET-positive lymph node mandates the need for mediastinoscopy or needle aspiration of the suspicious node.

PET for SPN

一個肺部結節, 作PET檢查若為positive, 則其有90%之準確率為惡性腫瘤
但PET negative並不能完全排除癌症,是因為BAC和carcinoid並不 uptake FDG