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Surgical Foundations: Essentials of Thoracic Surgery FREE TO VIEW

Charles A. Dietl, MD
Chest. 2005;127(6):2303-2304. doi:10.1378/chest.127.6.2303
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By Larry R. Kaiser, MD, and Sunil Singhal, MD, eds. Philadelphia, PA: Elsevier Mosby, 2004; 366 pp; $79.00

Surgical Foundations: Essentials of Thoracic Surgery is a concise and easy-to-read textbook, which is primarily written for an audience of cardiothoracic surgery fellows and general surgical residents, as well as for medical students searching for additional knowledge in general thoracic surgery. The text is very well-illustrated with diagrams, roentgenograms, and other imaging studies that are reproduced with excellent quality and consequently can be easily interpreted by the surgical trainee or student. These illustrations, together with the attached tables, contribute immensely to the ease with which the reader can comprehend the essence of thoracic surgery.

The book is divided into three main sections. The “Background” section reviews the anatomy and physiology of the chest, common diagnostic and surgical procedures, and the preoperative and postoperative care of patients with pulmonary, pleural, and mediastinal disorders. An additional chapter in this section concerns thoracic trauma. The section on “Pulmonary Diseases” covers congenital lung diseases, and the two most common acquired lung problems in the adult population: lung cancer and emphysema. The last section, “Nonpulmonary Thoracic Diseases,” covers disorders of the chest wall, trachea, diaphragm, pleura, and mediastinum. Each chapter within a given section is preceded by a list of the key topics to be covered; a useful and salient feature indeed.

The chapter on anatomy describes the relationships among the lungs and the mediastinal structures, and the chest wall. However, more space could have been dedicated here: esophageal anatomy is described very briefly, and no mention is made of the landmarks and distances obtained at endoscopy. Surprisingly, lymph node anatomy and stations are not included in this chapter. The chapters “Pulmonary Physiology” and “Perioperative Care” provide useful background information for the practitioner who evaluates patients with pulmonary disorders. The key points involve the understanding and interpretation of pulmonary function tests, and how the results obtained may impact outcome. The next chapter, “Diagnostic Procedures,” presents an algorithm for reviewing chest roentgenograms and CT scans that is of fundamental importance. This chapter also contains an excellent review of the anatomy of the tracheobronchial tree as seen through the bronchoscope, and a helpful and informative discussion on the current applications of video-assisted thoracic surgery.

The chapter on thoracic trauma emphasizes the initial assessment of the trauma victim. Common indications for emergency procedures (eg, establishing a surgical airway in patients who are difficult to intubate, chest tube insertion, or emergency thoracostomy) are covered here. The authors also make reference to chest wall, pulmonary, tracheobronchial, and diaphragmatic injuries, but they do not discuss any of the life-threatening cardiac or vascular injuries.

Overall, the most useful chapter in this text for cardiothoracic surgery residents is chapter 6 (“Pulmonary Resections”). The crucial subjects covered here include the need for a thorough understanding of accurate staging and the current indications for mediastinoscopy, and the notion that an operation without lymph node dissection must be considered incomplete is pointed out. The authors correctly emphasize that mediastinoscopy is particularly important when assessing tumors of the left lower lobe, since the left paratracheal area is difficult to access at thoracotomy and contralateral mediastinal node involvement is more common with lesions in this location. The authors also rightly stress that lung conservation should always be kept foremost in the thoracic surgeon’s mind, since pneumonectomy is associated with significantly higher morbidity and mortality than lobectomy. A more conservative resection, such as a lobectomy or sleeve resection, should be done whenever possible, despite the fact that they are technically more demanding procedures than pneumonectomy.

The section on “Pulmonary Diseases” begins with congenital lung malformations, containing a review of embryology and the most common congenital malformations of the lungs along with their prognoses. In the next chapter (“Bronchogenic Cancer”), the key issues covered are the histologic classification of bronchogenic cancer and the TNM staging system for non-small cell lung cancer. It is noted that TNM staging usually does not apply to small cell carcinoma, as most of these tumors are systemic at the time of diagnosis. An algorithm for the management of solitary pulmonary nodules is described. Also, a map with all of the regional lymph node stations for lung cancer staging is included, which is essential information for understanding the prognosis and appropriate management of patients with bronchogenic carcinoma. Finally, the treatment options for different stages of lung cancer are well-covered. This chapter is a very clear presentation of a subject that is of great importance to surgical residents as well as to internists and pulmonologists.

The following chapter describes two other malignant tumors of the lung (carcinoids and sarcomas) and several benign lung tumors. The next chapter covers surgery for emphysema, which is still a controversial therapeutic option. The main objective of lung volume reduction surgery (LVRS) involves the removal of functionless lung tissue, thus improving the elastic recoil of the remaining lung. The authors emphasize that patients with a diffuse pattern of emphysema will likely not benefit from LVRS, since airflow obstruction resulting from intrinsic narrowing of the small airways is unlikely to improve. Thus, patients with a heterogeneous pattern of emphysema affecting predominantly the upper lobes are more likely to benefit from LVRS. Current indications and contraindications for LVRS are well-summarized.

This section also includes a chapter on lung transplantation. The important points covered here include selection criteria, contraindications for lung transplantation, assessing a potential lung donor, and understanding the optimal conditions for the maintenance of the donor. The techniques of single-lung and double-lung transplantation are described, as well as postoperative management and potential complications.

The third and last section covers nonpulmonary thoracic diseases, including diseases of the chest wall, trachea, diaphragm, pleura, and mediastinum. The chapter on chest wall disorders discusses the decision to operate as well as current surgical techniques used for pectus excavatum, pectus carinatum, and Poland syndrome. The classification and recommended strategies for the diagnosis and treatment of chest wall tumors are very well-summarized. Key points discussed in the chapter on the trachea include congenital and acquired lesions, especially the management of postintubation injuries, and the chapter on the diaphragm includes information on congenital and acquired diaphragmatic hernias (eg, sliding hiatal hernia and paraesophageal hernia). The latter chapter emphasizes the mechanisms of gastroesophageal reflux disease, how to assess esophagitis and Barrett esophagus, and the goals of medical and surgical treatment for patients with these conditions. Other topics include diaphragmatic paralysis and the few indications for diaphragmatic pacing.

The next chapter deals with the pleura, and incorporates pathophysiology and management of pneumothorax, the differential diagnosis of pleural effusions, and treatment options for empyema and chylothorax. The book concludes with a chapter on mediastinal masses. Despite the fact that the description of each individual tumor is very brief, this chapter impressed me as one of the most outstanding chapters in the textbook, mainly due to the tables of algorithms for differential diagnosis and management. These useful tools are precisely what the practitioner needs to have at hand. In addition, the illustrations and diagrams in this chapter are superb.

In summary, Surgical Foundations: Essentials of Thoracic Surgery is a concise textbook on thoracic surgery, with emphasis on diagnosis, preoperative and postoperative management, and some of the common surgical procedures. Exceedingly well-illustrated, it is highly recommended for surgery and cardiothoracic surgery residents, and should be of interest to medical students, internists, and pulmonologists as well.




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