ANESTHESIA FOR THORACIC SURGERY IN THE ONCOLOGY PATIENT

Abstract

Thoracic surgery is a surgical discipline that has essentially had its birth and rapid development in the twentieth century. This incredible growth could not have been possible without advances in anesthesia, specifically the use of positive pressure ventilation. Early surgical and anesthetic difficulties were encountered related to the management of pulmonary collapse, pneumothorax, and mediastinal shift whenever the thoracic cavity was opened. Sauerbruch and others intitially designed elaborate negative pressure chambers for the patient and operative team to maintain the negative chest pressure and allow net flow of air into the lungs. Endotracheal intubation was used in the nineteenth century for experimental work in animals but was not applied and widely accepted into clinical practice until the 1920s. Early thoracic procedures were generally used to treat suppurative processes or tuberculosis. Ewarts Graham directed the scalpel to treat cancers involving the thoracic cavity and performed the first one-stage pneumonectomy for lung cancer in 1933; this was the standard resection for lung cancer for many years. Nearly 70 years later, thoracic oncologic resections still represent some of the most physiologically challenging procedures for patients who are usually elderly with many comorbidities. Minimizing surgical morbidity and mortality depends on the appropriate preoperative selection of the patient by the surgeon, meticulous intraoperative surgical techniques, and close monitoring and early intervention in the postoperative period should complications occur. Favorable outcomes, however, are equally dependent on precise preoperative and intraoperative anesthetic evaluation and techniques, which require an in-depth understanding by the anesthesiologist of the planned procedure and the potential complications associated with each. Most procedures require frequent communication between the surgical team and the anesthesia team, with adjustments of ventilation parameters and fluids, as significant hemodynamic changes can occur with manipulation of the lung and cardiovascular structures during the surgical dissection. The postoperative management of pain by a dedicated acute pain service is central to early extubation and ambulation and improved pulmonary toilet for these patients. Well-placed and well-managed thoracic epidurals can save lives and save money through shortened hospital stays. A poorly placed or poorly managed catheter can result in the death of a patient. Clearly, the welfare of the patients undergoing these complex procedures is dependent on the combined skills of the surgeon and the anesthesiologist. This article reviews the surgical aspects and potential complications of various thoracic oncology procedures. It is hoped that presenting these procedures from a surgical perspective will allow better planning and conduction of anesthetics in these challenging patients.