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Preface xiRichard I. Whyte

Smoking Cessation: Techniques and Potential Benefits 189Tomasz M. Ziedalski and Stephen J. Ruoss

Tobacco smoking significantly increases the risk of perioperative and postoperative com-plications. Observational evidence suggests that preoperative smoking cessation maydecrease the risk of certain complications. Smoking cessation programs that employbehavioral and cognitive therapy and pharmacotherapy have been used successfully inmany situations and should be used to discourage smoking preoperatively. Further eval-uation of the effectiveness of particular types of interventions is needed to clarify the bestapproach to smoking cessation for surgical patients.

Preoperative Patient Education in Thoracic Surgery 195 Richard I. Whyte and Patricia D. Grant

This article describes the role of preoperative teaching in thoracic surgery. Preoperativepatient teaching may take many forms and is offered to patients across many venues andformats. The goal of patient teaching is to improve patients’ understanding of their dis-ease process and the operation that they are about to experience with the goal of enlist-ing their active participation in the healing process. The additional goal of obtaininginformed consent is not only codified in law, but also has become an ingrained compo-nent to the current physician-patient relationship. The preoperative teaching process isbest approached as a team effort, and multiple modalities often must be used so that thepatient becomes a knowledgeable and willing member of the team.

The Value of Preoperative Pulmonary Rehabilitation 203Shanon T. Takaoka and Ann B. Weinacker

Although pulmonary rehabilitation is potentially beneficial before any surgery, it hasbeen applied and studied primarily in the setting of major thoracic surgical procedures,including lung volume reduction surgery, lung transplantation, and lung resection. Thisarticle defines the essential elements of pulmonary rehabilitation, outlines the prerequi-sites for enrollment, and discusses its current role in the setting of anticipated thoracicsurgery. Pulmonary rehabilitation seems to be a cost-effective, benign intervention withno adverse effects and should remain an essential component of patient managementbefore lung transplantation, lung volume reduction surgery, lung resection, and poten-tially any other elective thoracic surgical procedure.

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Informed Consent: Ethical and Legal Aspects 213Carole A. Klove, Sarah J. DiBoise, Betty Pang, and William C. Yarbrough

The doctrine of informed consent serves the dual function of promoting the beneficence,benevolence, and nonmalfeasance of the physician and the autonomy, bodily integrity,and self-determination of the patient. Conflict arises when a patient’s individual libertyrights clash with a physician’s medical conclusions formed in the patient’s perceivedbest interest. This article explores the ethical and legal nuances of the doctrine ofinformed consent in an attempt to empower the provider with a deeper understandingof the physician’s rights and responsibilities in obtaining a true informed consent.

Fast-Tracking: Eliminating Roadblocks to Successful Early Discharge 221Jules Lin and Mark D. Iannettoni

This article describes common obstacles to successful early discharge that face many thoracic surgeons despite technically successful procedures; these obstacles includeinadequate pain control, prolonged air leaks, and social issues. With continually increas-ing health care costs and limited resources, identifying the factors that affect length ofstay has taken on new importance. Potential solutions that also maintain the quality ofpatient care are discussed and include the use of minimally invasive techniques, opti-mizing pain control, early mobilization, discharge planning, patient education, and thedevelopment of clinical pathways.

Perioperative Antibiotics: When, Why? 229Mark S. Allen

The use of prophylactic antibiotics in general thoracic surgery is well established. Thisarticle explains the rationale for modern-day surgical wound infection prophylaxis, thewhy and the when. Various arguments about the use of antibiotics to prevent empyemaand pneumonia after a thoracic operation also are presented.

Pulmonary Embolism Prophylaxis: Evidence for Utility in Thoracic Surgery 237Dean M. Donahue

Patients requiring thoracotomy for the treatment of malignancy are at risk for develop-ing a pulmonary embolism. Few data exist on effective prophylaxis techniques in thisspecific patient population, yet effective strategies can be inferred from other major sur-gical procedures to reduce the risk of this potentially life-threatening complication.

Management of the Anticoagulated Patient 243Mark H. Meissner and Riyad Karmy-Jones

Patients who are to undergo surgery may be anticoagulated for therapeutic reasons(eg, deep venous thrombosis, valve replacement, lytic therapy) or because of comorbidconditions (eg, renal or hepatic failure). In addition, the proposed operative interventionmay be elective or urgent. The approach to managing the coagulation status is criticallyaffected by the circumstances and requires a basic understanding of the risks involved ofbleeding and correcting the underlying pathophysiology. This article reviews the indica-tions, pharmacology, and complications of common anticoagulation therapies (includinglaboratory and clinical assessment) in the surgical patient.

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Preoperative Cardiac Evaluation: Mechanisms, Assessment, and Reduction of Risk 263Euan A. Ashley and Randall H. Vagelos

Considerable uncertainty exists as to when it is appropriate to investigate cardiac disease ina preoperative thoracic patient and which tools are best suited to the task. Common diseaseorigins, commonality of symptoms, and coexistent disease all serve to make accurate diag-nosis and effective risk prediction difficult. Interventions known to reduce risk and savelives are few. This article explores the basis for anesthetic risk in cardiovascular and pul-monary disease. Common disease mechanisms and the utility of tools available to assess riskare discussed. Risk reduction also is discussed, and recommendations specific to the pre-operative cardiac evaluation of the thoracic surgery patient are offered.

Preoperative Preparation for Esophageal Surgery 277Jessica Scott Donington

Esophageal surgeries can be placed into two broad categories: anatomic modificationsfor benign esophageal disorders and resections for carcinomas. The clinical setting andscope of intervention are different for these two groups, as is the preoperative prepara-tion. The goal of preoperative evaluation for benign esophageal disease is to make anaccurate and complete diagnosis; the tools for this include barium esophagogram,endoscopy, pH monitoring, and manometry. The preoperative concerns for esophagealresection for cancer involve accurate staging of the cancer, using CT, positron emissiontomography, and endoscopic ultrasound, and complete physiologic evaluation of thepatient to determine his or her ability to withstand a large operation.

Preoperative Preparation of the Patient with Myasthenia Gravis 287Kemp H. Kernstine

The morbidity and mortality of patients with myasthenia gravis undergoing thymectomycan be substantial. The surgeon must have a thorough knowledge of the evaluation andtests necessary to confirm a diagnosis and should not rely totally on the neurologist’sassessment. Through partnership with the neurologist, the ideal means of medical andsurgical management can be achieved.

Preoperative Pulmonary Evaluation of the Thoracic Surgical Patient 297Aditya K. Kaza and John D. Mitchell

Surgery remains the mainstay of therapy for early-stage non-small lung cancer. Manypatients have poor underlying pulmonary function, in large part resulting from long-termtobacco abuse. It is the responsibility of the thoracic surgeon to assess accurately the pul-monary function of a potentially operable patient at the time of the preoperative evaluation.This assessment provides an objective risk profile associated with the planned pulmonaryresection for the patient and family, minimizes morbidity and mortality, and in some casesleads the surgeon to recommend alternative therapies. This article provides a systematicapproach to the pulmonary evaluation of the thoracic surgical patient.

The Preoperative Anesthesia Evaluation 305Clifford A. Schmiesing and Jay B. Brodsky

Timely and thorough preoperative assessment is a cornerstone of excellent patientoutcomes and efficient use of medical resources. This article focuses on the importantelements of the preoperative anesthetic assessment of a patient presenting for thoracic

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surgery. Areas of shared concern between the surgeon and anesthesiologist areemphasized. Cardiovascular risk assessment and preoperative management are high-lighted because cardiorespiratory complications are the major causes of morbidityafter thoracic surgery. Practical and simple strategies for common preoperative issues,including medications and diagnostic testing, are provided, and the benefits of a com-prehensive anesthesia preoperative assessment are discussed.

Index 317

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