Rays
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Postoperative management after elective esophagectomy for cancer has not been standardized. Thoracoabdominal incision with associated pain, extended operative time with consequent extracellular fluid shifts, single lung ventilation, potential for prolonged postoperative mechanical ventilation and comorbidities in patients with esophageal cancer, all contribute to high perioperative risk. Respiratory problems remain the major cause of both mortality and morbidity after esophagectomy for cancer. ⋯ Anesthesiologists should adopt strategies known to be able to optimize patient outcome. Decreased postoperative mortality and morbidity have been associated with epidural analgesia, bronchoscopy to clear persistent bronchial secretions, intraoperative fluid restriction and early extubation. It has been shown that setting up early respiratory physiotherapy and mobilitation may improve functional recovery.
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Esophageal cancer is essentially a disease of the elderly. Several studies suggested that age per se should not be considered a risk factor for surgical mortality and morbidity, and access to surgical treatment should not be denied only on the basis of age. ⋯ Therefore, a careful preoperative assessment of these factors, with particular regard to comorbid conditions (such as cardiovascular and pulmonary diseases), the physiological status, and social habits is necessary in elderly adults. In consideration of the need of a multidisciplinary assessment to identify comorbidities and operative risk, a close collaboration of pneumologists, cardiologists, radiologists, oncologists, thoracic surgeons, anesthesiologists, geriatric specialists, physical therapists is highly recommendable.
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The theme of health care and research in Italy is extremely large and complex. The two aspects are tackled in sequence though there are elements of combination related to the decree law 229 of 1999. ⋯ Hopefully, in our country the approach to health care will change. Health care and research should be no longer considered from the viewpoint of expenditure but rather as an investment and quality should be perceived as gain rather than as cost.
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Based on a review of the literature on resectable lung cancer, pulmonary risk factors before, during and after surgery are discussed. The role of preoperative evaluation in order to determine the patient ability to withstand radical resection is considered. Spirometric indexes as forced expired volume (FEV1) and diffusing lung carbon monoxide capacity (DLCO) should be measured first. ⋯ However, if FEV1 and DLCO are <60% of predicted, further evaluation with a quantitative lung scan is required. If predicted postoperative values for FEV1 and DLCO are >40%, patients can undergo lung resection, otherwise exercise testing is necessary. If the latter shows maximal oxygen uptake (VO2max) of > 15ml/Kg, surgery can be performed; if VO2max is <15 ml/Kg, patients are inoperable.
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Review
Preoperative assessment and risk factors in the surgical treatment of lung cancer: the role of age.
The incidence of lung cancer in the elderly is increasing in Western countries. This disease represents the second leading cause of cancer death in this age group and it is also responsible for a substantial increment in morbidity and health care costs. ⋯ Therefore, a careful preoperative assessment of these factors, with particular regard to comorbid conditions (such as cardiovascular and pulmonary diseases or secondary malignancy) is necessary in older adults. In consideration of the need of a multidisciplinary assessment to identify comorbidities and operative risk a close collaboration between pneumologists, radiologists, oncologists, thoracic surgeons, anesthesiologists, cardiologists, geriatric specialists, physical therapists is highly recommended.