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Hello. Hello everyone. Good evening. My name is N and welcome to this um teaching session on basics of cardiothoracic surgery, lung cancer and management. Um Sorry for the delivery, just trying to get the presentation um set up. So just give us a few minutes. Hi, good evening, everybody. Are you able to see or no? Oh, here we are. Are you able to see now? Yes. Ok. But um ok, I'm gonna go ahead now. Yeah, please. Thank you. Thank you, nay for uh inviting me uh to uh do this session. So, um we're going to do a uh a teaching session um about lung cancer in general. Um and the uh the surgical management uh of lung cancer. Uh My name is Patrick uh Dennis Hurley. And uh I'm one of the cardiothoracic surgery um SHS clinical Fellows at Royal Papworth Hospital. Um And uh welcome to this session on, on a Saturday evening. Um So the outline of the um the presentation is as follows. So, um you know, we'll have one or two slides of an introduction and then understanding lung cancer. So, what it's all about, you know, how we differentiate between different kinds. Um, what's the preoperative preparation, um, in thoracic surgery, uh, or in lung cancer surgery? What are the, uh, treatment options? Um, the postoperative care, um, and advances and, you know, uh, what the future looks like in, uh, thoracic surgery. So I use these two books. Um, the one on the left is, uh, sort of, um, a much more quick, uh, review and then the one on the right is a much more sort of fcs, very uh very thick big book. So if you're really interested in thoracic surgery, you can uh you can get that one. So, um lung cancer, um lung cancer is the most common cause of death in the United Kingdom of Cancer, death, sorry, in the United Kingdom. Um And this is the case um in multiple countries, it's the most common cause of cancer death in the United States as well. And um you know, more people die of lung cancer than colon breast prostate and pancreatic cancer combined, which is uh uh uh quite, you know, a lot of people and uh the care that goes into lung cancer management is um is, is uh very much a multidiscipline approach. So, um at any given moment, you could be, you know, discussing with respiratory physicians, oncologists, thoracic surgeons, radiologists, histopathology, uh palliative care is involved and then um the wider lung cancer uh specialist nurses. So, the surgeon uh point of view is to provide local control of the malignancy, as opposed to, for example, the oncologist who's doing chemotherapy or immunotherapy is a much more systemic approach. So the surgeon is trying to excise out um a, a local uh pulmonary nodule or a local pulmonary cancer. And um and the uh the number of operations have been trending upwards. So um uh these are the uh the royal calls of surgeon or physician's uh data and uh there's been a 3.1% increase since um 2017 and uh 20% increase uh since 2014. And this data is from 2018. So I assume that it has actually increased since then as well. Um So risk factors. Uh so the, the number one risk factor for lung cancer, um as you all, um probably guessed is tobacco, um uh accounting for as much as 90% of uh you know, lung cancer patients, uh they uh carry the risk factor of uh tobacco smokers. Um And they have a 20 fold increase uh compared to nonsmokers uh duration uh is um uh an important, um uh you know, factor more important than the quantity. In fact. So if a patient has smoked for uh 20 or 30 years, um you know, obviously the quantity is also a factor but duration uh is quite critical. Um And in the last three decades, um you know, lung cancer has actually stabilized um in or decrease. However, in women, the, the trend is going upwards and, uh, that actually uh mirrors smoking rates as well. Um So you can see the, the, the two are, are very, very strongly correlated second hand smoke, um, uh confers a two fold increase. And then the good news is, is that, you know, um, it's, it's actually uh somewhat reversible. So, uh 30 to 50% reduction in cancer mortality, um, when the patient or the person has stopped smoking, um, for more than 10 years, um there was recently in the United Kingdom anyway. Um uh an announcement that they're going to really push for um smoking, uh smoking laws and things like that to actually reduce the um the amount of smokers in the public. And um and that has direct effect on impact on lung cancer. Um So other than um smoking and tobacco, environmental carcinogens, you know, asbestos, arsenic radon, you know, you know, bunch of industrial things actually, especially asbestos, typically we used in industrial sites over um the last 40 50 years is now banned. Uh but they all account for about 10% of lung cancer. So the um there's AAA huge difference between tobacco and then the next risk factor. And um and not that, so when you actually combine um these environmental carcinogens with smoking, then you can have a 50 fold increase in cancer risk. So, um you know, they, they have, they can also act in a synergistic way. And um and then recent studies have shown that, you know, uh you know, family genetics are also involved, um especially uh genetic markers on chromosome six, have a strong evidence um to the uh susceptibility towards lung cancer. Um in terms of pathology. Uh So, uh how do we differentiate between um different lung cancers? The main um differentiation is uh between small cell lung cancer and then non small cell lung cancer. Um And uh you know, I appreciate that, you know, this is a cardiothoracic uh course, but this is what the histology looks like. Uh This is what the hist pathologist under the microscope is. And um you can see on the left hand side, the squamous cell, adenocarcinoma and a small cell. I mean, I it, I can't interpret it but, and then uh you can see the different staining. Um And uh this is just to emphasize the, the, the fact that these are uh histo histological um uh differentiations, the most common type. Um 80% of primary lung cancers are non small cell. And um they're further divided into um adenocarcinoma, which is the most common type uh amongst nonsmall cell cancers, lung cancers. Then you have squamous cell and large cell, um uh large cell, uh no non small cell lung cancer. And um and large cell is actually on the spectrum of neuroendocrine tumors along with uh carcinoid uh tumor and small cell cell as well. Uh So how do we differentiate between these three subtypes? So, you know, we discussed uh we briefly talked about, you know, the difference between small cell versus non small cell. But then we have three subtypes in uh the non small cell category. And the way that we uh differentiate between these is that uh you know, morphology. So once again, under the microscope, uh adenocarcinoma has a glandular round uh appearance and the squamous cell has, you know, keratin pearls. Um and then large cell is sort of a, a diagnosis of exclusion. So, if you have lar large cell needs to be distinguished from a small cell and you know, the, the name kind of gives it away in the sense that uh you know, the the the cells are much larger. Uh and then immunohistochemical is a sort of a second line. And um and this helps us when we're trying to uh differentiate between adenocarcinoma and squamous cell carcinoma. And uh I just wanna go back to the uh the, the previous slide just to demonstrate this TTF one. you can see uh so in, in the uh in the squamous cell, adenocarcinoma in the second column amongst the uh staining, uh there's a a significant difference between um adenocarcinoma, squamous cell and TTF one and this is how you differentiate between the two. Um So the uh the, the adenocarcinoma is uh stained by uh the TTF one. Actually looking at this image. Uh P 63 seems to be the staining of choice for squamous cell carcinoma as opposed to a adenocarcinoma and then going to, um, small cell, so small cell, uh, carcinoma, uh, accounts for about 20% of all pulmonary carcinomas. And, um, and they typically have a, a much more aggressive, uh, course, uh, they typically are quite advanced by the time of, uh, uh, presentation. Uh, and, you know, they have, they're usually located centrally, uh, they might involve the airways and they generally have a poor prognosis. Um, and these cells. So the, the, um, the, one of the, the difference from, uh, a thoracic surgery point of view is that non small cell lung cancer is actually operable. Whereas, uh, because of the advanced stage, the, uh small cell lung cancer is a typically non operable type of, uh, of uh lung cancer. Ok. So, moving on. Um, so, uh, you know, if the patient has been screened, um, for, uh, lung cancer, uh, because of risk factors, uh, or if the, uh, the lung cancer has been diagnosed incidentally, then, you know, there will be no presentation and, you know, you will know exactly, uh, or, you know, you'll have to skip all of this presentation. But, but if not, if the patient, I don't know, uh, is discussing this, um, you know, this recent symptomology with his GP, for example, they might include, you know, cough, uh dyspnea or hemoptysis. These are very common, uh, uh, presenting symptoms for, uh, lung cancer. Um, some people might present with pneumonias or lung abscesses. And um this typically presents as the lung cancer. I obstruct the um the uh the bronchus or, you know, the vessels. And as a result, the area that is no longer served by the bronchus or the vessels will develop uh a necrosis and uh it will become an infection. So this is one way that it might present um and then generalized symptoms such as weight loss, anorexia, fatigue. You know, we know that the, these three are actually quite common with uh cancer patients in general. Um and then uh advanced or metastatic disease might present with neurological symptoms or bone pain. And uh these are two locations of uh metastasis. So, uh a patient with brain metastasis might present with neurological symptoms and then bone pain is obviously a bone metastasis. And then there's also paraneoplastic syndrome which is more associated with small cell. And uh this might, they might develop um you know, uh sort of cushing like uh Cushing syndrome. Um uh as a result of the uh the secretion of cortisol uh or cortisol like peptide by a, a small cell current cancer. But um for, for the purposes of, you know, uh of us, uh you know, cough dyspnea, hemoptysis uh is uh are the three main uh presenting symptoms and uh generalized symptoms can be uh you know, accessory. Um and uh and then pneumonia, we have to think about it as well. Um, so the diagnosis, so let's say, you know, you, you've seen a patient, um, they have presented with the ones that we've just mentioned, so they've got a cough or they've got pneumonia. Um, so you, you, you go through the, uh, the regular, um, process, you take a history, physical examination and chest x-ray are typical, um, you know, starting points, especially the chest x-ray, you know, in, uh, in a GP surgery, uh general practitioner surgery, um, you know, uh, a patient will present with a cough, then they will get a chest x-ray. And then the next thing, the chest x-ray will show a, an, uh, a mass or a shadowy or something like that. And then that will lead, that will create suspicion and then the suspicion will then result uh in a CT scan where you can see the actual, uh uh the nodule if it is of course present. So this is usually, um, the timeline patient presents with cough or generalized symptoms or uh dyspnea. Um, you know, the, the, the primary uh physician then asks, does a history, physical examination, chest x-ray and then there's a mass and then they get a CT and then that starts a whole new, um, whole new, uh cascade. So, uh, on the left, you can see, um, the apical mass on the, uh, the left upper zone of uh this patient's uh chest or lung and then the subsequent, uh, CT has shown a uh uh upper lobe uh adenocarcinoma. It's uh it's also demonstrated or uh described as spiculated. And that refers to the uh the sort of the, the projections of the nodule on the uh the, the CT scan. So once you're at this point, once you've gone through the chest x-ray, you've gotten to the CT scan and you've got this spiculated, left upper lobe adenocarcinoma or let's say, left upper lobe nodule, then you wanna go ahead and try and get some sort of histological confirmation. So, I mean, remember that this is sort of a histological um diagnosis. We need to determine what subtype of lung cancer. This is. So there are a variety of methods to um to obtain tissue and then subsequently get a tissue diagnosis. So, um sputum cytology, percutaneous transthoracic biopsy, uh bronchoscopy biopsy, um fine needle uh aspiration using endobronchial ultrasound. Uh and then fine needle aspiration using uh esophageal ultrasound are some examples. The one that uh that will probably be highlighted here is the um endobronchial ultrasound. Um So this is quite commonly used uh in the NHS. Um And they get like a tissue, they get like lymph node tissues and they, they can sometimes get the tissue from the actual um the nodule as well if it's close to the uh the um the uh the mass or the, the, the, the bronchus rather. And then finally, um we have a pet CT uh and this will help um in staging and to see if there are any other location in the, in the body that has uh you know, a metastasis. So, uh you know, once you've got your histological confirmation that you have uh uh a lung cancer uh in your uh in your, in your, your EBUS, let's say, then the next step is going to be to do a pet CT to, to rule out any metastasis and to stage the lung cancer. Moving on. So, moving on to staging, basically. Um so let's say you've done the CT and there's typically uh the radiologist will give you uh a TNM staging uh which uh is uh you know, tissue uh nodal involvement, metastasis. Uh And then on top of that, you will get uh you know, an EBUS result uh possibly, and the EBUS will give you the histological confirmation. So now you've got a good idea of what's going on. So you, you've got a good idea of the size of the uh the, the lung nodule. So, is it above two centimeters? Is it below two centimeters? Is it above five centimeters because all of these have implications uh in terms of the T classification, uh as you can see on the right hand side of this page, the uh the, you know, there are subdivisions T one A T one BT one C and these are all are um you know, um differentiated by the uh the size of the nodule and thoracic surgeons, uh typically uh the uh their area of uh agency is between T one and T two. So anything that's like tt three or T four will typically go for uh the oncologist for them to go, go through chemotherapy or immunotherapy. But staging has direct. So, what I'm trying to say is that staging has direct implications on the treatment modality, whether the patient is for surgery or whether the patient is for, you know, chemotherapy or some o oncological treatment and the prognosis as well of the, the um with the patient. And uh and then nodal nodal involvement, lymph node involvement has a direct impact on, on survivability. So, uh the more uh the more uh deep the nodes are. So if it's on the contralateral side, let's say you have a leftsided up, uh you know, lung nodule and contralateral uh lymph nodes are involved that is of course a poor uh prognosis. Um So that, that's also very important to take into account. And then finally, um in the staging uh section. So um the pet CT um might uh give us, you know, uh an idea of where uh the um the metastasis may be. Um but these CT scans are, are important to do as well on the left hand side, especially if you have symptoms. So, on the left hand side, um this is directly from the key questions book and you can see um that a for example, has pleural thickening. Um And, and there's also an effusion there, which might be a result of the uh the actual uh malignancy. But the pleural thickening would suggest that the uh malignancy now and the pleura and it's beyond the, uh the lung B is very self explanatory. This is a CT head or MRI head. Um And you can see that the, the lung nodule has metastasized to the brain. Um C I think is a little bit more difficult to interpret. But then d again, the CT scan, you can see very clearly that the uh the liver is uh has multiple uh metastasis. Um uh you know, for the, for the, for the purpose of examinations and so on, like the most common sites are the brain uh bone and the adrenal gland. But as you can see, there are, there are multiple um possibilities or multiple uh examples. And then once you uh actually obtain tissue uh usually intraoperatively, uh then you can send it to the histopathology to get a histopathology assessment. And then that will be your final staging. So, you know, the, the radical staging might say T one A and then finally, you will, you know, resect the, the uh the tumor and then you will find out that it was T two B for example. So this is the actual final um pathological staging. OK. So that's uh a little bit of information or a little bit about um the, the background pathology on lung cancer. Um And uh now moving on to a little bit more kind of uh surgical uh and what we need to think about uh before we're gonna operate on a patient to excise uh a lung nodule. So, um before we operate, we need to prepare, um we need to uh address uh certain uh questions and um, and then we're going to make a plan in accordance to these, um you know, answers. So, um you need you the confirmation of diagnosis. So, um, you know, you really want to know whether or not this is um you know, uh an adenocarcinoma or a squamous cell carcinoma, uh or is it a small cell carcinoma? So, um it would go, it would be good to have some sort of confirmation of diagnosis. And that's typically through a tissue biopsy of the uh the lung cancer and then the indication for surgery. Um So once again, if it's, let's say a T three, tissue three on the TNM classification, then um the indication would be more for chemotherapy rather than surgery. So this question needs to be answered. Is there an indication for surgery? So, if the lung nodule is um T one A or T two, then there typically is an indication for surgery and then um, fitness and comorbidities including cardiopulmonary reserve. Um This, of course, uh means how fit is the patient, will the patient be able to undergo surgery and come out, uh uh you know, and then uh and then be discharged and, you know, recover or is the patient not fit enough um for an operation? Uh And should we um look for alternative um treatment modalities? And then this actually uh brings you to risk stratification. Um So all three, the first three points here actually accumulate into um risk stratification. And then this is, this is, you know, the risk of the operation. How risky is it depending on the cardiopulmonary reserve and the indication, then you have to make a decision about whether this, oh, well, I mean, you, as well as the patient needs to make a decision about whether the uh the risk, um you know, outweighs uh the benefits or, you know, that's really where the uh the judgment uh comes into uh play. And then if uh there is a malignant tumor, there are two further um uh considerations is the, is the uh the tumor resectable. Um So, can you actually get an R zero resection? Are you gonna be able to take out the entire tumor safely? Um And uh so that this is one consideration and completely and then operability is um uh uh you know, will, will I be able to take this tumor out at an acceptable risk of death or morbidity for the patient? So, these are all uh these all go into the preoperative thinking and preparation um in the build up of uh you know, excising the lung cancer. The first um thing that I, I'd like to talk about, there are multiple, um you know, multiple different things that uh go into a cardiopulmonary reserve. Um But one very, very simple um uh classification. This is actually, it's also called the who, you know, the World Health Organization classification and it's called performance status. So this depends on how active the the person is uh prior to surgery. So, you know, uh performance status zero is uh you know, a patient is uh or person who is able to go every day, everything, all the uh activities of daily life are without restriction. And then um performance status, one is the, the the person can do, you know, light uh house work or office work, but no kind of strenuous uh exercise. And then two is uh they can actually, they tire out quite quickly. They only are able to do um 50% of waking hours, they're able to work and then three and four get, you know, worse and worse. So uh three is they, they're only limited to self care and they're confined to the bed or the chair for 50% of waking hours. And then four is completely disabled, cannot carry out any self care, totally confined to bed or chair for the purposes of um you know, lung resection, uh you know, uh performance status zero and performance status. One are acceptable. Two, then you need some further information. 34 and certainly five is out of the question. Uh So, you know, for two, you really need to get some more information and one or uh or zero are, are candidates for surgery. Uh and then pulmonary function tests. So pulmonary function tests are, um, uh, you know, can be difficult to read, can be, can be difficult to interpret, but they're very important in understanding the uh the the the lung function uh prior to surgery. Uh typically, it's uh spirometry in a pulmonary function test, um laboratory. And uh what's uh what is uh measured is the, the forced vital capacity, um the forced expiratory volume in one second and then you can get the ratio out of this and this will give you a restrictive or an obstructive uh picture. Um a very important uh uh consideration is the, the diffuse uh capacity. Um So the the diffusion capacity uh so this will measure the uh the amount of uh gas transfer through the alveoli and the blood. Um Now, this is this is uh quite an important uh statistic uh in consideration of uh thoracic surgery. So, um if the patient is unable to uh you know, have a low uh gas transfer, it's only going to get lower uh after uh you know, undergoing a lung operation. Um and then it's typically due to the thickness of the alveolar uh capillaria. Um if it's thicker, for example, in uh in uh you know, emphysema, pulmonary fibrosis, interstitial lung disease. Uh the uh the diffusion capacity is gonna be much lower. So these patients are gonna be more uh you know, vulnerable uh in the postoperative period. And then how do you risk assess? So, on the right hand side, this is the the British Thoracic Society guideline. In uh determining the risk. There are all other guidelines. So there's the European Society of Thoracic Surgery, a risk assessment module, there is a Thoraco score uh uh risk assessment module. But I'm just, I mean, they, they all really take into account similar things. So we'll go with the British Thoracic Society. Um and the British, the Thoracic Society um take into account the predicted postoperative FV one and the predictive postoperative diffusion capacity. Um And the way that this is calculated is uh if you're going to do a right upper lobectomy, which has three segments, then you wanna take the, the remaining segments uh divided by the total segments in a normal lung and then multiply it by your pulmonary function test results. So the uh an example would be the FEV one times 16 divided by 19, we give you the predicted postoperative FEV one. And then according to that information, uh if it's, you know, if it's above 40% then uh you know, you're low risk, but then if it's below 40% then you need to really uh go into further uh research about whether or not this uh operation should go ahead. There are other uh methods of uh you know, uh So functional assessment here can also be done by a uh six minute walking test. For example, where the patient walks uh for six minutes, then you determine how far they've gotten, which is typically somewhere between three to 500 m. And then they uh and then you look at what the oxygen saturation in that time period was. And then that will, that's another functional assessment, for example. And then you will then uh determine whether you have moderate or high risk uh in this module. So you've gone through all the um the uh the uh preoperative uh preparation. Uh Now you're ready to offer it. What are your options? So what can you do? What are some lung rejections that we can go through? So, um first of all, just a little bit of uh you know, a trivial fact. Um So lung rejections have been, you know, been happening since 18 90. So it's a long time ago and um mainly at the time it was for the treatment of tuberculosis. However, it then evolved into um you know, much more uh lung cancer oriented um types of resections. Uh So you got like a nice uh uh illustration on the right hand side of the slide. So you have, we have Segmentectomy which only takes out a segment of the lobe, lobectomy takes out the entire lobe, and pneumonectomy takes out the entire lung. So you see that there's an increasing order in terms of uh invasiveness. And then uh the wedge resection is a non anatomical resection uh that takes out a certain area, certain bits of the, the lung. Um But historically speaking, um initially, uh you know, the patient had a pneumonectomy. So, like before the 19 fifties, uh pneumonectomy were much more common, but this is such an invasive operation, you know, you're taking out the entire lung. Um and it's a very high risk, high risk of mortality. So, they decided that, you know, we should probably go for a much a less invasive operation. And from the 19 fifties on the standard was lobectomy and the a lobectomy is still the standard. Um However, there is an effort, there's, you know, there's a increased interest in, you know, pushing it a little bit further into, you know, sub lobar resections in the form of segmentectomy for, you know, less, taking out less lung parenchyma and giving the the patient uh a more higher uh you know, uh chance to uh function at a high level, post-operatively segmentectomy. So, um let's go into the uh the different types of uh of resections. So they follow the, the bronchial branches and the lymphatic drainage of the anatomical segment. So, um we just talked about the right upper lobe, for example, there's three segments in the right upper lobe. So if you were to uh you know, do a segmentectomy, you take out only one of the three of, of the uh the right upper lobe. And when would you do this as opposed to lobectomy? Uh So, the current thinking anyway is that, you know, if the, the, the patient is um unable to uh uh to tolerate a lobectomy because they're already quite vulnerable from AAA respiratory point of view, then, you know, taking out less parenchyma will uh you know, give the, the patient the, the the best chance to survive the operation metastasectomy. Uh then, you know, you wanna take out as, as little um parenchyma as you possibly can. So it's either gonna be a segmentectomy or a wedge resection here. Um And then if you wanna do, if you have uh uh you know, if you're unable to obtain um uh a uh a tissue diagnosis through an endobronchial ultrasound, for example, uh resection, then you could take a little bit of uh the uh the lung in the form of a segment or a wedge. And then you will send that to uh frozen section uh for the for the histopathologist to determine whether or not it's malignant or benign. And then depending on their assessment, then you will go ahead with your lobectomy, for example, which is the more uh invasive or the, the, the, the, the the option with more lung parenchyma. And then if there's only a small peripheral tumor that's less than two centimeters, then um you know, you wanna, you wanna preserve as much lung parenchyma. So once again, you then take out only a segment as opposed to the entire lobe lobectomy. Um So this has long been the standard for lung cancer. Uh But increasingly, um we are doing lobectomies uh in a uh minimally invasive approach. Um The only times where the uh the lobectomy, uh you would think to do a thoracotomy or an open uh lobectomy is if the, if the tumor is, you know, quite large tumor for about four or five centimeters, if there's a chest wall involvement or if the patient is unable to go on single motel population, which is more sort of like a thoracic anesthesia uh reason or if, if it um if the uh the is adherent to the pulmonary vessels, if it has a more central location and it's closer to the hilar hi uh than uh or the hilar structures, then uh doing an open lobectomy might be uh a more prudent approach rather than a minimally invasive approach. Uh And then pneumonectomy. Um So the, the a pneumonectomy is reserved or tumors that cannot be excised by a lobectomy and are often positioned very centrally. So these are big tumors, central tumors that are in, you know, that involved uh hilar structures. And you, you know, they, they, they might be invading the bronchus, the main bronchus, and then if they're invading the main bronchus or the main structures, you, you take out the entire lung and uh that will be a pneumonectomy. The mortality is significantly higher uh compared to a lobectomy. Um you know, depending on which paper you read, it might be 3 to 12%. And uh so you really need to think about whether or not this patient would be able to survive a pneumonectomy. So, pulmonary function tests and preoperative assessment is uh you know, uh is, you know, needs to be very detailed and very uh you know, you, you really need to get to the bottom of this uh to see whether or not this patient really can take pneumonectomy. Uh And if you can, you do a sleeve lobectomy. So a new lobectomy is um is when you, you, you remove uh the area where the cancer is invading the bronchus, for example, you, so you take that section out and then you tie it, you suture it to together um rather than taking out the entire lung. Yeah, uh and a wedge resection. So this is uh the maybe the smallest uh you know, or the, the, the, the resection where you're taking the least amount of parenchyma. Well, first of all, the main difference between all the three that we've just talked about and the wedger section is that the wedge is non anatomical. So, um if you're taking out a lung nodule, um with a wedger section, it's a non anatomical resection and there's a chance that it, it is uh you know, it is um uh you know, uh spread through the lymphatics of that uh segment. So this would not be an ideal um ideal resection for a cancer. Um However, it is, it is a good resection for um you know, uh once again a frozen section where you don't know the etiology of the uh the nodule. So you wanna get a bit of tissue, send it to the his pathologist, see if it's malignant or benign. And then also uh metastasectomy is another uh possibility where there is a known primary and this is, let's say a colorectal cancer metastasis, then you just take it out with a wedge resection rather than taking out the lobe or the segment or anything like that because you know that there's no kind of local spread. You wouldn't think that there would be any local spread, um postoperative care. Uh So now you've, we've, uh we've, we've sort of gone through the timeline. So we've determined the patient had a cough. Then we got the chest x-ray, the, the patient had a mass uh on the other shadow on the, on the chest x-ray, we got a CT, there was a spiculated left operative, uh a adeno well nodule. We did the E bos we got the tissue diagnosis. It's an adenocarcinoma. Now, we, we've done the uh the preoperative assessment and the patient is OK to go ahead with an operation and we've done the resection and now we're in the postoperative period. Um And so, you know, II I thought that it would be more interesting to uh talk about the complications rather than the uh the routine postoperative period. So in, you know, routine postoperative period is going to be uh you know, chest dr management, uh you know, patients because the pleura has been opened, you will have to have a, a chest drain inserted. Uh and that will be taken out. Um uh and you know, the patient will then go home on day three or day four in, in a routine situation. However, of course, with all surgery, uh there are certain complications uh and these are the most common ones that I've listed here. So, cardiac arrhythmia, atelectasis, the most common one in fact, is actually atelectasis. I should have put that in the first uh row but, and then respiratory failure, pain, prolonged air leak, and surgical emphysema. These are all um uh common complications um following uh thoracic surgery. So, uh I'll talk a little bit further about cardiac arrhythmia and atelectasis. However, uh respiratory failure, you know, this is uh you know, a lung resection. Uh and then, you know, depending on whether it's type one, type two respiratory failure, then you will have to talk to intensive care about how, depending on how severe it is pain. Uh with any surgery, there's going to be pain. Um, you know, so especially for a thoracotomy, which is an open uh incision, quite a large uh incision. Uh then, you know, there is going to be pain because you're really uh you're moving the ribs apart and there are, you know, uh intercostal nerves that will um convey the pain. Prolonged air leak is we talked about the chest drin if the chest rain is in situ and the air leak has not settled for seven days, this is now prolonged air leak. Uh There are certain measures that you can uh take to uh reduce the air leaks such as uh a blood pleurodesis. This is a bedside procedure, uh surgical emphysema. Uh it's difficult to kind of rationalize how surgical emphysema happens. But it's typically there's a connection between the subcutaneous area and the, the lung and the air leak. The, the, the, the air that's leaking out of the lung is finding a way into the uh subcutaneous area. But uh for the purpose of this uh presentation, we'll uh talk about cardiac arrhythmia and atelectasis, which are the most important ones. So, cardiac arrhythmia, um uh it can happen in about 10 to 15% of uh lobectomy patients uh will get atrial fibrillation, uh much higher in pneumonectomy. Uh They typically happen day one to day three and uh digoxin uh is uh you know, a first line medication uh in uh thoracic, I know that in cardiac surgery. Um you know, patients usually get uh amiodarone but in uh in thoracic, it's usually digoxin. Um and the principle uh of management is to control the rate, uh control the electrolyte imbalances. So this will be your potassium and magnesium control the acid base imbalances and hypoxia. Um These are uh if you know, if the patient is getting worse and worse, then you really need to think about the acid base, whether there's lactic acidosis and uh and also respiratory failure in, in the, in the form of hypoxia prophylaxis. Uh So, this is a, a common uh postoperative complication where there's a collapsed certain segment of the lobe. Um And uh and it typically happens in day one and day two. So what will happen is that the each segment has uh its own vessel and its own uh uh you know, uh bronchus uh basically or, you know, part of the bronchial tree. Um And uh if that collapses, then the, the there's no air in that uh segment. And as a result, the, the, the segment collapses um in order to um prevent this from happening, uh you know, early mobilization, physiotherapy, breathing, breathing exercises. So, you wanna, you know, inflate the lung as much as you possibly can, you want to get the patient to sit out. Uh And uh you can also give nebulizers to um to kind of uh break down thick secretions. Um You know, these all come under the, um, the ias, you know, uh enhanced recovery after surgery guidelines in uh you know, in, um, you know, they, they're all under uh under those categories. The physiotherapy early mobilization, encourage the patient to sit out of bed. You know, this is uh one of the things in bunch of different surgical uh specialties, for example, colorectal surgery. Uh they, they, they also follow the er, a uh guidelines but I, you know, the, the, the implication of thoracic surgery uh comes under atelectasis, you know, you want to inflate the, the lungs as much as possible to prevent uh collapse, cause once the, the, the segment collapses, then the next thing is going to be, it's going to get infected and then you're going to have sort of a situation in your hands. Um And then just a couple of words about where, you know, where the advances are and where it's sort of moving towards. And this is actually the last slide in this presentation. So it's a more of a sort of an inspiring where we're gonna go from here kind of slide. Um So minimally invasive, uh you know, you might have heard robotic surgery is getting increasingly adopted, a bunch of uh units around the world have, uh you know, either da Vinci robot or CMR robot. Uh you know, and they, uh they do their minimally invasive operations uh from a robotic surgical approach. And in this approach, the, the surgeon is not bedside, the surgeons, you know, looking into a robotic console and the, the robot is then they're moving the um the apparatus by using the console. Um and, and you know, there are multiple reports of increased better lymph node dissection, shorter hospital stay. But there is also, you know, it's a very costly thing, you know, robot, it costs a lot of money. And the current discussion is whether or not uh you know, it's uh the the cost actually uh is justified. Is it that much better than video assisted thoracoscopic surgery? So, but the, the one of the arguments is that, you know, you get better lymph node dissection, the you the uh the, the um the apparatus, the instruments are much agile. So it's kind of like moving your hands rather than the clunky uh video assisted uh thoracoscopic uh instruments. Um So these are the arguments for robotic surgery, but obviously, the counterargument is going to be the cost and whether or not there's actually a a re increase or enhancement of the uh the patient postoperatively. Um So, uh like I sort of said in a couple of slides ago, there's a push to go uh sub lobar, there's a push to take out uh the least amount of parenchyma that you can uh you know, and get away with uh and to give the the patient the best uh postoperative respiratory function. Um So, and there are there are you know, there are increased uh you know, better uh preoperative planning strategies including uh you know, I don't know uh visual uh three dimensional um anatomy of the uh you know, of the personalized bronchial tree, for example. Uh And then once you get that image, then you can plan uh about which segment you could uh feasibly take out uh depending on the three dimensional uh representation of the bronchial tree. Um So this is another thing that uh you know, goes into the uh the preparatory uh period uh before the operation and it, it increases your chances of doing a segmentectomy rather than just taking out the whole lobe imaging. So, this image uh on the top here is uh an intraoperative imaging. So, uh you know, with national screening programs, uh you know, coming up with more and more uh small T one, a tiny, tiny tu tumors, the sort of like tumors, the size of a chickpea. Um It's actually very difficult to locate that tumor in uh intraoperatively. So you can see here uh on the uh on the left versus the right. Uh There are certain dyes that are inserted preoperatively. Uh And then uh you know, the dye then will light up um light up uh intraoperatively to show you to guide you uh to uh to see where the uh the the exact location of the pulmonary nodule is. So this is an exciting part of uh better understanding where the uh the, the nodule is, and I would argue that, you know, it's actually connected to the uh the second point here because if you're able to uh determine exactly where the nodule is, the likelihood is that you're gonna take out only the area around that nodule where rather than taking out the whole lobe. So this is another push to taking out as, as little as you possibly can. Um And then finally, so immunotherapy, um now, I don't really, I can't really comment on the intrinsic um you know, uh mechanisms of action of immunotherapy. However, uh the uh the recent studies have shown that immunotherapy has shown quite an increase, you know, great enhancement in overall survival in uh lung cancer. Uh And uh this is just 11 of the studies where uh it's uh Zuma uh plus uh chemotherapy uh versus placebo plus chemotherapy. And uh the uh the uh the, the graph on the top there is the overall survival and you can clearly see that there is a uh an uh uh an advantage to doing the immunotherapy over the uh uh over just chemotherapy. Um So this is sort of like changing uh the, the perspective on lung cancer because now you can actually a lot of the uh the, the tumors that were previously non resectable because they were large tumors are now uh once they undergo immunotherapy fall under the resectable category. And um and you know, and then that means that you actually have to operate on much more complex uh tumors and so on. But, you know, it's just another thing that's happening in, uh, in, in, in thoracic surgery. So, like going forward, we will be operating on more and more um complex tumors that have been treated with immunotherapy that were previously non resectable. And as a result of the immunotherapy are now resectable and, um, and that uh concludes my, uh, my, uh, talk on uh thoracic surgery and uh lung cancer. Um, and I thank you um for uh participating in, uh listening to me and thank you for your attention. And, um, I'm gonna pass it back over to, uh, to mi now um to uh conclude and if there are any uh questions, of course, I'm happy to answer them. Thank you. Thank you very much, Patrick. That was a really nice presentation. Thanks a lot. Um Do we have any questions? Um, it's time for questions. If you have any questions, you can drop it on the charts and, um, just give it a few minutes if anyone has any questions to drop it on the chart and Patrick can answer for us um, while we're waiting for questions. Thank you, everyone. Um, for joining this session. This is the night session of the teaching series Basics of Cardiothoracic Surgery. Um We have one last session left, um, which is going to be on um, imaging in thoracic surgery. In cardiothoracic surgery basically. And it's going to be in two weeks time. Um, so we've come a long way. We started this teaching session sometime in June and we've had, um, at least two sessions every month since then. And this is the, this is the like fifth month and it's sort of come to fourth month. It's coming to an end. And thank you everyone for joining. So far, we've had so many sessions, we've had uh cardiac talks which we've completed when we've talked about. Um, we talked about the anatomy, we talked about cardiopulmonary bypass. We talked about bypass graft, we talked about valve surgery. We've talked about aortic surgeries and coming to Thoracic. We've spoken about anatomy. Also, we've talked, spoken about non um no non-cancerous um, thoracic surgeries and this talk on. Now, this talk on um cancer and its management. I hope it's been helpful so far. Um Our last session will be on imaging, as I've mentioned, um initially planned for thoracic imaging basically. Um But I think it might be a combination of cardiac and thoracic. Um not sure that's going to be and that going to be in two weeks. Uh I'll pick up the announcement and the flares um As soon as it, it's all ready and the time is confirmed. Um Still no question so far. Um So I, I think it, it has really been a good session. Thank you very much, Patrick. I really enjoyed this talk and thank you very much for all the other sessions you've thought, I think you, you've thought to find this series. Thanks a lot for um being available for this. Thank you, everyone for joining. I'm going to share the feedback form now. Um So um feel free to feel the feedback. Thank you, everybody for your attention. I, I really appreciate it. Um And then everyone see, I think and then send the feedback. Ok? Now, so send your feedback form, fill the feedback form and then you'll be able to get a certificate of participation. Thank you, everyone. And uh hopefully see you in the last session of this teaching series in two weeks. Thanks Patrick and thanks everyone now. Thank you. Bye bye.