Mark K. Ferguson 
Difficult Decisions in Thoracic Surgery 
An Evidence-Based Approach

Why do thoracic surgeons need training in decision making? Many of us who have weathered harrowing residencies in surgery feel that, after such experiences, decision making is a natural extension of our selves. While this is no doubt true, correct de- sion making is something that many of us have yet to master. The impetus to develop a text on evidence-based decision making in thoracic surgery was stimulated by a conference for cardiothoracic surgical trainees developed in 2004 and sponsored by the American College of Chest Physicians. During that conference it became clear that we as thoracic surgeons are operating from a very limited fund of true evidence-based information. What was also clear was the fact that many of the decisions we make in our everyday practices are not only uninformed by evidence-based medicine, but often are contradictory to existing guidelines or evidence-based recommendations. The objectives of this book are to explain the process of decision making, both on the part of the physician and on the part of the patient, and to discuss speci? c clinical problems in thoracic surgery and provide recommendations regarding their mana- ment using evidence-based methodology. Producing a text that will purportedly guide experienced, practicing surgeons in the decision-making process that they are acc- tomed to observe on a daily basis is a daunting task.

Table of Content

Background.- Evidence-Based Medicine: Levels of Evidence and Grades of Recommendation.- Decision Analytic Techniques.- Nonclinical Components of Surgical Decision Making.- How Patients Make Decisions with Their Surgeons: The Role of Counseling and Patient Decision Aids.- Lung.- Radiographic Staging of Lung Cancer: Computed Tomography and Positron Emission Tomography.- Routine Mediastinoscopy for Clinical Stage I Lung Cancer.- Management of Unexpected N2 Disease Discovered at Thoracotomy.- Induction Therapy for Clinical Stage I Lung Cancer.- Induction Therapy for Stage IIIA (N2) Lung Cancer.- Adjuvant Postoperative Therapy for Completely Resected Stage I Lung Cancer.- Sleeve Lobectomy Versus Pneumonectomy for Lung Cancer Patients with Good Pulmonary Function.- Lesser Resection Versus Lobectomy for Stage I Lung Cancer in Patients with Good Pulmonary Function.- Lesser Resection Versus Radiotherapy for Patients with Compromised Lung Function and Stage I Lung Cancer.- Resection for Patients Initially Diagnosed with N3 Lung Cancer after Response to Induction Therapy.- Video-Assisted Thorascopic Surgery Major Lung Resections.- Surgery for Non-Small Cell Lung Cancer with Solitary M1 Disease.- Thoracoscopy Versus the Open Approach for Resection of Solitary Pulmonary Metastases.- Unilateral or Bilateral Approach for Unilateral Pulmonary Metastatic Disease.- Surgery for Bronchoalveolar Lung Cancer.- Lung Volume Reduction Surgery in the Candidate for Lung Transplantation.- Pleural Sclerosis for the Management of Initial Pneumothorax.- Esophagus.- Staging for Esophageal Cancer: Positron Emission Tomography, Endoscopic Ultrasonography.- Induction Therapy for Resectable Esophageal Cancer.- Transthoracic Versus Transhiatal Resection for Carcinoma of the Esophagus.- Minimally Invasive Versus Open Esophagectomy for Cancer.- Lymph Node Dissection for Carcinoma of the Esophagus.- Intrathoracic Versus Cervical Anastomosis in Esophageal Replacement.- Jejunostomy after Esophagectomy.- Gastric Emptying Procedures after Esophagectomy.- Posterior Mediastinal or Retrosternal Reconstruction Following Esophagectomy for Cancer.- Postoperative Adjuvant Therapy for Completely Resected Esophageal Cancer.- Celiac Lymph Nodes and Esophageal Cancer.- Partial or Total Fundoplication for Gastroesophageal Reflux Disease in the Presence of Impaired Esophageal Motility.- Botox, Balloon, or Myotomy: Optimal Treatment for Achalasia.- Fundoplication after Laparoscopic Myotomy for Achalasia.- Primary Repair for Delayed Recognition of Esophageal Perforation.- Lengthening Gastroplasty for Managing Gastroesophageal Reflux Disease and Stricture.- Lengthening Gastroplasty for Managing Giant Paraesophageal Hernia.- Management of Zenker’s Diverticulum: Open Versus Transoral Approaches.- Management of Minimally Symptomatic Pulsion Diverticula of the Esophagus.- Diaphragm.- Giant Paraesophageal Hernia: Thoracic, Open Abdominal, or Laparoscopic Approach.- Management of Minimally Symptomatic Giant Paraesophageal Hernias.- Plication for Diaphragmatic Eventration.- Pacing for Unilateral Diaphragm Paralysis.- Optimal Crural Closure Techniques for Repair of Large Hiatal Hernias.- Management of Acute Diaphragmatic Rupture: Thoracotomy Versus Laparotomy.- Airway.- Stenting for Benign Airway Obstruction.- Tracheal Resection for Thyroid or Esophageal Cancer.- Pleura and Pleural Space.- Pleural Sclerosis for Malignant Pleural Effusion: Optimal Sclerosing Agent.- Management of Malignant Pleural Effusion: Sclerosis or Chronic Tube Drainage.- Initial Spontaneous Pneumothorax: Role of Thoracoscopic Therapy.- Intrapleural Fibrinolytics.- Diffuse Malignant Pleural Mesothelioma: The Role of Pleurectomy.- Treatment of Malignant Pleural Mesothelioma: Is There a Benefit to Pleuropneumonectomy?.- Mediastinum.- Management of Myasthenia Gravis: Does Thymectomy Provide Benefit over Medical Therapy Alone?.- Thymectomy for Myasthenia Gravis: Optimal Approach.- Management of Residual Disease after Therapy for Mediastinal Germ Cell Tumor and Normal Serum Markers.- Management of Malignant Pericardial Effusions.- Asymptomatic Pericardial Cyst: Observe or Resect?.- Chest Wall.- Optimal Approach to Thoracic Outlet Syndrome: Transaxillary, Supraclavicular, or Infraclavicular.- Pectus Excavatum in Adults.