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Just gonna wait to see yeah brilliant ok fab, so yeah um well today, we're going to be looking at lung cancer and the surgical management, so it's the last um in our series um. This, this yeah the last in our series basically so um getting started. Um Things will be looking at today um are the epidemiology and risk factors of lung cancer um types of lung cancer, how it presents, how we diagnose and stage lung cancer um and the exciting part which is the management of it. So these would be things like lobectomy, pneumonectomy, wedge resections, and sleeve resections will also compare open techniques to video assisted thoracoscopic surgery otherwise known as vats and we'll also look into the complications of lung cancer as well so um looking at the epidemiology of lung cancer, so basically it's the third most common cancer in the uk, so it has a pretty big impact um in our practice and in the nhs, um, 79% of the lung cancers are preventable, which is quite astonishing thinking that this is something that you know is sort of within within our control um It's got pretty poor poor prognosis, so five year survival rates are really low so about 16% and um interestingly, the incidence rates in England are approximately 170% higher uh in the most deprived quintile compared with the least um So this is a disease that sort of affects people of lower socio economic backgrounds um as to why we can we can hypothesize, but um it might be that the high rates of smoking, in those those um populations um lung cancer is the most common cause of cancer death in the UK, so 21% of all cancer deaths are caused by lung cancer and approximately four out of 10 of all new lung cancer cases in the UK are diagnosed in people age 75 over, so it's predominantly a disease that's what catches up with people in later stages of life basically so um yeah 48% of the uh lung cancers are usually in the upper lobe or bronchus of the yeah, the upper lobe or the bronchus, um 26% in the lower lobe and the rest are much lower percentage. So predominantly you're looking at cancers in the upper upper airways uh with lung cancer, so how does lung cancer present, So in perhaps the g. P. Surgery people with early lung cancer might get things up persistent cough, repeated chest infections, finger clubbing um the usual things like unexplained weight loss um fatigue um and loss of appetite. They might also get chest or shoulder pain um and they might cough up blood um So that's one of the big red flags. I'm sure you've seen lots of uh so advertisements for for you know going to see your gp, if you cough up blood or if you've had a cough for six weeks um and also hoarseness of voice is something to look out for as well and breathlessness. Um patient's might present sort of late in in a and e, so, this is probably more signs of like later disease, so if they've got repeated pneumonias, um they might you might have consolidation on the x ray um or they might present with lung collapse. They'll just suddenly be really breathless um say with pneumothorax as well, very breathless um They can also present with pleural effusion, so I've seen it where someone's presented to us with uh exudative plural effusions that just means there's like high protein count in, in, in the infusion, it's likely caused by malignancy and that can sometimes be a first presentation. Um Other things as well paraneoplastic syndromes, so this is where um the tumor releases sort of ectopic hormones um and that can cause certain things like high calcium um or siadh, and we'll go into this a bit bit more in a later slide, um and yeah they can just present with any features of metastasis, so things like bone pain. Um uh you know other things like which will go into a bit later. Yeah uh So yeah presentations of local and regional spread so the lung cancer can cause superior vena cava obstruction, so if the mass is at the sort of, like the top top region or in the bronchus, um it can cause a mass effect, so it can compress on the s. V. C, which causes a reduced venous return to the heart um and that can lead to things like breathlessness or um patient's might look quite blue um and they can also have a visible jvp as well um other things that massive that the mass effect might cause um phrenic nerve palsies, so they might have problems with breathing on exertion because the mass is um compressing on the phrenic nerve, which uh causes well, which helps with the diaphragm um function another thing that might come up in your exams as Horna syndrome, so it's a triad of thing so it's tosis, may, aosis and anhydrouse iss, so tosis is where you get drooping, eyelids may osis, is contraction of the people and anhydrouse isS is a loss of sweating around around uh on the face that part of the face, and this is usually caused by a prickle lung tumor's otherwise known as pancoast tumor's, uh basically the mass compresses on the sympathetic chain, which causes this presentation in the face. It's also quite rare but it's something that people love to test you on in exams um and compression of the break or complex brachial plexus. Um yeah mass effect might press on to the brachial plexus and cause nerve palsies in the arms and you can also get pericardial effusions. So looking at the types of lung cancer, um It's usually split into two categories, so you've got small cell carcinomas and non small cell carcinomas with small cell carcinomas. These originate from neuro endocrine cells. They develop centrally near the main bronchus and are strongly associated with smoking um and they're associated with rapid growth and motasisis. Um Non small cell carcinomas make up the majority of lung cancers um So the most common two types of the squamous cell, so these are from the cells lining the lungs and adenocarcinomas from the mucus producing cells. You can also get carcinoid tumors and large cell um large cell carcinomas. Um These are both quite rare, large cell, is basically sort of, like the un, undue differentiated um cells, so people can't tell exactly what these cells are, but they just look large under the microscopes, they call the large cells um. And these both usually have quite poor prognosis as well, so moving on just looking at the common cancers in more detail, small cell cast, nervous, as I said these originate from the neuro endocrine cells um and they're named small cell carcinomas after their appearance under the microscopes, they all look very small, little like little beans um and they developed centrally near the main bronchus. They're really it's really strongly associated with smoking and copd, um and these often have really poor prognosis. They metastasize really early and patient's often present quite late, So these patient's with small cell carcinomas are very rarely considered for surgical intervention Because by the time they've metastasized, there's nothing really we can do to treat it surgically um uh So we won't be focusing too much on small cell casts name as in this presentation. Um Common site of metastasis include the contralateral lung, the brain, the liver, adrenal glands, and bone, and these cancers can also secrete ectopic hormones, so acth, which can cause cushing's disease, and a. D. H, which can cause symptoms of inappropriate adh production, uh sorry diuretic hormone production all right um and squamous cell carcinoma so as it says on the tin originates from the squamous cells which line the lungs and the main airways. These have strong associations with smoking as well um as radon gas um and they develop centrally near the main bronchus. Similarly to small cell, they're slower growing them small cell, but they still have poor prognosis, but these are the ones that you would likely see um as candidates for surgery. Um They these also produce ectopic hormone secretions. Sometimes the main ones are the main hormones, uh squamous cell carcinoma, secrete r. P, th, the parathyroid hormone and parathyroid hormone related protein. So with these cancers, you can some patient's can sometimes present cost door with hypercalcemia um So when they do that you probably do a ct tap um just maybe just to check if yeah check check your lungs, check if they've got any cancers um. So yeah here's the another histological side of squamous cell carcinoma. Um The things you look out for on the pathology are these keratin pearls so where it says, characterization you see these big round or pearl like cells um and you also have intercellular bridges and here's an excited plasm, so it's just something to look out from pathologies um adenocarcinoma, So with these, they developed from the mucosal cells, so the cells cells that produce mucus in the airways. It's associated with smoking, but the most, it's the most common subtype to be diagnosed in nonsmokers. Um. These usually develop in the peripheral lungs, so unlike the other two you'll see those in in sort of, like the outer lobes um are part of the lobes. Um extra extra thoracic metastases are often common and um adenocarcinomas are often diagnosed late um and again with poor prognosis. Um These usually don't have any paraneoplastic syndromes, so how would you diagnose and investigate for lung cancers, so um you'd probably if you're in gp practice you'd refer um for a two week wait lung cancer clinic. Um If you're in the hospital, you do bloods, do you f. B. Cs, use these calcium is really important because of the paraneoplastic um syndromes uh and you do LFTS as well um and you can also test for sputum, so you can do sputum cytology as well as pleural fluid, so if they've got pleural effusion and you drain the fluid. Um then you would send that off for cytology and see if there are any malignant cells. There chest x rays your first port of call for imaging um so you might be able to see nodules or masses on a chest x ray um If you do see nodules or masses on a chest x ray, your next um your next bit of imaging for would be a ct tap um or high resolution ct thorax for a more detailed imaging, Then you can see where the tumor's have spread or um yeah or maybe see where if there. If the lung the lung cancer is not the primary, then you might be able to spot where the primaries are um and then once you've done your imaging you might want to get a sample, so sampling is the gold standard, so with biopsy in order to diagnose a lung cancer. You need histological confirmation and the way that we do that is through bronchoscopy um and or E bus, which is in the bronchial ultrasound bronchoscopy. E buses usually used the mediastinal lymph nodes sampling um So it's basically the same as a bronchoscope, which is like a little camera that they put down your lungs to have a look down below, but I'll talk about that a bit more later um and then you can also do a pet ct scan to establish any further spread. So you scan the whole body and through that you can look for and stage um the cancer. Oh I forgot to say going back going back um This isn't so this sort of flow of investigations isn't always done for everyone, So people would have to so the doctors would have two types of um titrate the diagnostic procedures based on the patient's general prognosis and holistic well being. So for example, um If you've got a really old gentleman, you know who you see um uh metastasis on on the ct scan and they're very frail. This patient probably wouldn't be suitable for chemo or um surgery, so you probably wouldn't want to put them through an invasive investigation like a bronchoscopy, um and so you probably just leave it at that and and perhaps treat palliatively, so with lung cancer, it's a bit different from from other cancers in that you have to base the investigations and the treatment on the patient, their wishes and whether they can tolerate certain things. So this is just another slide just to show you about the procedure of bronchoscopy because it's perhaps not something that we've all come across um So what clear conditions will usually do is. They'll have a bronchoscope, which is like a long thin camera. The patient's are usually um sedated, so they'll usually have some midazolam, so they're awake, but they sort of don't really know what's going on um. And then the bronchoscope is just passed into the airways um and it has a camera and you can visualize both sides. They'll take pictures um as they go along um and this is the sort of image that you might see on a bronchoscopy um So here we can see the bifurcation of the trachea um and on the right you can see a mass. That's that's bleeding looks a bit friable um that's likely to be a cancer, so what they'll do in order to take a biopsy from it is they will um use like a thin needle and just take sort of multiple core biopsies um from that that site and then they can test it histologically um and grade the cancer. Um e buses very similar as well, so e buses basically they have a little ultrasound on the end, it just basically has better diagnostic properties for a lymph nodes, so they can see the lymph nodes a bit more clearly and so they can get targeted um samples from lymph nodes if they're suspecting any lymph node involvement, and by the way if you have any questions just put them in the chat and um I can answer them as we go along or um at the end as well, so, this is sort of the boring bit which is the staging for lung cancers. Um This is specifically for non small cell lung cancer because that's what we're going to focus on from the surgical perspective, so um I won't go into the details because it's just it's just very long well we can go through the staging, which is probably a bit better so TMM staging um So it's all based on top of the size and the spread, um so the larger the eczema is, uh the greater, the grade, so t three is between five and seven centimeters or if there's more than one tumor in a lung or locally invasive into local um structures, um and then a lymph node spread. If there's if there's local invasion in the lymph nodes into the lungs or highland, then it will be an n one and to so you find malignant cells in the ipsilateral mediastinum and the carina. Uh n three you'd have malignant cells in the lymph nodes of the opposite or a pickle lung, and in the lymph nodes above the collarbone and the metastasis is quite simple, so no metastasis or metastasis, um So these would be local extra thoracic or multiple extra thoracic, so if you're interested in that have a look through you know for the purposes of just not make sure you don't get too bored um. I'll skip through that. Um There's also staging for lung cancers, so again there's a lot going on here, um but stage one is usually cancers that are about less than three centimeters um that have maybe very local spread um So these are the cancers that we would consider for surgical intervention same with stage two as well. We consider these for surgical intervention, so stage two A is between four and five centimeters um with to be there's a bit of variation, so any cancers that are five centimeters um in size, with cancer cells in the lymph nodes close to the affected lung or 5 to 7 centimeters but with no lymph node involvement um or with lymph node involvement that has spread into one or more of the following areas. So these sort of surrounding um the structures such as the chest wall with phrenic nerve and the pleura, or if there's more than one tumor in the same lobe um three A. So, if the cancer spread to the lymph nodes in the center of the chest on the same side as the tumor, um, and if it's up to five centimeters or if it's slightly larger, then, um if there's more than one in the same low of the lung okay um or if it's spread to any of the surrounding areas and it's about 5 to 7 centimeter. Or if it's large and it hasn't spread into the surrounding nodes, but it spread into other surrounding structures like the diaphragm, mediastinum, heart, vessels, trachea, Then it's still to be okay um okay and then stage sorry, that was stage 33, not to my mistake um yeah, and then stage three B, So these are the cancers that we wouldn't even consider for surgery. These are all um going to be for chemotherapy or radiotherapy, So yeah three beef they're spread into lymph nodes outside of the thorax um and yeah basically the larger is the more it spreads. Um I won't go too deeply into these because you can look at them. They're on the cancer research website if you're interested, um but yeah, so I'll do a quick little summary page There's quite a lot going on, but we'll skip through um yeah, so basically the summary for staging of lung cancer because it's so complicated, don't worry about the finer details what matters most is that the size matters, so it sort of goes up in increments so three centimeters um up to over seven. These are sort of your cut off points um Local invasion is bad, Local invasion is too important, structures is worse um Live load involvement That's also not good, but in terms of severity, it goes from lung node to central node, so in the media sign em too distant nodes outside of the thorax. Um If you have multiple tumor's that's not good, and if it's in the same lung, it's worse if you have multiple tumors in different lobes and if it metastasizes, then then the grade, the grading will be higher, so those are the sort of things that you have to take into consideration um yeah as a summary, so um going on to the management, so non surgical management, we'll just touch upon um So usually long cats cases always go to m. D. T. So this would involve cardiothoracic, respiratory and oncology um just so that they can all sit together and make a plan for these patient's um so, for those for the stage three, stage fours, um you'll probably consider chemotherapy or radiotherapy um because we can't you know, exercise all of the cancer um as it spreads, you can also have pro, prophylactic radiotherapy to the brain, especially for small cell lung cancers. Since they they often metastasized by the time people present. Um Other things are, I mean therapy agents, so people can also benefit um from from this, so the the surgical management of lung cancers, like I said previously for stage one and stage two predominantly. Um These involved wedge resections, lobectomies, pneumonectomy, knees, sleeve resections, um and these can be done by either an open approach or video assisted thoracoscopic surgery, So in facts um so basically a wedge resection as you can see in this image is basically a little wedge out of the lobe, so it's a small part of a lobe or you can have a segment tech to me, which is just a slightly bigger part of a lobe, so you cut those out um and these are usually for your stage one cancers um haven't spread very far. Um Your lobectomy is basically the removal of a whole lobe of a lung. A pneumonectomy is the removal of a whole lung, um so it's quite curative in the naming a sleeve resection is basically the removal of a lobe and part of a bronch, I so these are usually used for um when there is spread into the trachea, um as well as um having cancer in the lobe, Um So the approach is that you can take for these either open or vats, and we'll go into that a bit in a bit more detail and in a second so factors that would influence the choice of surgical technique um and also whether a patient is able to go for surgery in the first place, So preoperative lung function is really important um basically with a pneumonectomy um the surgery itself will decrease your f. E. V. One by 50% and a lobectomy will decrease it by 20% um and roughly you need about an f. U. V. One of at least a liter, um postoperative to give you a good chance of, of survival basically um so if the estimated postoperative fVB one is less than 40% of predicted, the risk of more disability and mortality is quite high so that's something that people have to take into account before going for surgery, um. And people can also do some like cardiovascular tests um just to make sure that they're fit enough to go through with it because it's quite a big operation and and people need to be quite fit before they go for it. Other things that affect the surgical technique or tumor size, nature and positioning, so less suspicious lesions might require smaller receptions or as high suspicious lesion's might need a lobectomy or a pneumonectomy um The larger and more invasive a tumor is the more it needs to be resected, so um yeah if if a tumor invades the broncos, for example, you can't just remove the lobe and and things will be okay, you also have to cut off the part of the bronchus, which is why sleeve lobectomies are, are used, and I'll discuss that a bit later, um so we'll start off small, we'll look into wedge resections and segmentectomy knees, so as I said before we're removing part of the lung which is less than a lobe um it's the least radical so least invasive um and these used for tumor in situ or um t one n zero n zero lesion's which are in the outer parts of the lung. Um Sometimes you can use these for biopsies or for a less suspicious lesion, um and it can also be used as an alternative for those with poor physiological reserve. You might not survive a lobectomy, chest trains usually inserted after the operation to drain off any blood or fluids that might collect in the lungs. The last thing you want to have POSTOP is a you know pleural effusion or a new more thorax or hemothorax um so moving on to lobectomy, so a lobectomy is the most common surgery for non small cell cancers. Um These are mainly front stage one and two um It's usually done nowadays by vats, so yeah, rather than using the open approach, and this is because it's got better surgical outcomes. It's less invasive so what that is is basically a bit like laproscopic surgery. Um For you know that people use in General surgery but just for, for the thoracic region, um So what happens is, they'll make some small incisions um in, in the thorax, um and they will insert a camera in there um and all their instruments so they don't have to cut open a big section um. They can just sort of operate in sort of like a keyhole keyhole surgery way. Um Yeah positioning for a lobectomy is really important so they need to be in a lateral decubitus um position, and basically this position opens up the ribs um for greater access, um and the position the patient is positioned on the side on their side, um and the hips are sort of at the break of the table, so the hips, the legs will sort of be hanging off off the table and they'll prop the arms up as it's like in this picture, So this gives you. This picture gives you a better sort of image of of what the lateral decubitus position is um so there's a drop at the hips just to sort of stretch out the ribs a bit um so basically the incisions are made between the ribs to provide access to the chest cavity. Um So yeah this is this is the Vats procedure. Um This is a lobectomy via the Vats sort of procedure um So you can have different types of that, so you can do a unit portal that um which is the five, which is a five centimeter utility incision in the 4th and 5th intercostal space between the anterior and the middle axillary lines. Um The Dukes Vats is basically two incisions um and then the Copenhagen vax is the 33 incisions, um usually people would use the Copenhagen vats because it just gives extra access um to the thorax um and samples are usually removed through the unit portal that so the utility incision in the anterior part of the chest. Um So once they made the incisions, they'll put the ports in um um and the thoracoscope, which is like a small video camera and the surgical instruments will be inserted through the ports um So what they'll do is, they'll just explore the thorax first, so they'll make sure that they know where the location of the lung tumor is. Um they might use that to have a look at the pleura, bulge exclude any metastasis, um and they'll start on dividing the pulmonary pulmonary ligament, so the first thing that um they will do is to dissect the highland, but at this point they might take a wedge biopsy to remove um the specimen and put pop it in the bag and they'll just take it out through one of the ports. Um So yeah the anterior posterior approach is the most commonly used to dissect the highland, so the hilum is basically the area where you have all the vessels, the nerves and bronch, i, which are surrounded by the pulmonary ligaments. So first of all they dissect the pulmonary ligaments um and then they'd go and dissect all the other structures, so the way that the structures are uh sort of cut um is that they're basically they clamped, they clamp either side um They like gate them so they basically tie off the two um parts of the vessels or the nerves um and then they'll just do a cut through it, so they'll be tied off and I'll show you pictures of those later. Um So once all the highland has been dissected and you know you've got like a little bronchial stump, which is what it's called. Once it's all been cut, you can start um using careful incisions, just cut the affected lobe out and then what they do is, they'll put the affected lobe in a little specimen bag um and pull it through uh the, the incision port um basically the reason why we put it in the specimen bag is to prevent tumor cell implantation into the incisions, so you don't want to leave any of the tomb cells. They're basically you can also take mediastinal lymph nodes out and send them the histology. Um So once you've taken the low about you have to irrigate the heavy thorax with warm saline and then basically close up close up your incisions, so I've got some pictures here just to try and make things a bit more clear. Um So, here's an image of a clamp so what they'll do, they'll clamp off both sides um and and um like eight it so tie off with sutures um and make sure it's not bleeding and then they'll they'll give it a cut through and then here you can see on the second picture. Um When all the vessels have been cut like a little bronchial stump and that's what will be left in heavy thorax, so here's another picture of the how they tie it off and that's what will be left um. And also, yeah this is sort of the positioning where you will see the the port for that's so types of lobectomy, as I said, you get open lobectomies when they make a big big incision, but we're talking about that a bit later, that's which is what most people do and rats, which is a new sort of thing. Um It's called robotic assisted thoracoscopic surgery. Um That's usually that's mostly being done in america. I think there might be a few specialized centers in the uk, doing that, but it's not common practice um as of yet in the uk, so moving on to pneumonectomy knees. Um This is where you remove the third, where you remove the whole long, and these are indicated for more advanced disease such as tumor's located in the main stem bronchus or extending across a major fissure. Um So with these, um you usually require single lung ventilation, so you with the lung that you're trying to take out, you must make sure that um this long as an inflated. Otherwise, it would make it very difficult to extract um So usually what they do is they use a dual lumen endotracheal tube or a single lumen tube with a bronchial blockers. They'll block off one other side, or they'll just advance the single lumen tube into the main bronchus. So usually with surgeries, they just pop it into the trachea, but because you're removing one other side, you need to go a bit deeper and and just inflate the one lung. Um So pneumonectomy is, are usually done with the open approach, um So the main access um to the thorax is the posterolateral thoracostomy um and this starts from the line between the scapula and mid spinal line and extends laterally into the anterior axillary line um and it passes through quite a few muscles so you have to cut through the latinas, door, sigh serratus anterior, and the rhomboids and the trapezius as well in order to get to the two belongs similarly to the lobectomy, highly, dissection is the first step so as I said hilum, the highland structures are clamped, ligated, and dissected. Um Care is taken to ensure that lymph nodes are removed and sent for biopsy as well um yeah so the bronchus is usually the last structure to be transected and you have to be really careful when doing so because this um because when you're featuring the bronchus, you need to make sure there's no air leak or respiratory flora contamination in the pleural cavity um and this can be a POSTOP complication If you if you have any air leaks, so once the longest removed, the pleural cavity is washed with saline and the incisions are closed. Usually the pleural space filled with air and eventually pleural fluid. Um you can put a chest drain in or not. Um Studies say that practices are safe. Both practices are safe and effective, but um some most but then most people put in the chest drain anyway just just for safety basically. Um So that's pneumonectomy he's moving on to sleeve resections so sleeve resections would be done. Um If the tumor extends into one of the bronchus, the side of one of the main bronchus is um so you can do it, so it's basically a lobectomy with excision of the affected part of the bronchus um and so the tumor in the bronchus is usually completely resected, so in this image sort of take it out and then you anastomose the healthy parts back together the healthy parts of the broncos back together with end to end anastomosis and then this anastomosis needs to be covered with vascularized tissue because it's very cartilaginous and you need a good vascular supply to re, perfuse that area. Otherwise, it won't heal um and that would be very problematic. Um It's quite complicated surgery, but it has a great greater preservation of lung function, greater survival, and low mortality rates compared to pneumonectomy knees. Um So yeah you're just revert, preserving greater lung function, and it's now becoming the preferred method for locally invasive tumor's um So yes, so steve resections are changing the way we practice um surgery in these patient's so looking at post dot care now, So with all lung surgery, it's it's big stuff you know you're you're taking out a chunk of someone's lung which is essential for their daily daily functioning. So most if not all patient's who have had a lobectomy or a pneumonectomy or seed resection um go to i. T. U. Um The key to to good recovery is early excavation. There's lots of literature to support that so, the soon they get the tubes out the better it is for the patient um and most of them are put on oxygen as well. Um It's really important to avoid uh positive pressure, so not too keen on CPAP because that can cause stress of the lung and possibly um cause further complications again for your chest train, you wouldn't put the suction on you just let it drain naturally because you don't want to be pulling you know, pulling things out inside and causing causing mayhem in in the thorax and adequate analgesia is really important, so these patient have had major surgery, we need to make sure they're topped up um Sometimes, they'll use local blocks before they, before they go and um do any surgery, just to make sure that that area as well anesthetized and they might again do local blocks. Um once the yeah, once once the surgery has finished, um usually, there's some uh gut dysmotility or or a soft juul, dysmotility that's really important to get um your speech and language therapy. In there to, to review, um they might initially start them back on soft diets um as opposed to just going straight in or they might put an n. G. Tube in, but with n. G tubes, it needs to be on free drainage um So that you don't bloat the stomach and cause cause any further issues with that. Um fluid restriction is really important POSTOP to try and avoid pulmonary edema. Um This can often be a problem, so patient's postdoc might have hypertension, but it's really easy to think oh I need to you know, give them more fluids to pump their um uh to pump the BP back up, but actually this can cause pulmonary edema and further problems for the patient. Um and once they've sort of been excavated and um they're starting to eat and and they're getting better, um you want your physiotherapists and occupational therapists to see the patient get them moving early and get them recovering um from their procedures, so last but not least the POSTOP complications whole host of things because it's big major surgery, so most commonly you can get a pneumonia or empyema very common. About 25% of patient's get an infection afterwards. Um Atrial fibrillation is another one, um so this needs to be treated with anti regulation or rate control because patient's postop are in more hypercoagulable state, so they can either get PS and um strokes, so this needs to be controlled. Um If patients develop it. POSTOP one, you'd be worried about as well is hemorrhage, So the chest urine output after operating is about one liter in an hour or over 200 mils every 2 to 4 hours. Um Then you need to send the patient back to theater for re exploration um stump breakdown and broncofin bronchopleural fistulas, so the height with the highness stump. If there is any breakdown or um any sort of leakage, then you can get air leaks into that area into the heavy thorax and you can get um pneumothorax is or you get blood in in that in that space as well. Um right ventricular failure, so that can usually be caused by increased afterload due to increased resistance in the pulmonary circulation. So if you think about it, you cut the pulmonary arteries off and the blood from the heart can't go anywhere, so there's increased resistance there um. And you can get right ventricular failure pulmonary edema. I think we touched on before as well, so fluid overload postop um so patient should be fluid restricted uh post laminectomy syndrome. This is quite rare. It's basically the compression of the intact main bronchus because of a shift in mediastinal pressures structures. sorry. Um So, yeah it just sort of makes you feel a bit short of breath um and it's not pleasant but the way they can sort of fix That is um by going back to surgery, they can sometimes put like a little thing to shift shift the structures back to where they were before other things that just kyla thorax, so this is where your lymphatic fluid in the pleural cavity, especially if you've sort of fiddled with the lymph nodes a bit uh low birth or shin. So this is extremely where this is basically when the, the lobes twist upon themselves and just sort of like a testicular torsion in, reduces the blood flow to the to the lobe and can cause gangrene and is a really serious complication. Another really rare one is phrenic or recurrent laryngeal nerve palsies um Again very rare um So, yeah and then my last size basically touching on vats versus an open approach. So when we when would we choose to use vats is um basically for the smaller things like lobectomy um and wedge resections. It makes sense because it's less invasive, less morbidity, short hospital stays. It's just better, better outcome, um but the limited evidence for locally advanced disease, so this is where you might choose to use an open approach for, like pneumonectomy knees um that require wide access to the thoracic viscera um and the open approach can be performed without specialist equipment, so you don't need all the cameras and things um to do that, um but yeah, the open approach is being phased out pretty much with greater favor for vats um just purely because has better patient outcomes and I think it's probably more fun for surgeons as well. So yeah Just to summarize, um most lung cancers are non small cell cancers, um but small cell cancers are very serious um and then metastasize early, so there's usually less need for um uh surgical treatment for them. Lung cancer diagnosis should be confirmed with histological evidence, but choosing the diagnostic and therapeutic options should really depend on the patient's holistic well being and their prognosis. Um Generally, the prognosis of lung cancer is very poor um so surgery is really not suitable for most people that diagnosed with lung cancer um No metastatic lung cancer can be managed with with three sections segmentectomy, lobectomy and pneumonectomy, knees, and sleeve resections as we've discussed, um Vats is probably the best surgical approach for early diagnosed lung cancers and the open approach is still used for pneumonectomy knees um and good POSTOP care, prevents POSTOP complications from developing, so we know that making sure all those things that we've discussed are done, just prevents patient's going back to theater, prevents people from dying um. And yeah and that's that's lung cancer in a little nutshell grill, so um yeah I just look for any yeah question. If you have any questions, then pop them in the chat um and I'll see if I can answer those thanks for listening guys um yeah, if you're happy to fill in feedback as well, that would be really great and helpful um for us in the future. All right, thank you, Actually I was fantastic, well done um like I feel like I don't know anything about cardiothoracic surgery at all, and on such a good like whistlestop tour of the like the necessary investigations, the necessary types of the cancers and the surgical techniques what you actually have to go through. It's just amazing when you think about it and I feel like there's a lot of oversimplification in my view um uh with regard to a lot of the teaching with surrounding it, um have you ever come across anything where they might operate on both because you mentioned about the two lungs uh sorry of being bilateral are there any instances of where they've operated. I've done bilateral wedge receptions or anything like that that you're aware of. Um yeah that's a good question, so I think like I said as with this, really depends on the patient themselves, so if the patient perhaps has very rare cases, may have you know really small tumor on one side and resource you on the other side, um They might do a wedge resection sorry charlie, do you mind just turning off your mind because I think I'm hearing feedback from myself. Thank you. Thanks um yeah, so they might perform a wedge resection on one lung one on the first time, so they can still inflate the other lungs that I don't think they could do with three sections on both lungs at the same time because you need to still be able to ventilate the patient's um but yeah I'd say if the patient has has good functional reserve um and good Fvb one that maybe they're young um and you know they're they're they're fit um then you might be able to do a small wedge resection on one side and then later on down the line. Perhaps once that lung has recovered. Then then consider a wedge resection on the other side, but I think the chances of that happening are quite rare um And I'm not I'm not heard of any cases um of people that do that, but yeah thanks charlie, so Adam's asked how do surgeons choose between wedge resection and segmentectomy, is it based on tumor size, tissue invasion, etcetera, yeah exactly that, so um usually these cases will go to m. D. T. Um and um you know the thoracic surgeons will discuss you know. We also have to speak to the patient so are they happy to go. You know have have a wedge resection, have a segmentectomy. They need to know the risks of those um and yeah basically it depends on the surgeons, so some of them might want to have wider wider margins, wider free margins. Uh You know, depending on on the patient's function ability, so if they're really old, you might you might just chance and say actually we'll do a wedge resection as opposed to say Montek to me, um So that you know we preserve more of their lung function. Um yeah It, it all just depends on basically tumor size, tissue invasion, and we'll just reiterate the fact that it's all very patient dependent as well. Thanks. Adam, any other questions at all. No, if, if we've got no more questions, then I think we can close up um yeah, If you do, then then feel free to just give us a give us a message or anything like that and thank you all for listening. Um yeah. Please fill in the feedback that would be really helpful for us um and yeah any other last thing to add charlie or adam, uh just that uh this is the last uh session that will be running at least for the next few weeks, a few months. Uh Perhaps we can do a few more sessions and some different types of cancers or run the same sessions again, but thank you for uh come especially some of the names that I recognize from people that have come very frequently. Uh You know, I really appreciate people coming back as well as as new people. So yeah I hope you've enjoyed and yeah you know to get in touch because we all had emails from me, So yeah yeah brilliant ok, thank you everyone.