Intraoperative studies may have a role in determining how well a resection can be tolerated. Initial data suggest that long term cardiac disability (but not mortality) may be predicted at the time of ‘test clamping’ of the pulmonary artery by recording a right ventricular ejection fraction (RVEF) of 35%, a pulmonary vascular resistance (PVR) of at least 200 dyne-s-cm- and/or a PVR:RVEF ratio of 5.0 . Some groups use a variety of ‘angioplastic’ and ‘bronchoplastic’ reconstructions to preserve as much functional lung as possible in patients who are identified as high risk . Patients with peripheral T1 lesions without evidence of mediastinal metastases who are not suitable for thoracotomy may be considered for thoracoscopic wedge resection, although the risk of local recurrence is increased .
Patients whose pulmonary reserves fail to achieve institutional ‘limits’ should not be arbitrarily rejected for surgery, but rather all possible options should be discussed . Many patients improve with preoperative pulmonary therapy, bronchodilators and smoking cessation, and on retesting may become candidates for surgery. Improvements in postoperative care, especially pain management, have resulted in decreased morbidity in high risk patients following thoracotomy . Each centre needs to evaluate its own outcomes to determine individual limits. Safe online shopping for drugs: Buy Zyrtec online to make your drugs cheaper.
Local recurrence and restaging following induction therapy: The approach to staging in the setting of local recurrence or following induction therapy is the same as with the initial workup, except that mediastinoscopy (redoing or following chemotherapy) is more hazardous, and most centres advocate cerebral CT and bone scans as mandated by symptoms and signs, if not ‘routinely’. Ideally, suspicious mediastinal adenopathy should be biopsied before thoracotomy by one of the techniques described earlier because completion pneumonectomy is associated with increased operative risk .