Big for the multidisciplinary surgeries like large locally invasive tumor resections that offer hope to patients that might otherwise be turned away.. Small for the minimally invasive techniques and nonintubated techniques that improve the lives of our patients – faster recoveries, less post-operative pain and shorter hospital stays..
In a previous post, we talked about the John Wayne principle and large surgical resections. We’ve talked about multi-disciplinary surgeries before, but during today’s presentation by Dr. Michael Harden of Australia, he presented several cases that highlighted the critical importance of large scale surgical resections for stage IIB and IIIA lung cancers.
Dr. Michael Harden is a cardiothoracic surgeon at the Royal North Shore Private Hospital in a suburb of Sydney, Australia.
During his lecture, on chest wall reconstruction for lung cancer, Dr. Harden presented several cases illustrating successful large scale resections. While each of the procedures was technically challenging due to the presence of very large, invasive tumors, these cases were complex for multiple reasons such as pre-operative radiation, morbid obesity and other serious co-morbidities.
In each of these cases, he highlighted the importance of multi-disciplinary involvement, from plastic surgery for free flap harvesting and revascularization, to cardiac surgery (for ECMO/ CPR) for resection of tumors involving the great vessels or spinal surgery for a case requiring an enbloc removal of a vertebral body for a very large paraglioma involving the lung, vertebra and rib – which was encroaching on the the spinal cord.
One of his more notable cases is mentioned below. This case illustrates the importance of innovation and consideration for patient’s quality of living as this surgical technique allowed this patient to return to his job as a truck driver. (Many of the more commonly used techniques to repair the sternum such as muscle flaps are not as conducive to this type of occupation which requires more than sitting behind the wheel.)
We have reached out to Dr. Harden for more information about his work.
What does John Wayne have to do with it? Quite a lot, actually.
Occasionally, here at thoracics.org, we get comments about our various topics. Sometimes, we are even scolded for our enthusiasm for thoracic surgery by people who often misunderstand enthusiasm and genuine interest in advances in the field, and patient care for callousness. It’s not callousness, it’s the very opposite – it’s a sincere desire to better the lives of our patients thru surgery.
As the editor-in-chief, I don’t have to explain my love of thoracic surgery, but I often like to. I think it brings an otherwise clinical and somewhat dry sounding specialty alive. That’s essential to attract new clinicians to the field, and to drive innovation. We should want our surgeons, our clinicians and staff in thoracic surgery to have a passion for their work.
So today, I’d like to talk about what inspires my passion, and my continued interest in advances in thoracic surgery. Part of this editorial is related to a recent conference I attended with a lecture by Dr. Michael Harden of Australia, but we will talk more about Dr. Harden later.
First, we need to talk about John Wayne, the legendary actor of the classic westerns.
John Wayne has always been a hero of mine – and a reminder of my childhood. Before Netflix, Video-on-demand, VHS or even large cable networks, John Wayne was a staple of weekend television. Along with my father, we would sit in the living room and watch John Wayne films like “Rio Bravo”, “Hondo” or “The Man who shot Liberty Valence”. For the most part, as a Barbie-loving little girl, I could care less about the movies – it was a chance to spend time with my dad, who worked long hours most of the time. Except for “The Shootist.”
That movie, with it’s depiction of an aging, cancer-stricken gunslinger immediately grabbed my interest way back then, and even to this day, still makes me cry. Sometimes, I tear up just thinking about it.
More importantly, this film, (in a round-about way ) ultimately inspired some of my love of thoracic surgery. While readers familiar with the story already know, in John Wayne’s final film, his character is suffering from stomach cancer. As, in real life, John Wayne later died of stomach cancer. He died in 1979, three years after the film was completed. But if you ask anyone about John Wayne, they don’t mention his stomach cancer – they mention his lung cancer. So, I grew up thinking he died of lung cancer.
It wasn’t until I was well into adulthood that I found out that he survived lung cancer, and ultimately died of something else. It was even later, in 2004, during my training in cardiothoracic surgery that one of my older attendings mentioned John Wayne’s lung resection for a stage 3B cancer that prompted even more interest (by this point, google and the internet made it easy to satisfy this curiosity.)
John Wayne was larger than life, and his surgery was too..
That’s when I learned that not only did John Wayne have an extensive lung cancer requiring chest wall resection (that resulted in a complete cure) back in 1964, but that he received the kind of operation that many modern day patients are denied.
If he was alive today, he would need a surgeon like Dr. Michael Harden.
That’s because despite all of these modern day advances, (or maybe because of them), many patients with large bulky tumors, and local invasion (of ribs, spine, chest wall etc) are never even referred to thoracic surgeons in the first place. These patients are shunted to thoracic oncologists and radiation therapists where they receive systemic chemotherapy or radiation instead, despite the fact that our ability to resection these large, locally invasive tumors has greatly advanced since the early 60’s.
Not every thoracic cancer patient with advanced disease can or should have thoracic surgery. Many of these patients are frail, have distal/ widespread metastatic disease or other criteria that may make them ineligible for surgical resection. But often, for patients outside of very large academic centers, their cases aren’t even presented for surgical consideration.
A surgical resection like John Wayne’s in 1964, was a massive undertaking, and the risk of death from surgery was not insignificant. There were considerable hurdles to recovery related to all aspects of his care. H was a heavy (5 pack a day smoker), and the knowledge that cigarettes were linked to lung cancer was just beginning to seep into the public’s awareness. The vascular implications and other complications of smoking were not well known.
Bedrest was often prescribed for lengthy periods of convalescence post-operatively, which contributed to pneumonia, blood clots and disability – all the things that now prompt an almost fanatical zeal for us to get our patients up and out-of-bed as soon as possible after surgery. It’s not amazing that surgeons were able to perform this operation in the early 1960’s, there were many, many great surgical advances back then, but it is somewhat amazing that he was able to survive his post-operative course given many of the factors I’ve mentioned above.
But he survived – thrived even, and went back to making some of the best films of his career. His lung cancer never returned, and he lived another 14 years after that. That’s better than the average long term survival rates for most of our advanced cancer patients who receive chemotherapy or radiation.
For me, John Wayne’s recovery and surgical treatment has sparked a number of questions:
Shouldn’t the rest of us receive the opportunity to at least be considered for surgical resection?
Who is eligible for chest wall resection and these other large scale resections? What are our modern day options? What are the short and long-term outcomes?
Who should perform it? Where should patients go?
It’s been over 15 years, and I am still following the research, attending conferences and interviewing surgeons to best answer those questions.
While much of our normal lives are still on hold in many places around the world, particularly in the Americas, it’s still important for us to maintain our connections to the world at large. It’s critical that we remain interested and engaged in the latest advancements and educational opportunities in our specialty.
Pandemic or no, our patients still need us – and conditions like lung cancer don’t take a hiatus just because the world’s attention is directed elsewhere.
With that in mind, thoracic surgeons have moved out of the operating rooms and conference halls – online into virtual conferences and zoom meetings, so that we can continue to provide our patients with most up-to-date and evidence-based practices.
Now some of our favorites, including Dr. Diego Gonzalez Rivas are presenting “Global Connection — Reconstruction technique in lung cancer” live on July 29th, 2020 at 1900 (Hong Kong time). That’s 4 am for west coast viewers like myself in San Francisco or Los Angeles. 7 am for our viewers in Santiago, Chile, noon for our British colleagues and 4:30 in the afternoon for our friends in Mumbai.. So where ever you are, dear readers, set your alarms – and don’t miss this short meeting.
This two hour live-stream will include experts from around the globe talking about advanced reconstruction techniques for surgical resection of late stage lung cancer.
Thoracics.org is here with registration information for two upcoming thoracic surgery conferences online.
With the continuing pandemic, and related infection control measures, the majority of thoracic surgery conferences have been postponed or cancelled. However, the are two upcoming online thoracic surgery conferences to take note of.
This webinar hosted by the Argentine Society of Thoracic Surgeons, and Dr. Hector Rivero. Interested readers may register for this webinar at this link: Register for Webinar 26 June 2020.
Duke Masters of Minimally Invasive Thoracic Surgery
While readers have just a few days to register for the conference above, there is considerably more time to register for the 13th Annual Masters of Minimally Invasive Thoracic Surgery – Virtual Conference. While the traditional conference has become the annual pilgrimage south – this year’s online offering offers opportunities for greater attendance and participation from surgeons outside North America.
This conference runs September 25th, 2020. Interested readers may click here to register. The full online schedule of speakers has not yet been published
Attendees at a recent conference watching live surgery
Welcome to 2020!
Update! 4/8/2020: Editor’s note:
– 2020 is cancelled… well, maybe 2020 isn’t but it certainly feels like it with a large part of the world on lockdown as we fight this pandemic. So – roll forward to 2021 for conferences..and stay safe everyone!
In answer to some of the most frequent inquiries on thoracics.org, we have compiled a list of this year’s recommended thoracic surgery conferences.
Recommendations are based on multiple factors:
Timely content and topics (let’s not rehash the indications for 3 port VATS anymore, it’s not a novel technique)
Utility of content (is it practice-changing information? Is there a hands-on skills lab? Is it relevant? Or is half the conference a group of pulmonologists showing off their toys and talking about making inappropriate referrals for SBAR?)
International content/ International participation – Is there a good mix of speakers? Where are they from? Are the experts actually the experts in that area? Or is it just a bunch of North Americans talking to hear themselves talk? What about audience participation?
What about the topics themselves? Do they represent a variety of practice settings and conditions? Is there any discussion of relevant regional diseases or conditions (like XDR/ MDR TB cases and other regionally-based thoracic diseases)
Same old speakers on the thoracic surgery circuit? Or someone with something new to say?
Thoracics.org recommends: (in date order)
March 5th – 7th, 2020 – 4th Vienna -ESTS Laryngotracheal course in Vienna, Austria. The course includes a cadaver lab to practice hands-on skills. The full program is here, and includes a wide range of topics in laryngeal surgery, as well as presentation of data from several large centers.
November 13th – November 14th, 2020 – STS/ EACTS/ ESTS Latin American Thoracic Surgery– Rio de Janiero, Brazil. There isn’t a lot of information published yet on this year’s conference, but STS has made a huge effort in the last few years to push this conference and be more inclusive of Latin America, so it’s probably worth a go. (note: thoracics.org staff has attended the Latin American cardiac surgery conference in the past).
VATS International is always on the recommended list – once we have final date and program information, we will add it here.
Many of the modern masters of thoracic surgery were in Potsdam, Germany this June to discuss a myriad of topics in this year’s course until the heading of Troubleshooting. The lecturers included Dr. Diego Gonzalez Rivas, the inventor of the uniportal VATS technique, Dr. Alan Sihoe, a renown expert from Hong Kong, Dr. Timothy Yang from Shanghai Pulmonary Hospital, Dr. Marco Scarci, the creator of International VATS, and our host, Dr. Mahmoud Ismail. The course included both wet and dry labs so that surgeons unfamiliar with these techniques had an opportunity to apply what they learned during this and other sessions.
Standout presentations
Transcervical Uniportal VATS
Noted surgeon, and acknowledged expert in the area of transcervical VATS, Dr. Zielinski of Poland also gave a presentation on the transcervical uniportal approach, which is performed in the anterior cervical (neck) area. Using this collar incision, Dr. Zielinski is able to perform uniportal VATS for thymectomies and mediastinal operations as well as some lobectomies (generally upper lobes) and lung resections.
Dr. Zielinski talked about the challenges for this technique as well as the indications/ contraindications and potential complications while presenting data on his latest series of 32 patients. He gave surgical tips and tricks for using the transcervical approach, and how to avoid the most common complications.
There was a full session on setting up a uniportal VATS program with multiple speakers – along with troubleshooting the most common mistakes that surgeons (and their staff and administrators) make while starting a new uniportal VATS. They also talked about addressing the learning curve and ways to avoid common mistakes that occur during this period.
Common Complications after uVATS
Dr. Stefano Margaritora talked about how to prevent, detect and treat common complications after uniportal VATS. Drawing on his experience with over 1250 uniportal cases, Dr. Margaritora discussed the most common causes of bleeding such as dislodgement of vascular clips, bronchial artery bleeding, bleeding from lymph node harvesting sites and bleeding from the chest wall. He discussed the best ways to address this, such as use of newer anti-sliding clips, and the use of energy devices (like harmonic scalpels) for vessel sealing.
The ways to anticipate and prevent prolonged airleaks was also reviewed. Using anatomic fissures often lessens the incidence of airleaks post-operatively. The prevention of subcuatneous emphysema, as well as the relatively rare complication of lung hernia was addressed. Both of these complications can be reduced by meticulous and tight closure of the fascia at the conclusion of this procedure.
Using a serratus/ intercostal nerve block during this procedure is recommended to help reduce post-operative pain.
Dr. Firas Abu Ar spoke at several sessions – on both the use of uniportal VATS in pediatric patients as well as a case presentation on hydatid cysts. (Thoracics.org is planning to present this case study at a later date).
Hydatid cyst (photo provided by Dr. Firas Abu Akar)
There was a session on robotic VATs but with the exception of a discussion of preliminary trials of a robotic instrument that allows for uniportal VATS, most of the information has been presented on previous occasions.
The state of evidence for Uniportal VATS
Dr. Alan Sihoe gave an excellent presentation on the need more more randomized studies, and higher level evidence. “The time for case presentations on uniportal VATS is over.” As the leading academic researcher at this conference (as well as an active, practicing uniportal surgeon), and editor of multiple journals, Dr. Sihoe reminded attendees that as uniportal vats use continues to grow, and becomes a more common procedure, the types of articles surrounding the procedure need to advance as well. It’s no longer sufficient to submit papers like case reports where the purpose of the paper is to explain the procedure, and basically say, “look at this cool case I did.” Surgeons need to move beyond these sophomoric writings to produce high quality, high value papers that add to the body of scientific literature around uniportal VATS. He then gave the audience specific, helpful guidelines and advice on designing, writing and submitting articles for publication.
Attending watching the first of two live cases
After the didactic portion was completed, there were two live cases streamed from the local hospital for surgeons to review along with the dry and wet labs.
a Mexican surgeon using one of the newest tumor located/ marking systems during one of the dry labs
Note to readers: This will be the last article on uniportal VATS training. This topic has been extensively covered thru this and other posts here at thoracics.org. For more information on the essentials of uniportal VATS training, please review our archives under meetings and conference coverage.
Additional references
Eckland K, Gonzalez-Rivas D. (2016). Teaching uniportal VATS in Coruña.J Vis Surg. 2016 Mar 11;2:42. doi: 10.21037/jovs.2016.02.25. eCollection 2016. PMID:29078470
It’s the conference of the season – in Potsdam, Germany. This conference which includes lectures by the leading experts along with live surgery demonstrations with dry and wet labs is designed to address pitfalls and problems that surgeons may encounter when using the newer uniportal VATS techniques.
If you’ve wanted to learn about uniportal VATS – this is the class to do it! If you want to sharpen your minimally invasive techniques – this course has the full lab experience. Learn with the experts – and exchange ideas with your peers.
Thoracics.org will be there as part of an on-going research project this summer.
Potsdam VATS 2019 basic information:
Date of course: June 13th – 15th, 2019
Location: the Villa Bergmann in Potsdam, Germany
Cost: 500 euros for lecture and live surgery
1,600 euros for full course including labs (limited space availability)
Some of the videos are silly, cheesy even… But ugly track suits aside…
The results are, in arguably, wonderful. Patients eating, drinking, walking, and relaxing just an hour after major lung surgery.
Dr. Joao Carlos Das Neves Pereira is a Brazilian thoracic surgeon, who has been the primary author and leader on several articles, and programs for what he is calling ‘extreme fast track thoracic surgery’. He was also one of the featured speakers at International VATS 2018. “Better than before” is his model. “Patient empowerment’ is his ideology.
His presentation was easily the best in show, so to speak.. What’s more remarkable about his results are – that this isn’t new. He’s been doing it for more than a decade. In fact, he published an article on his experience in the European Journal of cardio-thoracic surgery was back in 2009. And now he is responsible for the implementation of a multi-disciplinary program at two hospitals on two continents – one on Paris, France and the second in Sao Paulo, Brazil.
So what does he do? How does he do it? And why aren’t the rest of us doing it?
What he does: “Feed & walk”
Change the existing surgical traditions:
no prolonged fasting
no cold operating rooms
no IV opioids
He does this with a multifaceted program that starts several weeks before surgery; with a comprehensive nutrition, smoking cessation and and an exercise regimen.
The night before:
Aromatherapy with lavender / Orange to promote sleep.
Avoid benzodiazepines
On the morning of surgery
patients are able to drink liquids within two hours of surgery, preventing dehydration and eliminating the need for IV fluids (no starving!)
During surgery
Normothermia
Multi-modality approach for anxiety/ nausea/ vomiting / pain
Opioid-free
Patient analgesia and anesthetic is treated with a combination of approaches including hypnosis, pre-emptive oral medications, BIS for awake anesthesia, minimally invasive airways. Patients are only given very short acting medications such as ketamine, or propofol combined with local anesthesia. By avoiding narcotics, there is a reduction in both sedation, and GI complications post-operatively.
Patients who are able to readily wake up after surgery and who haven’t had narcotics that adversely affect bowel function) are able to eat and drink immediately after surgery.
Post-operative
Immediate extubation (once the specimen is out of the chest)
Immediate feeding
Immediate exercise
“Hands free” care: No IV lines, oral medications only, patient controlled and opioid free.
Patients are encouraged to wear their own clothing before going to the exercise room, the outside garden or walking the halls. Post-operative pain management consists of oral medications only, and is augmented by physical therapy, acupuncture, aromatherapy and massage. Friends and family are instructed in the proper massage techniques so that they are able to participate in the patients care (also shortage of massage therapists). Patient recovery is enhanced by conviviality: patients don’t spend time in the rooms, alone or in bed. Patients are welcome to spend time in open spaces, aromatherapy areas, exercise rooms, a japanese style garden, an indoor garden and a tea room. Patients are encouraged to socialize and spend time with other patients.
While some of these ideas are novel, there is no magic surgical technique, and no miracle drug to account for these results – which are arguably better the most of ours. But it’s not just aromatherapy, it’s a philosophy of care.
More importantly, what Dr. Das Neves Pereira and his colleagues have; that many of us find difficult to replicate – is patient buy-in. We can call it “Patient empowerment” but it’s the part that many of us continue to struggle with.
But Dr. Das Neves Pereira’s lecture leaves us with more questions as well as answers..
Would this work for your practice? And why aren’t the rest of us already doing it? Will the patients accept it?
For the answer to this – we have to look at our own practices, in the here and now, in late 2018. A recent issue of the thoracic journal of disease did just that, devoting an entire issue to ERAS (enhanced recovery and fast track programs) while providing blueprints for anesthesiologists, nursing and physical therapists. But for many of us, the pat and simple answer is something like this:
“While most of my patients wouldn’t mind some aromatherapy or a massage after surgery, the unfortunate truth is that few would participate in a pre-operative program stressing diet and exercise. Even fewer patients would sign on for a program that restricts narcotics. Many of us already know this about our patient populations because we try routinely to incorporate more holistic practices into our treatment in a daily basis. While holistic premises and alternative treatments make billions of dollars in the United States (under the guise of prevention) it’s still a culture that is highly dependent on fast, and immediate remedies and a strong belief that very little post-operative pain is acceptable or tolerable. For every one patient that would embrace the philosophies of extreme rehabilitation, there would be another 200 screaming at the nurses for IV dilaudid.”
Much of the research actually confirms this view:
British researchers, Rogers et al. (2018) had a similar experience, noting in their recent publication that benefits of enhanced recovery protocols were dependent on compliance (and adherence) to protocols – particularly in regards to pre-operative dietary modification, and early post-operative ambulation. Refai et al. (2018) have attempted to address these issues with a comprehensive patient education component. However, their publication does not address whether these interventions increased compliance and reduced patient stress or anxiety.
Does this mean that we are skeptical of extreme rehab – no, not at all! Interest, participation and development in fast track thoracic surgery programs continues to grow despite these obstacles.
In fact, the tightening of many federal and state restrictions on narcotics due to the American opioid crisis may make this the best time in modern American medical history to bring this ideas and approaches to our patients (Bruera & Del Fabbio, 2018, Herzid, 2018). It also means that many of us have some preliminary hurdles and preconceived notions (on all sides) to overcome to engage our patients, nurses, therapists and fellow medical professionals to get their buy-in on the idea. We might be over a decade behind – but it’s not too late to start today.
Herzid, S. (2018). Annals for hospitalists Inpatient Notes: Managing acute pain in the hospital in the face of the opioid crisis. Annals of internal medicine 169(6): H02-H03.
Rogers, et. al (2018). The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. Journal of thoracic and cardiovascular surgery. 155(4) April 2018: 1843 -1852.
European Society of Anaesthesiology. “Hypnosis/local anesthesia combination during surgery helps patients, reduces hospital stays, study finds.” ScienceDaily. ScienceDaily, 21 June 2011.
From the Journal of thoracic disease – special issue: Supplemental issue #4 2018
Ospedale San Gerardo, site of International VATS 2018 is located in Monza, just an hour outside of Milan
Monza, Italy
Dr. Scarci has returned to his native Italy, and his first-born child, the International VATS Symposium has come with him. Now the chief of thoracic surgery at the 1,000 bed Ospedale San Gerardo, Dr. Scarci has again managed to assemble many of the world’s best and brightest in thoracic surgery.
Over 130 attendees participated in the live surgery, and lab event – with a multitude of other participants watching and commenting thru the CTSnet.org Live Streaming feature. While the majority of on-site attendees were from Italy, there were attendees and lecturers from around the world, including Myanmar, Panama and Pakistan.
The overarching theme of this year’s conference was segmentectomies (sublobar resections) but there were standout presentations in all areas.
The segmentectomy series of lectures discussed the differences between a wedge resection and a more anatomical sublobar segmentectomy). Piergiorgio Solli was not pleased to give his lecture on the anatomy and nomenclature of segmentectomies, and it showed. The usually composed surgeon was visibly irritated during his presentation.
Dr. Gaetano Rocco
The modern-day inventor of uniportal thoracic surgery, Dr. Gaetano Rocco discussed the latest data on morbidity and survival with segmentectomy. Formerly of Naples, but now representing Sloan Kettering in New York, made a point to discuss the difference between intentional segmentectomies (suitable for ground glass opacities and very small limited cancers) and “compromise” or forced segmentectomies, which are lung resections performed on patients with very marginal lung function. These forced segmentectomies are concerning for adequate margins.
He reminded surgeons that the scientific data isn’t always supported by our practice – while segmentectomies are superior to wedge resection, surgeons are doing wedge resections much more often even though the decrease in lung function (FEV1) after segmentectomy is only transient and limited in nature. He also reminded surgeons that no matter the operation, adequate lymph node sampling was essential and that to some extent survival is based not just on adequate staging (via proper node sampling), and good margins, but on the physical location of the primary tumor, (with subcarinal and basilar based tumors carrying the best survival.)
Alex Brunelli and Dr. Marco Scarci debated sublobar resection versus lobectomy on several different points – with Dr. Brunelli reminding the audience that segmentectomies are just 5% of all lung resections, and that 75% of all procedures performed in Europe continue to be open procedures – so that theoretical discussions on research findings as well as minimally invasive techniques (in general) aren’t being replicated in real world practice for the majority of surgeons.
Dr. Piergiorgio Solli discusses the anatomy and naming of pulmonary segments for resection
Sublobar resections in the “Compromise” patient
Dr. Scarci discussed the current literature and evidence regarding respiratory outcomes on patients undergoing sublobar resections versus lobectomy. Surprisingly, in the majority of these studies, the difference in post-operative lung function is very small – and transitory. He discussed several of the limitations in currently published research which may have skewed some of these results, but that [at present] there is a lack of clear evidence to support the use of sublobar resection for preservation of pulmonary function.
Nodes, nodes and more nodes
Luca Bertolaccini gave an interesting lecture on lymphadenectomy in segmentectomies – which boiled down to: take more nodes. Do a complete and thorough lymph node dissection – and take at least TEN nodes.
Dr. Dunning: Fantastic style but still leaves you hungry
As usual, Dr. Dunning’s dramatic and charismatic style meant that he could argue just about anything in thoracic surgery and successfully acquit himself. But not without hurtling a live grenade into the audience – criticizing Gonzalez Rivas and his adherents multiple times for slavish devotion to uniportal techniques.
I guess without Dr. Lim there to make thoughtful and logical arguments during the conference, someone had to stir up a ruckus. Who better than thoracic surgery’s own Pied Piper? Part showman, and part infomercial salesman, Dr. Dunning did his best to argue for open surgery using the “It’s not the size of your incision, but the quality of the post-operative care” argument.
Despite his whimsical delivery style, Dr. Dunning was able to deliver the data – reams of it. Unable to resist a dig at the absent but larger-than-life Robert Cerfolio, Dr. Dunning repeated last year’s technique and cited a mountain of Cerfolio’s work in his defense of the humble thoracotomy, all while assuring the audience that “it’s not your grandfather’s thoracotomy.”
Using that thread, he went on to remind attendees of the importance of ongoing work in the area of massive resections for advanced cancers. He presented a myriad of published titles highlighting major chest wall resections and advanced techniques for metastatic disease.
His always enjoyable delivery style as also punctuated with praise for another one of the speakers, Dr. Joao Carlos Das Neves Pereira, and his “extreme rehabilitation” program. He also made a point of highlighting the published works of surgeons outside of the traditional confines of Europe and the United State, focusing on contributions of our colleagues in Brazil and Asia.
While it was a great lecture, it left the audience feeling a little bit hungry for more substance, instead of a remote control like flashing thru channels. It was the perfect set up for the end of the day lecture by Dr. Das Neves Periera. Too bad there were something like 12 other presentations between the two.
Out of all of the topics covered here at Thoracics.org – one of the most popular topics among surgeons and surgical residents is minimally invasive surgery – uniportal, in particular. There is a steady stream of inquiring readers wanting to know more – about the data, the current evidence, and state of uniportal surgery. There is also a flood of inquiries on where to obtain training in these minimally invasive techniques. With the annual VATS International conference, attendees can have it all – access to the leaders in the field, while listening and participating in (sometimes) heated discussions on evidence based data, surgical outcomes and relevant research. This year, the conference moves out of merry ole England, and over to Italy. This year, the conference is being held in Monza, outside of Milan on September 28 – 29th.
Dr. Diego Gonzalez Rivas at VATS International 2017
It continues to be the best of all of the available surgical conferences for thoracic surgeons, with the opportunities to learn from the masters themselves, in the surgical lab that accompanies live surgery, panel discussions and formal presentations.
Long time readers know that tuberculosis, and the surgical treatment of tuberculosis have been high on our interest list here at Thoracics.org. While surgery was once the mainstay of treatment for tuberculosis (and was in fact, responsible for the emergence of thoracics as a surgical specialty) since the development effective antibiotic regimens
Now, the European Society of Thoracic Surgeons is hosting a dedicated course on the surgical treatment of tuberculosis in Cepina, Italy this November. The course runs from November 20th to November 23, 2017 and includes presentations on surgical treatment of tuberculosis, including the technical aspects of thoracoplasty, as well as the clinical and medical indications for surgical treatment of tuberculosis.
Unfortunately, thoracics.org won’t be there (and the organizer I met with recently made it very clear that thoracics.org was not welcome). But if you have a chance to attend – and would like to pass on your notes or observations about the course, please contact thoracics.org.
Most helpful: Dr. Marco Scarci & Dr. Diego Gonzalez Rivas
For less abstract, and more clinically relevant information, particularly for surgeons new to uniportal VATS, the lectures by both Dr. Marco Scarci and Dr. Diego Gonzalez Rivas were standouts.
Dr. Marco Scarci’s presentation, entitled, “Uniportal VATS: Hilar dissection” was a thorough review of the technical aspects of performing hilar dissection using the uniportal VATS approach.
Dr. Marco Scarci, presenter and founder of VATS International course
He began by discussing the basic pitfalls of incorrect port placement. Since there is only one port used, correct placement is essential for good visualization and operative access. A port placed too high makes it impossible to place the stapler intra-operatively. A port placed too low will create an angle too narrow to allow the surgeon to manipulate the hilar vessels.
Dr. Scarci has a standardized approach for each procedure. During his lecture, he reviews a step-by-step approach to a right upper lobectomy with a complete lymph node dissection. He gives concrete, helpful advice with tips and techniques based on experience.
As he explains, in uniportal VATS it’s easier to take lymph nodes during the procedure than to work around them, making a complete and thorough dissection an easy and methodical process. Dr. Scarci gives additional tips for surgeons including:
Have the proper equipment. A standard right angle doesn’t work well for hilar dissection.
Don’t rip nodes, use an energy device to avoid unnecessary oozing.
He also discussed addressing, treating and controlling intra-operative errors and complications in a frank, and candid fashion – including the dreaded and feared complication of pulmonary artery injury.
This complication was addressed again in Dr. Diego Gonzalez Rivas’ lecture, “Management of Complications.”
Dr. Diego Gonzalez Rivas
This popular lecture includes a frank discussion on anticipating and managing serious complications, including massive hemorrhage, accidental bronchial injury and pulmonary artery injury.
Best Orator: Dr. Joel Dunning – for overall style, presentation as well as his lecture content. In particular, his lecture on microlobectomy is excellent for being both informative and entertaining in delivery. He promotes this 3 port technique, which utilizes a subxiphoid port as the utility incision, stating that the subxiphoid area is more flexible (no ribs) which results in less post-operative pain even when very large tumors or sections of lung5 are removed via the subxiphoid port. He uses CO2 insufflation, and two 5mm accessory ports. Insufflation decreases the amount of instrumentation needed, and he can perform most cases easily with the standard laparoscopic general surgery instruments, which fit easily in the 5mm posts. The most impressive part of this technique is his pot-operative statistics, with 22% of his patients being discharged on post-operative day #1.
His second lecture: Robotic surgery is better than VATS: Against was a more-tongue-in cheek poke at Dr. Robert Cerfolio. While entertaining, Dr. Dunning answered the debate challenge in a less progressive fashion than I would have anticipated. (While stating that RATS wouldn’t be needed if surgeons would follow all of the best practices for general thoracic surgery because of the excellent outcomes in areas of pain, mortality, length of stay, infection etc. with standard (open) thoracotomy using data researched and published by Dr. Cerfolio was a clever presentation, it doesn’t really address the fact that this very expensive procedure is being touted as “state-of-the-art” and “cutting edge treatment” despite the lack of scientific evidence to document any real surgical advantages for patients.
While around 100 thoracic surgeons are gathered here this morning for the start of the 4th VATS International conference, there are another 500 viewers watching Dr. Eric Lim (UK) deliver his opening remarks on a live stream video feed on CTSnet.org.
Dr. Lim, who is one of the dynamic young thoracic surgeons leading the charge into minimally invasive thoracic surgery (MITS) reviews the state of the current evidence VATS and other MITS techniques, and the role of research in advancing thoracic surgery. Today’s lecture is delivered in a more measured, and calculated manner in comparison to his more fiery orations in the past – but the message remains the same: Surgeons need to remain engaged and participate in the research because if we don’t, and if we continue to stay in the operating room while other specialties define the outcomes, than we (and our patients) will continue to be short-changed by competing specialties.
While the conference started off with a call to research – once the topic of robotic -assisted thoracic surgery (RATS) was introduced, it wasn’t long before there was a quick shot across the bow.
Dr. Piergiorgio Solli (Italy) was delivering a well-thought out review of the current literature of RATS with the question: Why are they using robotics (despite a lack of evidence?)
Dr. Piergiogio Solli talks about the widespread use of robotic assisted surgery despite a lack of evidence to support its use.
He was cut short in his review by the American surgeon, Dr. Robert Cerfolio. Dr. Cerfolio, the ‘Gordon Gekko’ of thoracic surgery, and world-reknown RATS surgeon took that moment to issue a challenge to the podium, “and how many robotic surgeries have you done?” He then continued to defend the use of RATS stating that using RATS was like buying expensive luxury items (tailored suits, custom shoes, first -class airline tickets, etc.) by stating, “It costs more money because it’s good”
Dr. Robert Cerfolio
That was all that it took for Dr. Lim to enter back into the fray, asking ,”Is it one million [dollars] good?” (referring to the excessive start up and operating costs).
Cerfolio: “It costs more because it’s better” stated the self-proclaimed surgeon of the industry. “You don’t know it’s better because you haven’t done enough.”
The gloves are off my friends. Welcome to the 4th session of VATS International.
The fourth VATS International Symposium is this October 20th – 21st, 2017. As readers know, this course has been highly recommended in the past by Thoracics.org.
The preliminary program has been released, and it looks like audience favorite and straight shooter, Eric Lim will be opening the conference.
Italian thoracic surgeon, and the inventor of the first uniportal VATS procedure, Dr. Gaetano Rocco, along with the prominent American surgeon, Dr. Robert Cerfolio will also be presenting. There will be several presentations comparing uniportal VATS with robotic assisted surgical techniques (RATS). But this is more than an academic discussion – in addition to notable speakers, the conference includes live cases, practical tips and hands-on training.
Representatives from Storz will be speaking to thoracic surgeons on caring, repairing and maintaining thoracoscopic equipment. There are still spaces available for attendees, including the state-of-the-art wet lab. This wet lab offers surgeons the opportunity to try new techniques using 3-D models, while proctored by leaders in the field.
Dr. Marcello Migliore reports on the highlights from the recent Mediterranean Symposium on Thoracic Oncology
A great success the IV Mediterranean symposium in Thoracic Oncologic surgery. One hundred and eighty participants including thoracic and general surgeons, oncologists, and medical students attended the symposium.
IV Med Symposium in Thoracic Surgery: Speakers and the Students of the Faculty Medicine of the University of Catania
The symposium was organized to pose the basis for new research studies in advanced lung and esophageal cancer. The Rector of the University Prof Francesco Basile pointed out that the symposium is becoming a fixed international scientific appointment of the surgical thoracic community. It was noted that many research and thoracic publications which were done in Sicily in the 50ies and 60ies were only published locally or in Italy, meaning that many of these very good publications remain unknown internationally.
From the general discussion it was noted that it is necessary to prolong survival in patients with advanced stage lung cancer to obtain a global better survival in patients with lung cancer; unfortunately still today 60-70 % of patients arrive to us with a “non surgical” cancer. Although surgery has been always not considered for stage IV lung cancer, recently, new hope is emerging.
Initially the precious value of radiology and the recent emerging role of immunology confirmed the necessity of a multidisciplinary team to treat this group of patients. New technologies such as HITHOC, the same technique which has been used for mesothelioma, could help to prolong survival in a multimodality therapy in patients with stage IV lung cancer. A recent study involving 33 patients with advanced lung adenocarcinoma with pleural dissemination that a 6-month, 1-year and 3-year progression-free survival rates for the HITHOC group were 87.0%, 47.8% and 24.3%, while those of surgery group were 44.4%, 33.3% and 0.0%, respectively (1,2) Nevertheless, as for mesothelioma (3) it is imperative not to give false hope, but a “real” hope is mandatory only within a well design study. Surgery for N2 disease remains at the moment under investigation as there are conflictual data, but a single N2 not bulky metastasis could be an indication for surgery without neoadjuvant chemotherapy. Surgery for oligometastasis is feasible but a multidisciplinary decision is necessary, and this is essential when complex surgeries for locally advanced lung cancer is planned; long term survival depend from a well posed surgical indications, and it should not based on personal opinion (4). Advantages of the precision technique has been carefully presented by Michael Mueller from Vienna and Pierluigi Granone from Rome.
Prof Antoon Lerut from Leuven presented the tremendous experience with 3000 esophagectomies with the main conclusion that this complex surgery must be done in centralized centers where experience is present. Although minimally invasive and robotic surgery techniques are feasible by expert hands in some patients with advanced lung cancer, it is evident that randomized trials are necessary before their wider use in clinical practice. Semih Halezeroglu from Istambul presented his experience with uniportal VATS pneumonectomy, and commented that many patients with advanced lung cancer who undergo extended operation do not survive as expected, and therefore some indications should be at least revised to avoid usefulness operations. Finally, the personal feeling is that “individualized” surgery, which seems to be more human to me, for advanced lung and esophageal cancer could become more common in the next years.
From the left to the right: Prof Luigi Santambrogio, Prof Semih Halazeroglu, Prof Marcello Migliore, Prof Antoon Lerut, Prof Michael Mueller
References
Yi E, Kim D, Cho S, Kim K, Jheon S. Clinical outcomes of cytoreductive surgery combined with intrapleural perfusion of hyperthermic chemotherapy in advanced lung adenocarcinoma with pleural dissemination. Journal of Thoracic Disease. 2016;8(7):1550-1560. doi:10.21037/jtd.2016.06.04.
Migliore M, Calvo D, Criscione A, et al. Cytoreductive surgery and hyperthermic intrapleural chemotherapy for malignant pleural diseases: preliminary experience. Future Oncol 2015;11:47-52. 10.2217/fon.14.256
Maat APWN et al. Is the patient with mesothelioma without hope? Future Oncology 2015; 11(24s):11-14. November 2015
Treasure T, Utley M, Ian Hunt I. When professional opinion is not enough. BMJ: British Medical Journal 2007; 334.7598: 831.
It’s not too late to register for the upcoming Thoracic Oncology Symposium in Catania, Italy. The symposium is being held April 6th and 7th and is sponsored by the University of Catania and Policlinico University Hospital.
This year’s topic is “Surgery for “advanced” lung and esophageal cancer: New horizons or a false dawn?” Lectures include a presentation by Dr. Migliore on HITHOC for M1 lung cancer, a discussion on the use of hyperthermia, as well as several lectures on the use of VATS in advanced lung cancer and a segment devoted to esophageal cancer that includes the presentation of research findings by Dr. Toni Lerut based on findings from 3000 esophagectomies.
The full program and registration information can be seen Here. Potential registrants may also contact Dr. Migliore at mmiglior@unict.it
A guest post on last year’s conference is viewable here.
The first ever Thoracics.org Award to recognize innovation and achievement in thoracic surgery is now accepting submissions.
The Thoracics.org VATS International Award
Thoracics.org is pleased to announce our first international award for innovation and achievement in thoracic surgery. This award is designed to recognize and encourage research and publication in the area of VATS, including uniportal VATS.
This award is being offered by thoracics.org for a previously unpublished paper, study or case report on any aspect of thoracic surgery involving VATS (video-assisted thoracoscopic surgery). Topics can include case reports on complex cases, use of VATS in specific populations or disease conditions, unpublished research results / retrospective analyses or similar themes.
This award will be presented at the VATS International conference in London, UK on October 20 – 21, 2017.
Award Sponsors
This year we are honored to be sponsored by VATS International and Dr. Marco Scarci.
VATS International 2017 – We’ve written about this conference in the past, so thoracics.org is very excited to be able to present the Thoracics.org award at the 2017 conference. This year’s roster of speakers and topics includes some of our favorites, as well as introducing some timely new topics such as certification in minimally invasive thoracic surgery.
The Thoracics.org award to be presented at VATS International 2017
Dr. Marco Scarci – Dr. Scarci is a thoracic surgeon at the University Hospital of London and the founder of VATS International.
Rules:
Deadline: All submissions must be received by June 1, 2017 at 8 am eastern standard time.
Authorship: Papers must be the work of a sole author, and each author may only submit one entry. Entries are limited to practicing specialty thoracic surgeons, and surgeons completing their thoracic surgery fellowships. This contest is not open to general practice surgeons, or non-thoracic surgery specialties.
Originality: All entries must consist of previously unpublished work. Evidence of prior publication of material submitted for consideration is grounds for immediate disqualification.
Entry format: Entries consist of three (3) parts; the paper, the title page and the CV. Incomplete or partial entries may be ineligible for the award.
A. Paper specifications:
Papers must be written in English.
Maximum length is ten pages double-spaced with a 12 point font.
All submissions should be in Microsoft Word or a similar PC compatible type document. No pdfs will be accepted. Multi-media materials such as photographs, or short video clips may be attached to the paper for inclusion in the on-line publishing format. Video clips should be less than 10 minutes in length. No individually identifying information should be included in submitted photographs or videos.
B. A separate title page should be included with the essay.
This title page should contain:
-Author’s name
-Contact information including physical address, email and telephone number
-Institutional or Academic affiliation(s)
-Name and contact information of immediate supervisor
C. (Optional) – Author photograph – as a separate attachment, labeled as first initial_lastname.
D. A current curriculum vitae (CV) should also be submitted as part the entry package, as a separate attachment.
Send all submissions to: k.eckland@gmail.com
Publication:
All entries are submitted for publication at thoracics.org as a guest post. These posts will be published with the author of each paper to remain anonymous until the award winner has been announced. The winner of the Thoracics.org Award will be posted on thoracics.org on August 1st, 2017.
Following the announcement of the name of the recipient of the Thoracics.org Award, on-line articles will be amended to include author information, including name, affiliation, location and author photograph (if included with the original submission).
Judging:
Judging of the entries received will be done by a panel of thoracic surgeons. The names of the members of the panel will be revealed at the awards ceremony. While visitors to thoracics.org may comment on published entries, these comments will not be part of the judging criteria.
The Award:
Thoracics.org award
The award will be presented in person at the 2017 VATS International conference in London, England.
In addition to receiving recognition within the international thoracic surgery community, the award recipient will receive*:
Complimentary registration to the 4th annual VATS International conference in London, UK. This course is one of the best courses on uniportal and minimally invasive thoracic surgery and includes content on uniportal vats, robotic surgery, awake and nonintubated surgery, and other minimally invasive techniques. The lectures are given by the masters of these techniques, including the master of uniportal surgery, Dr. Diego Gonzalez. This year’s preliminary line up of speakers and topics looks like another stimulating session of minimally invasive techniques interspersed with timely discussions on current issues in VATS (Registration courtesy of VATS International).
A copy of the new textbook, Core topics in thoracic surgery.
Core topics in thoracic surgery
Core Topics in Thoracic Surgery provides accessible and concise coverage of the topics most often encountered in thoracic surgery practice. This handbook will guide the reader through revision of the topics covered in the FRCS(CTh) examination, and also covers more specialist topics in detail. In-depth technical sections offer guidance for difficult procedures, with useful commentaries from leading surgeons. A broad range of thoracic surgery issues are examined, with the latest evidence and information relevant to the speciality presented in a clear fashion. Combining an easy-to-use revision guide for trainees and a comprehensive reference text for cardiothoracic surgeons and recently appointed consultants, this is a one-stop guide to thoracic surgery. Authored by leading experts in the field, this resource will be invaluable to cardiothoracic surgeons, respiratory physicians and specialist nurses seeking to refresh or expand their knowledge of this field. (Textbook courtesy of Dr. Marco Scarci).
Additional sponsors include:
*Corporate and individuals wishing to co-sponsor this award may contact k.eckland@gmail.com
If you can only attend one thoracic surgery conference, shortlist VATS International.
Attendees with Dr. Marco Scarci (2nd from the left)
VATS International
VATS International (previously known as Cambridge VATS) is the brainchild of Mr. (Dr.) Marco Scarci. The Italian surgeon recently made the switch from NHS Papsworth (Cambridge) to the historic Royal London Hospital. Each year, Dr. Scarci gathers the world’s specialists on minimally invasive surgery to meet here in the United Kingdom to share knowledge and practice techniques for traditional VATS, uniportal approaches (standard and subxyphoid) and robotic surgery.
This is the third year of the conference and it’s reputation for dynamic speakers and controversy continues. With over 100 attendees, and a wide range of global participation as well as live surgery sessions and a wet lab, Dr. Scarci has had runaway success despite some last-minute challenges posed by his recent defection from the Cambridge facility. (Having met several members of the rather staid and traditional thoracic surgery department at Cambridge, Dr. Scarci, with his emphasis on minimally invasive surgery, is undoubtedly better-suited to the London-based facility).
Excellent lecture content, dynamic speakers
There were several excellent speakers, making it difficult to narrow the selections for presentation here. The obvious standout was Dr. Lim, (as discussed in a previous post).
As one of the course directors, and the inventor of the uniportal approach, Dr. Diego Gonzalez Rivas gave several lectures on the technique aspects of uniportal VATS.
Dr. David Waller followed up with a lecture entitled “Intra-operative problems in VATS lobectomy: Avoidance and Management.” He discussed complicating patient factors such extensive adhesions, anthrocotic lymph nodes, anatomical variance and incomplete fissures that increase the complexity of uniportal cases. He also identified common surgical problems such as difficulty identifying the target lesion, development of large air leaks and inadvertent damage to hilum or bronchus with strategies to prevent & manage these issues. He reviewed surgical techniques on bleeding control/ major vascular injury as well as absolute indications for surgical conversion such as equipment failures, airway injuries and stapler jams. In closure, he also warned against using conversion rate as an outcome measure. It was a fairly dry lecture despite being an interesting and important topic.
Among the remaining speakers, the overwhelming theme of change, and evolution along with an underlying sense of defiance continued. These surgeons are here to discuss, learn and practice uniportal surgery even if more traditional surgeons don’t approve.
Some of the best presentations were:
Dr. Alan Sihoe, (Hong Kong) gave a modified lecture called “Reasons not to perform uniportal VATS lobectomy”. This lecture which was adapted from a previous lecture from last year’s conference also addressed criticism of uniportal VATS. He reviewed the existing literature on uniportal surgery which suggests that uniportal surgery is a safe alternative to other surgical approaches.
Dr. Alan Sihoe
During the lecture, Dr. Sihoe encouraged surgeons to move past case reports to performing higher level research such as randomized control studies to create evidence in the area of uniportal surgery. He also encouraged participation in the European database, to gather prospective data on uniportal surgery. Until there is a larger body of literature utilizing higher levels of evidence, uniportal surgery will continue to face significant (and justifiable) criticism as a fad procedure. While it wasn’t a ground-breaking lecture by any means, it was also a reminder for thoracic surgeons to think like a researcher. It was a good follow-up on Dr. Lim’s opening lecture.
Dr. Gaetano Rocco (Italy).
Dr. Rocco, one of the pioneers of the uniportal approach, continued the discussion of the need for evolution and adaptation but with a different approach in a talk entitled, “VATS major pulmonary resection for (very) senior surgeons. He extended an olive branch to older, experienced thoracic surgeons with limited experience with VATS. His lecture discussed the ways to remediate older surgeons, and build their skills and comfort level in performing VATS procedures. His lecture offered a clear-cut and concrete , step-wise curriculum and self-assessment tool for surgeons looking to improve their VATS skills, starting with VATS lobectomy.
Dr. Gaetano Rocco (left)
Dr. Ali Khan (India) delivered two lectures, the first on operating room technology, but it was the second on uniportal surgery for inflammatory and infectious diseases that really piqued my interest. Part of this is due to my interest in the surgical treatment of tuberculosis, and my great appreciation for empyema as a surgical disease. Most readers know that reducing the time from presentation/ diagnosis of empyema to surgical decortication is one of my goals in daily practice, so any reminder that the morbidity/ mortality of decortications have been greatly reduced by minimally invasive surgery is always welcome.
Dr. Ali Khan
Honorable mention: Dr. Alex Brunelli, “Fast track enhanced recovery for MITS”. Basically a talk on care plans with specific markers for timely progression and discharge. While this is standard fare for nurses, the use of care plans for many surgeons is unfamiliar territory. It would have been nice if the care plans were available as a handout for surgeons who are still fine-tuning their own programs. It also would have been nice for a better breakdown of how specific items reduced the length of stay (how/ how much) or decreased the rate of complications. Nice to mention care plans but better to have measurable and specific examples.
After the extensive lecture series on the first day of the conference, the second day was devoted to live surgery cases and the practice lab.
Wet Lab
Since animal research of any kind is tightly controlled in the United Kingdom, 3D printed models were used for the wet lab portion of the course.
3D model of thoracic cavity
This is the first time that this type of model has been used. While the green plastic housing looks rudimentary, on closer inspection of the ’tissue’ inside, one gets a better appreciation for the models. The tissue is soft, and sponge-like. The lung doesn’t inflate but appears more lifelike than other models.
I don’t have the patience or temperament to shoot video footage, but I did record a couple of seconds so readers could have an idea what the wet lab portion of the course is like. In the video, Dr. Sihoe is instructing two trainees on the proper technique.
Despite its relative youth, VATS International remains one of the best conferences on minimally invasive surgery, inferior to none. This conference is highly recommended and considered superior to many of the traditional conferences on the topic (such as the annual Duke conference), due to lecture content on timely topics and controversial issues. The hands-on wet lab and participation by internationally recognized and globally diverse speakers makes this conference more valuable to attendees looking for exposure to newer surgical techniques.
Thoracics.org 2017 wish list
What would I like to see next year? As mentioned above, VATS International is one of the better courses available for surgeons interested in uniportal, subxyphoid and other minimally invasive techniques. But there is still more content I’d like to see – on nonintubated and awake surgery, for example.
However, with regards for this year’s speaker, an anesthesiologist from Papsworth Hospital, this topic would be better covered by one of the “masters” of the field; Dr. Eugene Pompeo of the Awake Surgical Group or Drs. Hung & Chen. The “Papsworth Experience” per se is limited to heavy sedation/ general anesthesia without mechanical ventilation. Patients still have LMAs and are heavily sedated. One of the main benefits of nonintubated anesthesia is the ability to operate on the medically fragile. It would be enlightening to hear more about operating on this population from more experienced clinicians. One of the topics that has been essentially ignored in the literature on this topic, is the implications for thoracic surgeons, anesthesiologists, operating room and recovery room staff on operating on this population of sicker patients. I think readers would like to hear about the new challenges in managing patients that were previously inoperable due to serious co-morbidities.
A discussion on developing or actualizing a formal certification process with examination for minimally invasive surgery with suggested curriculum, and case log requirements would be a nice addition. Blackmon et al. published a credentialing guideline but it’s a multi-part overly complex document full of “levels” of competency. I’d like to see a discussion on the development of an actual certification to be offered by a surgical licensing body or surgical society. Since the American agencies would probably take another 20 years to consider the idea, perhaps one of the guest speakers’ native society would be more willing to take on this project?
I’d also like to see at least a limited amount of content on esophageal surgery. I know, I know..While practice areas for thoracic surgeons vary around the globe, with the rapid rise in esophageal cancer, a lecture on the role of minimally invasive surgical techniques for esophageal surgery would be a great addition to the current roster of topics, particularly if it was given by one of the modern masters of esophageal surgery like Dr. Benny Weksler or Dr. Roy Chen.
Lastly, one of the most enjoyable aspects of this conference is the truly international flavor. Watching a surgeon from Israel demonstrate uniportal techniques from a practice site in Shanghai brings home the importance of global collaboration. Hearing surgeons from India, Brazil, France and Canada present data on their practices is critical to gain perspective, and exchange ideas. It also helps prevent attendees from falling into the trap of “we’ve always done it this way.” This concept could be expanded to include designated global snapshots, to highlight research or data in specific geographic areas, like Dr. Khan’s lecture on uniportal approaches for infectious and inflammatory disease.
A full lecture on cost containment techniques for surgeons practicing in hardship areas would be a great topic. Dr. Sihoe touched on the issue during one of his lectures, but since I’ve heard other surgeons talk about the limitations posed by having only one thoracoscope, I’d love to see an equipment representative give a lecture on maintaining thoracoscopes, where to donate old scopes or how to rehab these scopes for a second life. A talk about modifying existing surgical instruments for surgeons who can’t afford the Scanlan set would be helpful as well. One of the reasons these courses have been so successful it the fact that they are technically based, so adding a section like this might help spread the uniportal technique to a whole socio-economic and geographic segment of patients that it might not otherwise reach.
This last item might be a tall order for Dr. Scarci and his group but he’s done pretty well thus far.
Dr. Eric Lim challenges thoracic surgeons to remain relevant with a call to action at the 3rd VATS International conference in London, England
“Act different or watch thoracic surgery die”
With that dramatic shot across the bow, the dynamic and forthright Mr. (Dr.) Eric Lim of Royal Brompton Hospital opened the third VATS International conference. In a lecture entitled, “The Why of advancing minimally invasive surgery,” Dr. Lim put out a call to action to thoracic surgeons around the world, in an effort to remain relevant.
In an increasingly competitive world of thoracic oncology, nonsurgical options like stereotactic radiotherapy, and the developing MRI proton beam therapy are gaining traction for the treatment of early stage lung cancers. These nonsurgical treatments are gaining publicity and popularity due to the efforts of radiation oncologists.
The PCI of Lung Cancer Treatment
Reminding thoracic surgeons of the plight of their cardiac counterparts, Dr. Lim taunted the audience that having superior long-term outcomes does not guarantee success in a consumer-driven market. Public and medical perception is shaped not only by clinical research findings, but by the inherent bias introduced by the authors of these publications. As he explained, this bias, along with a public desire for simplicity, has driven the overwhelming success of percutaneous angioplasty (PCI) and declining rates of cardiac surgery despite well-documented research studies and clear evidence demonstrating the overwhelming superiorityof coronary artery bypass grafting (CABG) for long term survival. Thoracic surgeons must not fall into the trap of complacency and arrogant belief in surgical superiority that has plagued cardiac surgery if we want the specialty to survive.
Dr. Lim has identified three behaviors of thoracic surgeons that are harming the specialty:
Refusal to look at the evidence – thoracic surgeons must be willing to continuously review, understand and accept new clinical evidence and publications. Evolving and emerging treatments have changed many of the cornerstones of thoracic surgery, and core concepts of 1980’s thoracic oncology management need to give way to the increasingly body of knowledge favoring VATS resections, neo-adjuvant treatments, and improved outcomes.
An important caveat to this – is the need for Surgeon led research, and clinical trials to help eliminate the medical bias that has crept into much of the existing literature. Surgeons need to stop allowing other specialties to control the narrative. This is what allowed cardiologists to introduce concepts such as “non-inferiority” when research studies failed to show the benefit of cardiology interventions.
These research trials need to compare surgical interventions with non-surgical treatments. Our inter-specialty debates over which surgical technique need to take a backseat to studies designed to compare relevant outcomes like long-term survival and cancer recurrence if we want to demonstrate surgical superiority over medical treatments. “We need to stop arguing about which surgical technique and favor surgery over other therapies,” Dr. Lim explains.
Refusal to engage with industry – industry drives and funds innovation. If we want to continue to develop wireless technologies, robotics and other innovations for use in minimally invasive surgery, thoracic surgeons must be willing to engage and participate with industry.
3. Refusal to evolve – this is a fundamental problem plaguing thoracic surgery and addressing this issue is the underlying theme of many of the presentations at this year’s course. Dr. Lim has also addressed this refusal to evolve previously. Surgeons need to evolve, and be willing and able to change their surgical practices based on evidence and clinical guidelines. The failure to adopt VATS as the primary surgical approach in thoracic surgery in North America, and Europe despite decades of evidence and clear clinical guidelines favoring this approach is a symptom of this failure to evolve.
The future of thoracic surgical oncology
How will thoracic surgery survive? We already know that surgical excision offers the best long-term outcomes for our patients. But as we have seen, having ‘right’ on your side isn’t enough.
Make surgery the most attractive option
For surgery to succeed, thoracic surgeons need to focus on making surgery safer and more acceptable to our patients. Many patients prefer surgical removal on a philosophical level, but this preference is being eroded by promises of “easy” with SABER and newer chemotherapy regimens.
One of the benefits of surgery versus many of the newer treatments is that surgery is a single treatment versus multiple episodes of care. If we can make that single encounter better for our patients, with shorter hospital stays, less pain/ less trauma and less risk, then surgery will remain the first and preferred treatment option for lung cancer.
There were plenty of reasons for surgeons from all over Latin America to converge on Cuscu, Peru for the 2nd annual VATS PERU Uniportal Master Class, which covered the basics of the uniportal approach as well as nonintubated and awake uniportal surgery. There were subxiphoid and uniportal cases streamed live from Shanghai Pulmonary Hospital. But beyond the usual reasons of networking, discussing and sharing case knowledge, and the presentation of research findings and evidenced-based practice, there were several reasons why VATS Peru was more than just your average regional thoracic surgery conference.
Why attend VATS Peru? The three best reasons:
1. The wet lab – which allowed surgeons and their surgical assistants to apply the theoretical knowledge they learned during the first two days of lecture in operating room scenario en vivo. The “en vivo” is critical, fancy simulators aside, there is no better challenge to ‘book knowledge’, and application of practical skills than in the scenario of an operating room, with real models and active bleeding.
A surgeon in the master course receives instruction from Dr. Diego Gonzalez Rivas
2. Lectures from the master surgeon himself; Dr. Diego Gonzalez Rivas: That’s where the second critical component comes in, in the form of the candid, direct and straight-forward lecture by Dr. Diego Gonzalez Rivas on Control of Inter-operative Bleeding. If you weren’t paying attention during this lecture, it’s obvious in the lab. This isn’t a computer course where you can dial in your answers, fast-forward thru lectures and print off a shiny new certificate. This isn’t a computer app, or a simulation that you can reset and re-start as soon as the surgery heads off course, to try again.. It’s real surgery.
3. Dr. Carlos Fernandez Crisosto
Lastly, if you didn’t attend VATS Peru, then you missed an opportunity to know and to talk to Dr. Carlos Fernandez Crisosto. VATS Peru is his brainchild, and the organization was created specifically to advance minimally invasive surgery in Peru. VATS Peru is separate from ALAT (the Latin American Society of Thoracic Surgeons), of which Dr. Fernandez is the current president. VATS Peru is also separate from the Peruvian Society of Thoracic Surgeons which has its own focus in the thoracic surgery specialty.
Dr. Carlos Fernandez Crisost0, Cardiothoracic and Vascular surgeon
Dr. Fernandez, a Tacna native, works at Daniel Alcides Carrion Essalud facility in the southernmost region of Peru. He is the sole cardiovascular and thoracic surgeon for the city of Tacna, and performs cardiac, vascular, and endovascular surgeries in addition to general thoracic surgery. While he is a trained cardiovascular surgeon, (in addition to general thoracic) thoracic surgery is what he enjoys most.
He trained in Argentina, and practiced in Cordoba, Argentina for 23 years before returning to Tacna in the last few years.
His average case volume is around 380 surgeries a year, and he reports that all of his thoracic surgeries are generally performed using the uniportal thoracoscopic approach. He also does transplant, which requires him to travel to Lima specifically to perform the procedure. The transplant program is small and performs 4 to 5 transplants per year.
In his practice he sees the usual oncology cases, and empyemas but he also sees a large number of patients with tuberculosis, as well as an assortment of hydatid cysts, and pectus cases. Trauma from accidents, as well as injuries from guns, and knives also comprises a large part of his practice.
Dr. Fernandez is pleased with the success of his course, since this is only the second time the course has been available here in Peru. It was a complex logistical arrangement to hold the course in Cusco this year, but with the help of his wife, a professional events planner, they were able to pull of the event with very few hiccups. Next year, they plan to hold the event in Lima, the capitol of Peru and a city famed for its gastronomic offerings.
If you missed this year’s VATS Peru, look for VATS Peru 2017 here at Thoracics.org next fall.
One of the guest lecturers at the 2nd VATS Peru Uniportal Master course is Dr. William Guido Gerrero from Costa Rica. Dr. Guido talked about the challenges of implementing a minimally invasive thoracic surgery program in the small central american nation that boasts a total population of less than 5 million.
Despite the small population and the low surgical volumes that accompany it; Dr. Guido is one of ten thoracic surgeons in Costa Rica, who are affiliated with two thoracic surgery departments within the nation.
Dr. Guido initially performed his first two uniportal cases with some trepidation. The first cases were simple biopsies and drainage of pleural effusions. He then performed his first lobectomy but it was a slow tedious process. After that experience, he traveled to Shanghai, and the Shanghai Pulmonary Hospital to attend and train with Dr, Diego Gonzalez Rivas in the wet lab, practicing cases on live animals.
At Hospital Rafael Angel Calderon Guardia
Dr. Guido primarily operates in a 350 bed hospital in the capital city of 1.4 million habitants. The thoracic surgery unit consists of eight beds, and cases are performed three days a week with an annual case volume of around 350 cases.
Majority of cases by Uniportal VATS
The majority of surgical cases (67%, includes all types of cases) are performed using the uniportal approach. 31% of the remainder are performed via a traditional ‘open’ approach with only 2% of cases performed using traditional (multiport) VATS. This discrepancy is explaned by Dr. Guido in that there is currently only one thoracoscope in the hospital, and it is not always available. He predicts that the rate of uniportal VATS cases will soon increase, as the second thoracoscope is scheduled to arrive in just a few weeks, followed by a third thoracoscope next year. These equipment limitations are not the only challenges for Dr. Guido and his fellow thoracic surgeons.
Low volumes, suboptimal equipment and a lack of institutional support
The low volume of surgical cases and a lack of institutional support are also problems. Unfortunately, it’s harder to convince the medical community of the value of uniportal VATS (and thus boost surgical volume) than it is to order new equipment. Despite these limitations, Costa Rica also manages to maintain a struggling lung transplantation program, that performs approximately two transplants per year, with five patients with pulmonary fibrosis and pulmonary hypertension currently on the waiting list.
Excellent care, at home
Dr. Guido hopes that many of these problems can be resolved in the future. He wants Costa Rican patients to feel that they can stay in Costa Rica for their thoracic surgery without making any sacrifices in care. He’s already lost one patient to Dr. Gonzalez Rivas himself (when the patient traveled to Spain for surgery) and another to the United States (where the patient ended up getting an open thoracotomy). Losing a patient to the Master of Uniportal Surgery himself is inevitable, but losing a patient to a country where the patient received an inferior procedure at an exorbitant cost is a bit harder to swallow.
Day One of the VATS Peru 2016 Conference was a primer for surgeons interested in learned and performing uniportal VATS. Dr. Gonzalez Rivas’ lectures formed the basis of theory and principles of uniportal thoracoscopic surgery, with additional lectures by Dr. William Guido, Dr. Timothy Young and Dr. Deping Zhao.
Surprisingly, many of the surgeons at the event informed me that they already use some uniportal techniques in their practice. But they came here to Cusco, Peru to learn more from the Master of Uniportal surgery himself, Dr. Diego Gonzalez Rivas before attempting more complicated and complex surgical cases like sleeve resections. Others came to learn more about nonintubated surgery in their uniportal patients. The remainders were the core group of surgeons who came to get their first taste of uniportal surgery.
Some came from the local areas; from Lima, from Chile, and Ecuador. Others came from other parts of Latin America; from Mexico and Costa Rico. There was even a practicing surgeon from the United States, who realized that if he wanted to pursue the most advanced surgical techniques and minimally invasive surgery in thoracic surgery, that he couldn’t do it at home. That’s a big paradigm shift for a surgeon from a nation that tends to think if it wasn’t invented in the United States, that it doesn’t exist, or has no merit. It is also, from my perspective, a welcome change.
With Dr. Tim Young, Dr. Diego Gonzalez Rivas and Dr. William Guido
In the five years that I have been travelling the globe, writing about surgical innovation, I am usually alone in my quest, in seeking innovation outside of American medicine. That’s not to say we(Americans) don’t have our own great surgeons – I can easily rattle off quite a few – but it’s an acknowledgment that surgical innovation (or any innovation in general) is not the exclusive domain of the United States. That sounds like a fairly basic principle, but one that is rarely seen in practice. American doctors and nurses just don’t attend international events to learn. They only attend to teach – and often leave as soon as their lecture is complete, ensuring that an accidental opportunity to be exposed to new ideas is minimized.
So it was a pleasure to meet the surgeon from California, who took time off from a perfectly successful practice performing routine thoracotomies, to learn more about uniportal surgery at this and another upcoming master course.
VATS Peru 2016 – learn uniportal and subxiphoid techniques in the wet lab, at the hands of the inventors of these techniques at this year’s conference in Cusco, Peru.
Cusco, Peru – September 2016
The 2016 VATS Peru conference and wet lab is scheduled for September 7th – 9th and this year’s agenda looks to be interesting and exciting.
Dr. Carlos Fernandez Cristoso is this year’s director of the course, and he has all the essentials of uniportal (single port thoracic surgery) VATS including special sections on : Management of intraoperative bleeding, difficult / advanced uniportal cases, and uniportal VATS on awake and nonintubated patients in addition to much of the standard uniportal fare.
Dr. Diego Gonzalez Rivas is honorary president of the course.
The course also includes lectures on the uniportal subxiphoid approach, as well as how to teach uniportal approaches to residents and fellows. The surgeons of Shanghai Pulmonary Hospital as well as Dr. Diego Gonzalez Rivas , the inventors of subxiphoid and uniportal approaches (respectively) will be there. The surgeons of Shanghai Pulmonary Hospital will be sharing their experiences of performing over 8000 uniportal resections a year, as well as presenting a live case direct from Shanghai during the conference.
Also – this conference is unique in offering an opportunity for surgical assistants, and scrub nurses to gain insight and share experiences in uniportal techniques with concurrent courses scheduled for operating room nurses. Both sections spend the last day of the conference in the wet lab applying newly learned techniques.
To register for this course – click here or e-mail : consultas@vatsperu.org
An invited report from Dr. Marcello Migliore on the recent Italian conference on VATS and lung cancer
Report from the 3rd Mediterranean Symposium in Thoracic Surgical Oncology on VATS RESECTIONS FOR LUNG CANCER: moving toward standard of care.
Speakers and moderators at the 3rd Mediterranean Symposium on Thoracic Surgical Oncology
The third mediterranean symposium on thoracic surgical oncology was successful. The symposium was held the 21st – 22nd april 2016 at the Aula Magna of the Faculty of Medicine at the University of Catania. More than 150 people attended, and among them there were thoracic surgeons, general surgeons, oncologists, chest physicians, residents and medical students. This year, we had speakers from Europe and the USA. The main topic was VATS resections for lung cancer (Photo 1). During the opening ceremony, the Rector Giacomo Pignataro awarded a medal to Professor Tom Treasure for enhancing our outstanding education and research experience (Photo 2).
Photo 2: The Rector of the University of Catania is giving the medal to Professor Tom Treasure
Although the concept of operating thru a small port was born and developed in Europe (1- 7) it has been noted that 90% of papers on uniportal VATS lobectomy come from East Asian countries (8-11). Throughout the symposium different speakers agreed that a proper definition of uniportal VATS is mandatory to speak the same language worldwide.
Awake thoracic surgery was discussed together with the need of accurate preoperative staging procedures such as endobronchial ultrasound, videomediastinoscopy or Video-assisted mediastinal lympadenectomy. It was concluded that a wide spectrum of factors must be considered when determining the appropriate tests to assess the lymph nodes in NSCLC, which includes not only the sensitivity and specificity of the test, but also the ability to perform the procedure on an individual patient.
Data from New York showed very clearly that there have been no large-scale randomized control trials to compare open and VATS lobectomy. Although most may agree with the short-term superiority of VATs lobectomy over its open counterpart, many argue that is an in adequate oncologic procedure. Hence whether the approach is equivalent in overall and cancer specific survival to its open counterpart is not known. He also reported an important recent analysis of SEER-Medicare which confirmed that VATS lobectomy appears to have similar survival to its open counterparts (12).
A magnificent video was presented to explain every step of the lobectomies performed through a small skin incision. A long discussion followed and all auditorium proposed that ‘single incision’ VATS probably define better than uniportal VATS what surgeons are doing worldwide. Certainly the length of skin incision is important and should be taken in serious consideration. We felt that a consensus conference is probably necessary consensus conference is probably necessary. The indication for a Wedge resection rather than lobectomy in initial stage lung cancer is still weak.
The Italian VATS group was formed in 2013 , and nowadays there are 65 participating centres and that 2800 VATS lobectomy have already been included. In Catania we joined the group few months ago (13)
A very interesting session for juniors and medical students from UK and Italy was carried out, and 12 abstracts have been presented as interactive posters. Two of them have been chosen for possible publication in Future Oncology.
Finally, the first data survival seems to benefit little from the various even growing “personal” modifications of the standard VATS technique. Since there is a limited variation between VATS and uniportal VATS, the likelihood is that either VATS and uniportal VATS will be operative in the near future. Its success will depend on survival advantages and decrease chest pain and not just on new technical instrumentation. To protect patient’s safety, the length of the skin incision should be chosen on the basis of several clinical factors and not in relation of modern “demand”. Although the trial VIOLET is ongoing in UK to demonstrate if VATS resection for lung cancer is better than open thoracotomy, doubts arises as standard postero-lateral thoracotomy for lung cancer seems to be an incision which is performed rarely today. A skin incision of 6-8 cm (mini-thoracotomy) with video assistance is enough for most of lung resections. The question which arises is if a mini-thoracotomy of 6 cm should be called “uniportal” or not.
Marcello Migliore, MD
Thoracic surgeon and invited commentator
Dr. Marcello Migliore
Migliore M Initial History of Uniportal Video-Assisted Thoracoscopic Surgery. Ann Thorac Surg 2016;101 (1), 412-3.
Migliore M, Calvo D, Criscione A, Borrata F. Uniportal video assisted thoracic surgery: summary of experience, mini-review and perspectives. Journal of Thoracic Disease 2015; 7 (9), E378-E380
Migliore, M., Giuliano, R., & Deodato, G. (2000). Video assisted thoracic surgery through a single port. In Thoracic Surgery and Interdisciplinary Symposium on the threshold of the Third Millennium. An International Continuing Medical Education Programme. Naples, Italy (pp. 29-30).
Migliore, M., Deodato, G. (2001). A single-trocar technique for minimally invasive surgery of the chest. Surgical Endoscopy, 8(15), 899-901.
Migliore M. Efficacy and safety of single-trocar technique for minimally invasive surgery of the chest in the treatment of noncomplex pleural disease. J Thorac Cardiovasc Surg 2003;126:1618-23.
Rocco, G., Martin-Ucar, A., & Passera, E. (2004). Uniportal VATS wedge pulmonary resections. The Annals of Thoracic Surgery, 77(2), 726-728.
Gonzalez D, Paradela M, Garcia J, et al. Single-port video-assisted thoracoscopic lobectomy. Interact Cardiovasc Thorac Surg 2011;12:514-5.
Yang HC, Noh D. Single incision thoracoscopic lobectomy through a 2.5 cm skin incision. J Thorac Dis 2015;7:E122-5.
Ocakcioglu I, Sayir F, Dinc M. A 3-cm Single-port Video-assisted Thoracoscopic Lobectomy for Lung Cancer. Surg Laparosc Endosc Percutan Tech 2015;25:351-3.
Kamiyoshihara M, Igai H, Ibe T, et al. A 3.5-cm Single-Incision VATS Anatomical Segmentectomy for Lung Ann Thorac Cardiovasc Surg 2015;21:178-82.
Zhu Y, Xu G, Zheng B, et al. Single-port video-assisted thoracoscopic surgery lung resection: experiences in Fujian Medical University Union Hospital. J Thorac Dis 2015;7:1241-51.
Paul S, Isaacs AJ, Treasure T, Altorki NK, Sedrakyan A. Long term survival with thoracoscopic versus open lobectomy: propensity matched comparative analysis using SEER-Medicare database. BMJ 2014;349:g5575
Migliore, M., Criscione, A., Calvo, D., Borrata, F., Gangemi, M., & Attinà, G. (2015). Preliminary experience with video-assisted thoracic surgery lobectomy for lung malignancies: general considerations moving toward standard practice. Future Oncology, 11(24s), 43-46.
Migliore M. Will the widespread use of uniportal surgery influence the need of surgeons ? Postgrad Med J 2016 (in press).
Details about the upcoming Robotic thoracic surgery course at NYU this June.
New York University School of Medicine has an upcoming CME course on Robotic Thoracic Surgery this June (10th & 11th). The day and a half course will be held at NYU Langone Medical Center in New York City.
The conference covers robotic surgery basics as well as lectures on robotic esophagectomies and mediastinal surgery. Robotic master surgeon, Dr. Robert Cerfolio will be giving two presentations.
Dr. Robert Cerfolio with a Latin American thoracic surgeon at a conference in Orlando, Florida 2015
Dr. Inderpal Sarkaria from the renown University of Pittsburgh Esophageal & Lung Surgery Institute will be giving a presentation on esophagectomies by the robotic approach. Dr. Sarkaria is the newest thoracic surgeon at the UPMC program run by Dr. James Luketich.
While it is a short conference, it’s a chance for interested thoracic surgery professionals to learn more about establishing a robotic surgery program. It is also part of a larger robotic surgery conference, the Second Annual NYU Langore Multi-Specialty Robotic Surgery Course.
All robotic surgery enthusiasts, fellows and interested surgeons – can register for the course here. Allied health professionals are encouraged to attend.
Join Dr. Marcello Migliore (Italy) and Dr. Tom Treasure (UK) this April for the 3rd Mediterranean Symposium in Thoracic Surgical Oncology in Catania, Italy.
The 3rd Mediterranean symposium is on VATS resections for lung cancer will be held in Catania 21-22 April 2016.
Conference focus:
Although more than 20 years have elapsed since the first VATS lobectomy was performed, there are remain open questions that need answers. Moreover, uniportal VATS made possible in 2011 the feasibility of the single incision VATS lobectomy, which has led to in an increase in interest in VATS resections. As a result yet more questions have arisen. Surgeons have to consider the best strategy for lymphadenectomy for example. The recent reports of awake uniportal VATS for lung cancer and the uniportal sleeve resections alert us to expanding indications and the necessity of a targeted surgical training in minimally invasive surgery.
Who, and when should uniportal and other minimally invasive techniques be used?
But smaller incisions to treat cancer should never put patients at risk. These techniques are not for every surgeon to explore, but if proven to be in patients’ best interests, they should not be avoided but adopted. Another goal of this symposium addresses how the next generation of surgeons should learn these techniques. And then the big question of how to test whether innovations are true improvements in randomized trials.
We can hear and discuss new ideas in the relaxing and collegiate atmosphere is provided by the Catania Symposia
Interested surgeons may register at FullCongress.it
Guest post on the Mediterrean Symposium authored by Dr. Marcello Migliore
Learn Uniportal VATS from the masters – with a hands-on wet lab..
Attendees at the November 2015 course
La Coruna. Espana
Beyond the theoretical
The Advanced course on uniportal VATS differs from the rest of the courses covered here at Thoracics.org in that it goes beyond didactic lectures and surgical demonstrations. The three day course, sponsored by Johnson & Johnson is one of the few to offer hands-on training in a one-day ‘wet lab’.
Dr. Dario Amore (Hospital Monaldi, Naples, Italy) operates under the watchful eye of Dr. Maria Delgado of Hospital Universitario de Coruna.
During the lab portion of this course, attendees are encouraged to perform several lobectomies using the uniportal approach while being proctored by several well-experienced surgeons including Dr. Diego Gonzalez Rivas himself, and his surgical colleagues (Dr. Maria Delgado Roel, Dr. Mercedes Del la Torre and Dr. Ricardo Fernando Prado). These surgeons make up the world famous thoracic surgery department at the Coruna University Hospital. They are joined by Dr. Miguel Congregado, another Spanish surgeon from Seville, who is also well experienced in uniportal VATS.
Course attendees with Spanish mentoring surgeons:Dr. Maria Delgado (3rd from left), Dr. Mercedes de la Torre (center) and Dr. Ricardo Prado (far right). Dr. Miguel Congregado (first row)
While there have been multiple discussions among STS and other organizations regarding the minimum training required for surgeons to be credentialed and to practice Uniportal VATS and other advanced surgical techniques in their respective hospitals – the wet lab gives no doubt as to the need for ‘hands-on’ experience for even experienced VATS surgeons*.
Lecture content becomes reality
Visiting surgeons during didactic component
Powerpoint discussions, video demonstrations and even the most engaging lectures on bleeding complications quickly take center stage once surgeons enter the lab.
For surgeons who have spent their time watching Dr. Gonzalez Rivas perform a complete lymph node dissection in under 9 minutes, the lab is eye opening.
Despite being cautioned during lectures on preventing and managing bleeding the day before, as well as short review immediately prior to entering the lab, essential pre-operative preparations on surgical trays are noticeably absent in the lab. None of the two man teams takes the time to place spongesticks on their mayo stands or make any other modifications to their instruments prior to making the initial incision.
Attendees experience the reality of bleeding complications during initial attempts at Uniportal VATS
One by one – with two notable exceptions, each of the 8 teams encounters catastrophic bleeding – injuries to the pulmonary arteries, accidental tears to the vena cava and other major problems. But that’s why they are here: to become familiar with uniportal surgery, its specialized instruments while being guided by experienced uniportal VATS surgeons. One by one, the surgeons remember the mantra of Dr. Diego Gonzalez Rivas: “Don’t panic!” as they maneuver and do the best to re-establish hemostasis. Surgeons practice placing stitches in the PA, and repairing the great vessels. All remember the first lesson Uniportal VATS – hold pressure. Some manage these complications quickly with relative ease, others struggle initially and some fail entirely.
Bleeding is not the only possible complication for novice uniportal surgeons
Others, like the pair of general surgeons from the Netherlands demonstrate that despite a steep learning curve, success is possible with uniportal VATS. After initially learning traditional VATS in 2008, these surgeons had just 5 uniportal cases under their belt prior to coming to this course. However, each of their cases were completed quickly and without complications.
The wet lab was followed by a day of live-surgery performed by Dr. Gonzalez Rivas – where attendees could ask questions about his techniques during the operations. Their new found experience in the web lab served as a useful framework for their questions and observations.
*Dr. Gonzalez Rivas and his colleagues recommend attending several courses, followed by a web-lab and then finally, proctoring with an experienced Uniportal VATS surgeon.
Interested in learning uniportal VATS?
Start by familiarizing yourself with the basics – watch YouTube and other surgical demonstration videos like the Virtual VATS uniportal lobectomy on December 3rd 2016, read articles and reviews.
Attend conferences and moderated discussions on the technical aspects of uniportal VATS
Observe ‘live-surgery’ events – like the week long courses at Shanghai Pulmonary Hospital
Attend wet lab courses
Finally, arrange for mini-residencies or mentoring at home facility as you begin to implement these techniques into your own practice. Be prepared to encounter bleeding and other complications and remember: Don’t panic!
the second annual Cambridge VATS : uniportal VATS, nonintubated thoracic surgery and the masters
Cambridge, UK
Cambridge center for continuing education
It may only be the second annual Cambridge VATS conference but Dr. Marco Scarci has managed to assemble one of the finest assortments of speakers in one short course since the days of the original giants. This included a roster of the biggest names, publishers of innovative research and the Masters of Minimally Invasive Surgery including Gaetano Rocco, Alan Sihoe, Joel Dunning, Thomas D’Amico, Henrik Hanson and Diego Gonzalez Rivas.
Dr. Ismail (Berlin), Dr. Hansen (Copenhagen) and Dr. Alan Sihoe (Hong Kong)
However, one of the standout presentations was given by none other than Dr. Guillermo Martinez, an Argentine anesthesiologist from Cambridge’s own Papworth hospital. He immediately leapt into one of thoracic surgery’s more controversial topics, nonintubated thoracic surgery. While Dr. Martinez primarily focused on the nonintubated but heavily sedated (or generally anesthetized patient with LMA for airway support) he gave an excellent presentation on the anesthetic considerations for nonintubated surgery. As he explained, it’s a natural progression for nonintubated surgery and VATS go hand in hand, as surgeries become less traumatic to patients, the anesthesia should be less invasive as well. He discussed the rationale for nonintubated surgery from an anesthesiologist’s perspective and outlined the practices at Papworth Hospital where he is part of the thoracic surgery team.
He also discussed the many challenges posed by this method of patient management including the fact that anesthetic techniques for nonintubated surgery need to be reproducible, safe and feasible for eligible patients. Anesthesiologists and thoracic surgeons also need to pre-establish criteria for conversion (such as heavy bleeding, patient hemodynamic instability or conversion to open surgery) to general anesthesia prior to cases, and to be fully prepared to perform urgent intubation as needed.
He also touched on the methods of analgesia used during these cases such as adjuvant like local anesthesia (chest wall infiltration), regional blocks and thoracic epidurals as well as cough suppressant mechanisms.
Reigniting controversey
This along with Dr. Diego Gonzalez Rivas’ subsequent presentation on uniportal surgery combined with nonintubated and awake thoracic surgery reignited much of the firestorm that we first saw at the Duke conference.
Dr. Diego Gonzalez Rivas
Commentary by Dr. Eric Lim perfectly captured some of the sentiments of younger members of the audience, when he took the stage as part of a separate debate on the merits of VATS versus SART when he stated, “I am tired of surgeons calling [new techniques/ technologies / treatments] crap when they’ve read the papers and seen the videos [demonstrating the procedure]. It’s not crap – if you just watched it.” He continued to address the resistance to change in surgery, and the attitudes of surgeons unwilling to adapt. It was a refreshing moment of forthrightness and candor that has been sorely missing from many events. It was also a 180 degree perspective from many of the more critical and conservative attitudes that liken techniques like nonintubated, awake anesthesia or uniportal surgery as being a type of showmanship rather than real innovation, or critics who question the relevancy of pursing research in this area with the “just because we can do it, should we?” mantra that has pervaded many of the recent surgical discussions.
Representatives from Shanghai Pulmonary Hospital (SPH) also gave several presentations. Dr. Haifeng Wang discussed high volume surgical training while Dr. Lei Jiang discussed uniportal surgery using a subxyphoid approach.
Dr. Wang explained how the research and lessons learned from the Shanghai Pulmonary Hospital has authenticated the uniportal VATS technique to many surgeons in China. He presented original data from his facility on over 1500 uniportal cases.
While he and his colleagues initially debated the safety of this procedure, after learning this technique, it has been adopted throughout Shanghai Pulmonary Hospital. He and the 39 other surgeons on staff use this technique every single day. In fact, the sheer volume of cases at Shanghai Pulmonary Hospital has made these surgeons some of the most experienced uniportal surgeons in the world. After the first uniportal VATS case was performed at SPH in 2013, the technique has rapidly gained popularity. Last year (2014), surgeons at SPH performed 6855 cases, with uniportal cases comprising 50% of all cases. That percentage will only grow, as this year, the hospital is on target for over 8000 cases.
Cambridge 2016?
Now, with such a great entree, what will be the encore for 2016? It would be great to see more “micro-invasive surgery” like a serious sit-down debate among the Awake Thoracic Surgical Group, Gonzalez Rivas, Hung et. al and the traditionalists on the merits of nonintubated surgery along with presentation of more original research, on-going projects and a meta-analysis of the work to date in this area.
It would be interesting to hear more from Dr. Scarci himself, who has been responsible for bringing these surgical innovations to the NHS specialty hospital in Cambridge. Like Dr. Alan Sihoe, who spoke during this session on how to start a uniportal program, Dr. Scarci himself undoubtedly has some excellent experience and insights to share.
More subxyphoid, including bilateral surgical case presentation or a live surgical case also top the wish list here at Thoracics.org.
That doesn’t mean that all of the old standards should be phased out – Henrik Hanson’s standardized approach to 3 port VATS is a classic, for good reason. As Dr. Hansen said himself, “The Gold Standard should not be what Diego [Gonzalez Rivas] or I can do, but a safe, standardized approach.” Not every surgeon is ready to embrace subxyphoid or uniportal approaches, and particularly for surgeons in the twilight of their careers, maybe they shouldn’t. But there is certainly no excuse for any thoracic surgeon on the planet not to excel at traditional VATS.
Topics that should be retired include debates on whether VATS of any approach respects oncological principles, and many of the topics in Robotic surgery. If it’s anyone but Dr. Robert Cerfolio or Dr. Mark Dylewski, then there’s probably not much that they can add to the topic. For everyone else, robotic surgery remains more of an expensive surgical toy than a legitimate area of research. In that vein, less presentations on developing toys and more guidance to the younger audience on transitioning from case reports to more academic research would make for a nice change. If we are going to continue to promote minimally invasive surgery, that we should encourage more advanced research; like the development of more randomized or multi-site trials on topics in this area.
Dr. Diego Gonzalez Rivas discusses intubated and nonintubated uniportal thoracic surgery for complex thoracic procedures
Orlando, Florida
Dr. Diego Gonzalez Rivas discusses non-intubated thoracic surgery
One of the standout presentations on Day One of the Duke Masters of Minimally Invasive Thoracic Surgery was Dr. Diego Gonzalez Rivas’ presentation on performing uniportal surgery on non-intubated patients. Surprisingly, this presentation was greeted with significant skepticism in the form of comments by fellow presenters.
No trocars, no rib spreading, one incision (with no rigid port placement)
The use of one small 2.5 cm incision with the camera placed above the instruments allows the surgeon to maintain the traditional perspective of open surgery using a minimally invasive approach. “Eyes above hands” Dr. Gonzalez states, reminding surgeons how to keep their visual perspective unaltered. He also discussed some of the findings from an upcoming 2016 paper [in-press] entitled, “Pushing the envelope” which reviews the developments in the areas of single port (uniportal) thoracic surgery in non-intubated patients. This along with his new textbook, have dominated the international thoracic surgery news in recent years.
As part of his discussion, he demonstrated the ease and feasibility of performing a complete and thorough lymph node dissection using the uniportal approach.
Complete paratracheal lymph node dissection in a non-intubated patient
He also presented several complex thoracic cases such as a bronchial sleeve resection for carcinoid tumor in a young, otherwise healthy female, as well as a double sleeve case, and a uniportal bronchovascular reconstruction. He discussed distal tracheal resection using high frequency ventilation jet in a non-intubated patient after resecting the carina – tracheal anastamosis and several chest wall resection cases via the uniportal approach. But the main portion of his talk was devoted to the specifics of non-intubated surgery – from anesthesia protocols to creating a anatomic (surgical) pneumothorax which eliminates problems of lung inflation during surgery. He discussed that while totally awake nonintubated surgery can be performed (with patients awake and talking), that he prefers the use of conscious sedation for patient comfort.
Nonintubated patient – VATS lobectomy
He highlighted the benefits of these approaches – with non-intubated surgical techniques allowing surgeons to operate on frailer, sicker patients who might otherwise be ineligible for surgery. He also talked about the benefits of uniportal surgery versus robotic surgery. Uniportal surgery is faster, and cheaper than costly robotic techniques that require lengthy patient positioning as well as the use of robotic tools that have to be replaced after 10 to 20 cases.
He also reviewed the relative contraindications for nonintubated surgery:
obese patients (BMI greater than 35)
patients with Malpati scores of 3 or 4 (difficult to intubate patients – in case of the need for emergent intubation)
patients with pulmonary hypertension (who will not tolerate permissive hypercapnia)
Masses greater than 6 cm in size
But he also reminded attendees that relative contraindications often change in the face of more experience.
Highlights from Day One of the Duke Masters of Minimally Invasive Thoracic Surgery conference in Orlando, Florida.
Orlando, Florida
The conference started out with a grim statistic, reminding surgeons that only 45% of all lobectomies in the United States are performed with VATS (or minimally invasive techniques). With that sobering reminder, Dr. Scott Swanson, a thoracic surgeon from Brigham and Women’s in Boston, Massachusetts began the first session.
Dr. Shanda Blackmon from the Mayo Clinic in Rochester, Minnesota gave the first presentation, entitled, “Thoracoscopic Lobectomy in 2015: Can we teach it better?”
She used part of the presentation to discuss her recent STS paper on credentialing for minimally invasive surgery. She also spoke about how the recent developments in technology (3D printing, creation of better anatomic models, surgical simulators and telementoring) have changed the learning process.
Dr. Shanda Blackmon with Dr. Thomas D’Amico.
Unfortunately, this lecture was disappointing. While conceding that all of these techniques were inferior to a surgical fellowship, there was little discussion on how these techniques are affecting the learning process (or how well students actually learn using these techniques). It was more about the newest toys and less about the actual learning process. With the resident hours limitations, resident’s concerns about how this is limiting their exposures to a wider range of pathology as well as difficulty attracting surgical residents to the thoracic specialty, it would have been interesting to hear how effective these new technologies are at addressing these concerns. It would also have been interested to hear the downside of these technologies, or a debate regarding the recent STS paper. However, Dr. Blackmon more than acquitted herself with a later presentation on the management of bleeding complications.
“Technical Aspects in 2015: 16 years of progress”
Dr. Thomas D’Amico discussed the development and advancement of VATS over the last two decades. He reported that an increase in procedures being performed by dedicated thoracic surgeons as one of the reasons for improved outcomes. He also gave this as a reason for the increased number of VATS lobectomies since general thoracic surgeons are more likely to be experienced and comfortable performing this procedure (versus general or cardiac surgeons). He questioned the accuracy of data reported to the STS general thoracic database, which, as we’ve previously mentioned – is only utilized by a fraction of American thoracic surgeons. All of this information is a documented fact – and has been presented here at Thoracics.org before (with relevant citations).
However, he ventured into more tenuous territory when he questioned global statistics and stated that the United States is better than all of Europe in regards to the adoption and use of VATS technologies. While this is demonstratively true (as previously reported in Italy), it comes close to being dismissive and close-minded as to the contributions of the remainder of the world.
The Duke Modified Approach?
The most interesting point of his presentation was his announcement of the Duke appropriation of Dr. Diego Gonzalez Rivas’ Uniportal technique. In true American (and Duke) fashion, this was done in a backhanded style, as he announced the creation and adoption of a “Duke modified uniportal approach” which is actually a two-port approach (with the second incision being made in the same intercostal space as the initial incision).
Duke modified uniportal approach
He concluded his presentation with a review of the newest technologies in bronchoscopy, and biopsy procedures as well as a few hints for a successful VATS lobectomy.
He advocates for a full mediastinoscopy for lymph node dissection immediately prior to VATS, for both staging as well as ease of mobilizing the left main bronchus from this position, reminding surgeons that mediastinoscopy remains the gold standard for tissue diagnosis, despite being greatly underutilized in recent years.
He advises surgeons to routinely dissect the hilum and main pulmonary artery to increase their experience and comfort level in handling the pulmonary artery while performing VATS. Lastly, he states, “Do the easiest part of the operation first” and save the harder parts until the area has been cleared.
However, there were two standout presentations during the morning session.
The first was Dr. Diego Gonzalez Rivas’ presentation on non-intubated uniportal lobectomies. The second was Dr. Robert Cerfolio’s presentation on his experiences with Robotic thoracoscopic lobectomies*. As one of the most prolific thoracic surgeons performing robotic surgery, it was particularly illuminating.
Dr. Diego Gonzalez Rivaas, Dr. Scott Swanson, Dr. Thomas D’Amico, Dr. Robert Cerfolio, Dr. Shanda Blackmon, Dr. Todd Demmy and Dr. Mathew Hartwig. (photo provided by Dr. Blackmon)
The effect of Obamacare and the fiscal health of the American health care system and thoracic surgery
Reflecting many of the recent changes in the USA healthcare system, many of the presentations as well as the Question and Answer panels with the American surgeons were dominated by cost considerations.
Notably, Dr. Cerfolio used the term “save money” over 8 times to describe recent changes in techniques (using only bipolar energy versus staples to control the pulmonary vessels, for example) used while performing surgery with a two million dollar robotic system. But this “wal-marting’ of thoracic surgery is just part of general overall trend in American medicine and surgery which is forcing large-scale, and painful changes to American health care practices for financial and fiscal reasons under Obamacare, “pay-for-performance” measures and the new ICD-10 system. There will be more changes and adaptations as surgeons attempt to adopt these new federal mandates and institutional policies.
Dr. Diego Gonzalez Rivas headlines the ALAT sponsored event this September.
Cardiothoracic surgeon and the coordinator and director of VATS Peru, Dr. Carlos Fernandez Crisosto cordially extends an invitation for all interested thoracic surgeons to attend VATS Peru. This event is co-sponsored by ALAT being held at the Hospital Essalud Tacna in Tacna, Peru on the 21st and 22 of September. The 2 day course includes a wet-lab for a hands on approach at teaching uniportal VATS with Dr Gonzalez Rivas.
Thoracics.org has written for additional information – so I will update this post as information arrives. To register – click here.
Corrections: as many readers know, I do much of my writing on the fly, in airports, waiting rooms etc. The sometimes results in spelling and grammatical errors. As always my sincere apologies.
Interested surgeons, don’t worry – there’s still plenty of time of register for the upcoming Minimally Invasive Thoracic Surgery course offered by the Duke Center for Surgery Innovation. The course will be held September 24th – 26th, 2015 at the Waldorf Astoria in Orlando, Florida.
Dr. D’Amico is organizing the event – which will surely be one of the highlights of the 2015 conference circuit. (Alas! No live surgery).
Several of his Duke colleagues will be presenting including Dr. Matthew Hartwig, Dr. David Harpole and Scott Balderson PA-C.
Surgery with Dr. Shu S. Lin and Dr. Matthew Hartwig at Duke University Medical Center
Dr. Diego Gonzalez Rivas will be talking about uniport lobectomies and segmentectomies in two separate segments, as well as participating in a case presentation.
Dr. Diego Gonzalez Rivas
Lovers of esophageal surgery take note: there will be an entire session devoted to minimally invasive esophageal surgery.
Dr. Todd Demmy will be talking about the use of 3D optics as part of a segment on recent advances in thoracic surgery.
Dr. Jiang Gening (Shanghai Pulmonary Hospital) performs dual port thoracoscopy using a 3D monitor
For more of the course schedule – please see the course agenda.
Dr. Henrik Hansen on how to streamline your surgery, and Dr. Diego Gonzalez Rivas at the Live surgery sessions of the Minimally invasive surgery conference in Naples, Italy.
Monaldi Hospital – If these walls could talk
Hospital Monaldi
It’s the second day of the conference at Monaldi Hospital which is located in Zona Ospedale, in the hills of Naples. The corridors of the 800 bed, 135 year-old former tuberculosis sanitarium give away few hints of the rich and interesting history of this institution. Commandeered by the Allies during the second world war, and containing a small but extensive pathology museum hidden in a back office, showcasing lung disease and many of the disseminated tuberculosis cases that were cared for here, one can only be intrigued by the stories contained within such as the first specimen in the collection, a five month’s gestational fetus (in utero) of a deceased tuberculosis patient.
Dr. Majorino, thoracic surgeon (who has worked at Monaldi Hospital for over 30 years and the head of the pathology department – in the museum of pathology
But we digress. As intriguing as all the tales of thoracic disease past are, we are gathered here today to advance the present and change the future of thoracic surgery here at Monaldi Hospital. As mentioned in a previous post, the surgeons here in the department of thoracic surgery have only recently adopted VATS surgery. Now after four years of practice, it is time to perfect it. For that reason, the first guest surgeon to perform the live demonstration today is Dr. Henrik Hansen.
Live Surgery with Drs. Hansen & Gonzalez Rivas
Dr. Henrik Hansen
Dr. Henrik Hansen
Dr. Hansen is a Denmark native who currently operates in one of Europe’s busiest VATS programs, located in Copenhagen. 80% of all the thoracic surgeries performed at his institution, Rigshospitalet. (In comparison, in most of Europe, VATS comprises of 52% of thoracic procedures, according to data presented by Dr. Hansen).
As the head of the minimally invasive surgery department at Righospitalet, he has mastered and streamlined the ‘traditional’ or three-port VATS approach, so there are no wasted efforts to maximize efficiency.
During a short lecture prior to surgery, Dr. Hansen discussed the literature, including a paper by WS Walker et al. in 2003, which compared cancer survival outcomes in patients undergoing VATS and standard open procedures. In the paper, the authors unequivocally recommended VATS as the operation of choice. It was this paper that led Dr. Hansen to aggressively pursue VATS for the majority of his patients. This position was not echoed in the official guidelines until 2013.
slide from Dr. Hansen’s presentation
Dr. Hansen allows that not all cases should be VATS cases; he prefers to perform sleeve resections via thoracotomies instead of VATS pneumonectomies, to prevent excess tissue loss in these cases).
Interestingly enough, residents in Dr. Hansen’s program learn VATS techniques without knowing the equivalent open surgical technique. He cites one of his thoracic surgery fellows as performing over 80 VATS procedures but only two thoracotomies. As a surgery purist, this disturbs me in some way, but then again – by much of Dr. Hansen’s criteria, I would be labeled a traditionalist.
For the morning’s case, he is performing a left upper lobectomy. (There are no other case details available to spectators in the auditorium)*.
He places the first port along the transverse line where the standard thoracotomy incision would normally be placed. He then triangulates the second and third ports, though only one actual trocar port is used, a 12 mm port for the camera insertion.
The “working” incision is the uppermost incision, which appears to be quite large, (but this may be a distortion due to my perspective – from a camera placed above the operating room table). At times he uses more than one instrument in this incision – and watching him, he seems that he could easily convert to single port surgery with equal efficiency. He almost forgets about his second port at times, and uses the remainder (3rd port) solely for the camera access.
He is precise and exacting in his movements, which is what makes his reliance on traditional VATS a little puzzling. Habit, mainly, I suspect because the surgery proceeds as if by rote. He really is the master of efficiency – and the case progresses quickly.
He uses ligasure for greater precision during dissection and isolation of tissue and minimizes the external torsion and retraction placed on the lung during hilar dissection, isolation and ligation of the pulmonary vasculature. He completes the procedure by performing an extensive lymph node dissection.
*Since I was outside of the operating room for this case, there are not very many operative photos, and none of Dr. Hansen operating.
Dr. Diego Gonzalez Rivas
As part of his pre-surgical lecture, “Recent advances in uniportal VATs,” Dr. Gonzalez reviewed the recent history of uniportal VATS as well as surgical tips for surgeons learning the technique. He also reviewed some of his more recent forays into surgery including complete uniportal resections using only the harmonic scalpel, and surgery on non-intubated (and awake) patients on nasal cannula. He discussed that the non-intubated project was a anesthesia counterpart to minimally invasive surgery. Since the risks and complications related to thoracotomies and other large incisions have been eliminated, it’s a normal progress to advance towards less invasive anesthetic techniques (since general anesthesia is associated with serious risks such as severe hypotension, peri-operative myocardial infarction and cardiovascular collapse). While rare, eliminating general anesthesia in many cases, greatly reduces the risk of adverse anesthesia-related events.
Surgical procedure**: Left upper lobectomy with radial lymph node dissection for a left upper lobe peripheral nodule in a 65 year patient.
Pre-operative CT scan
Surgeon: D. Gonzalez Rivas. Assistant Surgeon: D. Amore Scrub nurse: Guiseppe
1445: Initiation of patient prep (betadine). Patient is in a side-lying position.
1510 First incision (only incision)
1515: camera inserted, initial chest cavity inspection, lung deflated. No significant adhesions or unexpected findings. Hilar dissection commences, with attention being given first to the pulmonary artery. By 1605, the left upper lobe branch of the pulmonary artery has been divided.
Dr. Gonzalez Rivas operating with Dr. Amore assisting. Dr. Casazza looks on.
1608: Bronchus stapled (resected). Patient noted to have an incomplete fissure of the upper lobe.
By 1612: The lobe is out. Dr. Gonzalez proceeds with radical lymph node dissection – including the nodes of the paratracheal area/ aortapulmonary window. The surgical field is essentially dry, with small amount of liquified fat from electrocautery dissection with just minor oozing from the aortopulmonary window. He places a small amount of surgicell in the subcarinal space, after harvesting several nodes to show the best angle of approach (posterior).
Dr. Gonzalez Rivas examines the lung specimen after removal
During surgery, he spends a few minutes demonstrating alternative techniques to hold and manipulate several instruments in one hand so that surgeons can minimize wasted movements.
After final inspection, Dr. Dario Amore assumes the role of primary surgeon – to place the chest tube (1653). Lung is re-inflated, and the ventilator/ respiratory loop is used to determine that there is no air leak. Camera out of the chest at 1655.
Vital signs: HR 76, NSR B/P 121/62 Sats 100% No hemodynamic instability or hypotension during the case. EBL for the case is around 90ml (+/- 10 ml due to lack of graduations on the suction canister).
Skin incision closed: 1710
By 1715: Patient is awake, extubated and able to verbal respond to commands/ questions.
**Since I was present in the operating room, I was privy to a great deal more information than audience members in the auditorium such as the pre-surgical patient review, monitor readings, etc.
It’s the second day of the minimally invasive surgery course at Monaldi Hospital and there are a score of Italian physicians speaking in addition to the main events – Dr. Henrik Hansen and Dr. Diego Gonzalez Rivas.
Dr. Andrea Droghetti
One of the surgeons addressing the group this morning is Dr. Andrea Droghetti, a thoracic surgeon from Carlo Poma Hospital in Mantova, Italy. Dr. Droghetti is here to present the latest information on the Italian VATS registry, Vatsgroup.it.
Now long-term readers know how we love a registry! We have talked a lot about the STS thoracic database and how it is woefully underutilized, we’ve talked to other surgeons who have been involved in creating their own national databases, and we even created our own.
As we discussed during a recent interview, data collection and publication are essential for research and advancement of the specialty – and that all starts with accurate data and statistics. But not all data collection tools are alike.
It is interesting, and encouraging to hear about the successful enrollment of 57 Italian facilities into a nationwide VATS registry to track VATS surgery and outcomes.
The database itself is pretty detailed and much more involved than the high altitude database or even STS. There are multiple risk stratification measures as well as quality of life indicators. The database is also designed to allow greater categorization – of pre-operative conditions, staging, procedures, and just about anything else you can think of.
the registry is extremely detailed
Sounds like a great way to improve the quality of the data being used for research. After all, plenty of surgeons in Italy are participating – and as we know, getting surgeons to participate is always difficult. Even the STS database is lagging with just over 215 surgeons participating.
That’s awesome.. Now if only we could get more global participation!
Unfortunately, these kinds of large-scale projects never go off without a hitch – and during the presentation, we noted several potential pitfalls. One the major ones that Dr. Droghetti addressed was:
– Getting surgeons/ hospitals to participate
Out of 57 sites that are eligible to participate, only 44 are actually submitting data, and the data volumes have been measly – at just over 2 cases per day. (There is certainly more than two cases being performed every day.)
It also makes you wonder about the ‘randomness’ of the cases being entered. Maybe it’s one very diligent site entering cases everyday, or maybe it’s different sites entering their best outcomes – so the potential for data skewing seems to be there.
But since it seems like such a great project, Thoracics.org asked Dr. Droghetti to talk to us some more about this project, (translational issues during the conference made parts of the presentation unclear) and answer some additional questions. He was nice enough to talk to Thoracics.org for a few minutes.
From our own experience, we identified several other potential problems for the registry: so we posed these problems to Dr. Droghetti for his input.
Time consuming / repetitive entries for single patient
Data has to be entered on two occasions for the registry. The first submission takes approximately 30 minutes and the second – the post-surgical follow up – takes around ten minutes. The nice part about the project is that the patients actually participate in the follow-up evaluation and enter their own answers for the quality of life answers.
Now the QoL stuff is pretty unique to this registry, and the two entries per patient – allows for real-time time entry instead of retrospective review (which can get pretty skewed) so these are also strengths of the project. But..
After our own adventure with data collection as well as our experiences with the STS (cardiac) database, that this also immediately identifies this study as relying on 3rd party data entry. That’s because there is no surgeon under the sun that is going to spend that kind of time entering data when he could be seeing consults, performing surgery etc..
Third party data entry
is a dirty word in my book since it requires surgeons to rely on others to enter data about their outcomes. It’s also a negative because in many cases, the data entry is being done by a person who is more computer literate than medically literate. This means that they can’t always extrapolate data correctly from charts because they often don’t understand the data in the first place. This leads to unnecessary errors which skew data.
Dr. Droghetti and his team are addressing this issue, by appointing a specific “team member” but if that team member is someone specifically hired to enter your data (and not your anesthesiologist or other invested person) – then it’s no different from the third-party data entry systems we’ve seen before with STS (so expect similar problems). Computerized data entry tends to be tedious – and that might also be leading to the low participation rates we are seeing. With the amount of data to be entered, 30 minutes of drop down boxes might actually translate to more than an hour (just take a look at the cardiology PCI registry).
Hopefully these issues won’t impede Dr. Droghetti and his colleagues in their efforts. We wish them luck and look forward to seeing more publications based on this data.
No sign yet of the elusive Dr. Diego Gonzalez Rivas and Dr. Henrik Hansen, but they are both scheduled to speak (and operate) on the second day of the conference.
Instead, there were several local speakers to address the exclusively Italian crowd of surgeons, nurses and therapists. Several staff members at Hospital Monaldi, along with the past and current president of the Italian Society of Thoracic Surgery gave some opening remarks before starting the conference with several lectures on pre-operative and post-operative care.
Dr. Carlo Curcio was among the opening speakers and is the Director of this event.
Dr. Carlo Curcio talks about the history of minimally invasive surgery at Hospital Monaldi
During Dr. Curcio’s introduction, he discussed the fact that the thoracic surgery department at Monaldi were late adopters to video-assisted thoracoscopic surgery. In fact, the first VATS procedure was performed just a few short years ago in 2011. This makes it more remarkable to note that the department now performs over 80% of cases by VATS. As such ready converts, learning and applying the uniportal technique should be relatively painless.
The remainder of the morning lectures discuss topics in pre-anesthesia evaluation, pre-operative cardiac evaluation and post-operative care. Not much new ground is covered here, but the speakers acquit themselves with their through knowledge of the topic.
Dr Nespoli, (Anesthesiologist) talks about pre-anesthesia evaluation and stratifying global risk
Dr. Nespoli did a nice job of bringing in functional status & quality of life indications as part of the evaluation to predict post-operative complications. I always think that as medical professionals we tend to dress it up and overly complicate matters when we start relying on numbers such as Vo2 in addition to FEV1, DLCO and the like. I think inclusion of the 6 minute walk test, stair climbing and the shuttle walking test give a more global indication of the patient’s overall status which can be sometimes overlooked. (As noted by some of my peers, it’s fine if the DLCO is acceptable for surgical reception, but if you can not motivate your patient to perform the 6 minute walk as part of their pre-operative evaluation, then you should expect a whole host of post-operative complications).
The chair of cardiology spoke about cardiac evaluation – when to perform echocardiogram, exercise stress testing and when to proceed to move invasive measures such as coronary angiography. He also gave a thumbnail sketch of current strategies for patients on anti-platelets and similar therapies after prior revascularization (CABG, BMS, DES).
A nice portion of the morning was set aside for lectures regarding both pre and post-operative physical and pulmonary rehabilitation along with a discussion of the evaluation of the surgical literature relating to their therapies. As readers know, I think that both of these therapies (pulmonary rehabilitation more so) are essential in our lung patients, so it was good to see support for the specialties and services.
The remainder of the morning was dedicated to post-operative management strategies and the prevention of common complications. There was a nice talk about the use of intrathecal pain management after thoracic surgery by Dr. Rispoli but, in general, we have talked about much of this content in-depth at the site before, so I won’t go into detail again here.
For the same reasons, I didn’t even take notes at the lectures comparing VATS to open surgical techniques. There is such a wealth of existing data supporting the use of VATS even in surgical oncology that we don’t need to review that argument yet again.
Minimally invasive surgery course in Naples at Hospital Monaldi (April 23 – 24th, 2015)
Munich airport, Germany
I am on the last leg of a long journey to the beautiful southern Italian coastal city of Naples. Best known for its claim as the home of pizza and the nearby ruins of Pompeii, for the next few days, the department of thoracic surgery at Hospital Monaldi will be hosting surgeons (and one wee writer) from around the world for a two day course on minimally invasive and robotic surgery.
The event features live surgery demonstrations by Dr. Henrik Hansen and Dr. Diego Gonzalez Rivas, with a host of other speakers. For more details on the V corso VATS Monaldi Napoli dr Curcio dr Amore dr Casazza click the highlighted link for the full program.
Meanwhile, I will bring readers photos and highlights from the event.
Thoracics.org talks to the Brazilian Society of Thoracic Surgery and result isn’t what you might expect.
A very different article here at Thoracics.org! For starters, I’m the interviewee – which doesn’t happen very often. This interview was a joint collaboration after meeting and talking about issues in thoracic surgery with several Brazilian surgeons including Dr. Sergio Tadeu Pereira, at the ALAT conference in Medellin last July.
The positive outcome of a thoracic surgery depends on several aspects, among them is the teamwork, the harmony between the various professionals involved in making decisions and actions. All experts have an instrumental part in restoring the health and maintenance the patient’s life. Each with its due importance, towards a single goal. The SBCT ratifies such thinking, and this issue of the Journal conducted an interview with K. Eckland, an acute care nurse practitioner in thoracic surgery, writer, and also the founder of Thoracics.org” – a blog about thoracic surgery with an international focus. She has written several books on surgery in Latin America, including a community sociological examination thoracic surgery in Bogotá, Colombia.
In this conversation, K. Eckland talks about the future of thoracic surgery worldwide and recognizes the contribution of Brazilian surgeons for growth in the art.
Journal SBCT: For us at SBCT is a great pleasure to have their participation in our newspaper. How do you evaluate the specialty in Brazil? K. Eckland: First, I would like to thank the editors this paper for the invitation to forward my message to Brazilian doctors. More importantly, I would like to serve as call to action to all the experts and future thoracic surgeons. When I look at Brazil, I see the future of thoracic surgery. While, in my own country, our thoracic surgeons are aging with an average age of 60 years, Brazil is full of young, dynamic and innovative surgeons.
Journal SBCT: This predisposition to new techniques of many the Brazilian thoracic surgeons implies an increase in research?
K. Eckland: The high fluency in minimally invasive techniques (in Brazil) combined with some of the largest academic and clinical settings worldwide, outside China, affords unique opportunities in research, development and discovery. Brazil is already home to many of the modern masters of thoracic surgery, names that resonate worldwide.
These surgeons have brought Brazil to the forefront, but it is up to the newest crop of thoracic surgeons to maintain Brazil’s forward momentum for the future. However, this is hampered by a lack of awareness of the contributions of many Brazilian and other Latin American surgeons.
As a foreigner, writing about developments within the international surgical community, I have noted a large dearth in published research from much of Latin America including Brazil. What research I do find, is often not widely dispersed or readily available to the rest of the world. It has taken several years and many thousands of dollars for Cirugia de Torax to acquire and publish information about your many triumphs. However, this is not the most efficient way for research to be disseminated.
Journal SBCT:In addition to increased investment in research, what more should be done in its assessment to mitigate this gap in publications and contributions (to the specialty of thoracic surgery)?
K. Eckland: It’s possible to change this story from one of limited international exposure to greater recognition. But for that to happen, several things need to occur. Firstly, the momentum must be Brazilian thoracic community to participate and publish research on a large-scale.
Surgeons in São Paulo, for example, have unique opportunities to publish practice-changing work. The Department of Thoracic Surgery, University of São Paulo tracks more thoracic cases in a year than many American institutions have access in a decade. This gives greater impact to studies from this institution than anything that their (North) American colleagues could expect do.
Second, Brazilian surgeons need push for further publication in international journals, and in the international literature language, in English.
Lastly, surgeons need to look outside their corner of the globe and present their findings internationally and outside Latin America on a greater scale. More groups of Brazilian surgeons should attend international conferences to gain knowledge,and take the opportunity to spread their own knowledge and research findings. Surgeons should not depend on the United States and Europe to take the lead in surgical innovation or research.
There is no reason why these findings will not occur at home, but research needs to be part of your daily practice. It should be more than reading the occasional surgical journal. It should be a part of active problem solving and solution-seeking.
Journal SBCT: The wide practical experience associated with the host new techniques can be considered as a basis for the growth of the specialty and development more innovative research in Brazil?
K. Eckland:
For this to happen, each surgeon needs ask yourself**:
– How can I improve my practice? – How can I improve the lives of my patients?
– What can I do to identify and document the phenomena I’m seeing? – What we are doing now that we need to change? How can we implement these changes? How does this apply to people outside my immediate environment?
Once a potential search area is identified, other questions to ask include:
How I can improve my specialty? How can I represent my country to the world? Sometimes the answers
involve the development of new technologies, sometimes a reframing of the information we already know,
to apply the new clinical scenarios. Other times, we simply need to identify the phenomena and document it to serve as guidance to other professionals. That is what drives the research, and this combined insight with professional curiosity are essential for growth within the specialty. By embracing these concepts, we can begin a new era of thoracic surgery in Brazil and worldwide.
* Corrections to the English translation have been made for ease of reading. This is an excerpt from a larger interview.
** This is how we identify research to discuss and publish here at Thoracics.org/ Cirugiadetorax.org
An Ordinary Afternoon at Shanghai Pulmonary Hospital
The Uniportal VATS course continues for much of the rest of the week (March 9 – 20th).
Dr. Gonzalez Rivas performs uniportal lobectomy
After Dr. Gonzalez completed his second case today, we had a short break before the start of his next case. I took the opportunity to peek into the operating rooms to give everyone a better idea of what surgery at Shanghai Pulmonary Hospital is like. There were 32 surgeries scheduled for today. I couldn’t watch them all, of course, but at 2:30 pm – the operating rooms looked something like this:
In OR #10 – surgeons were completing a right-sided thoracotomy (bilobectomy with pulmonary artery resection secondary to tumor invasion).
OR #9 – was in the midst of a subxyphoid resection of a mediastinal mass
OR# 2 was finishing up a “traditional” three port-VATS case for lung resection
OR #7 was finishing ligating the last branches of the pulmonary artery for a giant-sized left upper lobe tumor requiring open thoracotomy
OR #8 was performing a 3 segmentectomy of the left upper and lower lobe by dual port thoracoscopy using a 3-D monitor
Dr. Jiang Gening performs dual port thoracoscopy using a 3D monitor
OR # 5 sternotomy with resection of a large thymoma
OR # 4 subxyphoid approach for mediastinal tumor resection in a patient s/p previous right upper lobectomy
OR # 1 uniportal lung resection (left lower lobectomy)
OR #11 uniportal lung resection – right lower lobectomy
Dr. Hu
OR # 12 just wheeled in a patient for a right sided pluerodesis after spontaneous pneumothorax.
I also passed a patient being wheeled to the post-operative recovery room, when 4 more patients were recuperating.
I’ll be writing a couple case studies to publish over the next few days, so check back soon.
Shanghai Pulmonary Hospital is a dream come true for a thoracic surgery aficionado like myself. Twelve operating rooms, a 30 ICU beds, 30 to 40 operations per day and over 40 staff surgeons means that there is always something interesting going on down the hall.
Am case presentations is like a review of Robbins’ pathology. Bilateral nodules, ground glass opacity nodules, giant-sized tumors, mediastinal masses of all types and atypical presentations abound. By tradition, all tuberculosis cases must come to the medical complex at Shanghai Pulmonary Hospital because they have a designated tuberculosis hospital on site. Even with other facilities competing for some of the pathology, there is plenty to go around, and I am able to see a couple of lung abscesses as well as several varieties of cavitary lesions. I am sure that there is still a wealth of untapped pathology for me to explore, but I suspect that more interesting infectious cases and occupational diseases are probably confined to the more distant provinces.
I briefly talk to one of the surgeons here, who is from Kashdar region, on the far western side of China. Kashdar is located in one of the more mountainous regions of China, which was part of the famous Silk Road trade route explored by the likes of Marco Polo more than half a millennia ago. We discuss the region and compare it to its American counterpart of West Virginia. It’s not a perfect analogy but there are enough similarities to help me for a picture of life, and industry there. That is where the mines are concentrated, and that is where I might find the black lung disease, the silicosis and similar type diseases, though the surgeon I speak with reports that the rates of occupational disease for this occupation to be quite low. Given the dangerousness of underground mining, I wonder if many of the miners worry about living long enough to see a chronic disease like black lung. I don’t know enough about China to ask a lot of the other interesting questions that are swarming in my mind, but I wonder about mesotheliomas and other diseases related to all the heavy industry that forms the backbone of the booming Chinese economy. I wonder about the prevalence of empyemas given the pollution levels and the closeness in which many people are forced to live. It seems like it would be a daily surgical feast, but I don’t know a polite way to ask directions to the hospital with the pus-filled buffet.
My hosts also tell me regretfully that they also only see a limited amount of esophageal cancer because many people are misled by the name of the facility, and are unaware that esophagectomies are performed here. One of the surgeons looks so woe-begotten as he tells me this that I know he has the same love of that surgery as I do – that feeling of joy when surgical planning, pre-operative optimization, surgical skill and aggressive post-operative care come together flawlessly for an uncomplicated post-operative course in a complex case. It’s not just satisfaction with a job well-done but pure joy at seeing our patients walk out of the hospital and back to the regular lives.
I am here at part of the Uniportal VATS conference with Dr. Diego Gonzalez, but it’s also an opportunity to literally wander the operating rooms at will, listen to case discussions and interview surgeons as I encounter them. I always joke about feeling like a kid in a candy store, now I really am. If I hear a particularly interesting case during am rounds, I am welcome to come into the operating room, watch the case, listen to the discussions and talk to the surgeons.
As one of the largest general thoracic surgery departments in the world*, it would be impossible for me to know and present all staff surgeons in the few days that we are here for the Uni-portal Surgery conference. Instead I would like to highlight a just a few of the interesting and talented surgeons at this busy facility.
Dr. Jiang Gening – Chief of Thoracic Surgery
Dr. Jiang is the head of one of the world’s largest thoracic surgery services, but it doesn’t seem to faze him. Then again, he’s been here at Shanghai Pulmonary Hospital (SPH) since he came here to train in 1982. At that time, the thoracic surgery department was just a fraction of the size it is today.
As resident, staff surgeon, and then now Chief for the last ten years, Dr. Jiang has seen numerous changes, many of which have occurred in just the last few years. Volumes have dramatically increased, resulting in annual hospital construction to expand the operating rooms. A 16 bed thoracic surgery department has grown to over 250 beds.
Dr. Jiang has a strong vision of where his hospital ranks in the world, and where he would like it to be. He sees a strong future for this facility as an international leader in thoracic surgery and clinical research, and he has been working aggressively towards these aims.
Dr. Jiang has trained with Dr. Patterson (Bowman Grey, St. Louis) and other leaders in thoracic surgery in Boston and Los Angeles, and he encourages his surgeons to do the same. He strongly supports surgical development among his staff such as bringing leading surgeons like Dr. Diego Gonzalez Rivas to train staff in the most up-to-date procedures.
As a surgeon himself, he enjoys the more complex cases, the larger surgeries for the challenges they bring. When I mention, ‘chest wall resection,’ he smiles and nods before Dr. Wang can translate.
He is also very interested in expanding the lung transplant program but acknowledges that his facility has difficulties in obtaining donors now that China has discontinued the policy of using incarcerated people for organ donation. Organ procurement has been complicated by the traditionally low rates of voluntary donation in Chinese societies. As Dr. Jiang explains, Chinese culture and many Chinese families has a hard time recognizing and reconciling with the concept “brain death” in the absence of physical death. This means that Dr. Jiang and his program are focusing on donation after cardiac death and ex-vivo implantation. But this too is problematic – the scarcity of organs means that despite being in a metropolitan area of almost 30 million, surgeons may have to travel to Beijing or other locations for available organs. Often on arrival, these organs are not in suitable condition for transplantation. Another problem is the reluctance of Chinese insurance companies and third-party payers to cover the cost of ex-vivo support. Dr. Jiang acknowledges that his facility has several large hurdles to overcome if Shanghai Pulmonary Hospital is to become the transplant center for Singapore, Korea and the rest of Asia, as he envisions.
I am hoping to find my way into Dr. Jiang’s operating room. I have been advised by the Taiwanese surgeons that Dr. Jiang is widely-known and admired for his ‘nimble fingers’ so I want a chance to see him in action.
Dr. HaiFeng Wang
Dr. HaiFeng Wang is a very nice 41 year old surgeon who assisted in translating during the interview with Dr. Jiang. It was strange, as soon as I started talking to Dr. Wang, it was like we recognized each other. I immediately knew that we would see eye to eye. And so it was, as he presented his daily cases, and we discussed the findings, the planned surgeons and related research. So it seemed natural for me to spend the day with Dr. Wang in the operating room.
Like Dr. Jiang, Dr. Wang is from Shanghai. After completing a combined medical school and internship program, (with training in urology), Dr. Wang decided to switch to thoracic surgery (a decision that cirugia de torax wholeheartedly supports).
After receiving the World Health Organization fellowship, he traveled to Australia to train with Dr. Peter Clarke at Austin Hospital in Victoria. He focused his studies on the surgical control of cancer. More recently, in 2013, he received the Graham fellowship (from AATS) to study with Dr. Mathisen in Boston, Massachusetts. He also spent one month with Dr. McKenna in Los Angeles and another month with Dr. Patterson in St. Louis.
His areas of interest include minimally invasive surgery, tracheal surgery, lung transplantation and the diagnosis and treatment of ground glass opacities.
HIs first surgery of the day is an asymptomatic middle-aged patient with an incidental finding[1] of a large bronchiogenic cyst in the right middle lobe.
On the CT scan, it looks like an egg-yolk with solid material within a fluid-based cyst. The initial suspicion is a possible aspergilloma but this presumptive diagnosis is eliminated during surgery based on tumor appearance.
Frozen section is requested intra-operatively but the results of that only deepen the mystery when a diagnosis of a possible sarcoma is suggested by the pathologist. The resection is completed quickly, but the mysterious aspect of the case has me intrigued as we wait for the final pathology.
Update: Final pathology completed 3/17/2015. The report says pulmonary lymphangioma, a rare disease in the lung, and the pathologist says that the cyst itself is actually the lymphangioma, not only the small nodules we see inside the cyst wall.
The second case is a young patient with a GGO (ground glass opacity) in the right upper lobe. A needle biopsy confirms that the mass is a malignancy, an adenocarcinoma. This surgery is also smooth and uneventful.
There is a third case still scheduled, (and interesting too!) but unfortunately, it’s time for me to race back to the hotel, do some writing before I go to sleep to get ready to do this all over again.
I’ll be here in China for three weeks, so this isn’t the last you will hear about Thoracic surgery in China or Shanghai Pulmonary Hospital.
[1] In China, a CT scan is a fairly affordable diagnostic tool ($40) for most middle class Chinese citizens. Healthcare among certain classes, is also consumerized to a degree that the United States is only beginning to approach. This means that many Chinese residents have CT scans with the same gravitas that a many of us may approach a new hairstyle, or similar type purchase.
* noncardiac. There may be larger combined CTS departments.
Note: this article has been edited for corrections due to translational and other inaccuracies.
on location with Dr. Diego Gonzalez Rivas as he embarks on his latest project: teaching uniportal VATS to surgeons in China
Arriving at Wenzhou
Right now, I am on a Air China flight heading to Beijing after finishing up the first date on Dr. Diego Gonzalez Rivas, “7 Days, 7 Cities” Uniportal VATS instructional tour. I am here at the invitation of Dr. Gonzalez to chronicle the making of his second documentary film.
with Dr. Gonzalez Rivas and Spanish filmmaker, Danilo Lopez
Our first stop was Wenzhou, China where Dr. Gonzalez Rivas gave a lecture and performed a right middle lobectomy on a patient with a large lung lesion.
Dr. Gonzalez Rivas reviews patient films in consultation with local surgeons
It’s a different kind of experience for me, and it takes getting used to – knowing where NOT to stand, or walk so Danilo can get his shots. The whole live camera thing is a little bit off-putting. Everything is a production, nothing is left to chance. It can’t be – like the title of the film – it’s a fast trip, in and out. But it’s also an amazing experience. Danilo is amazingly talented (and very nice), and it’s hard to reconcile what looks like every day, run of the mill stuff with the footage he manages to capture. It’s strange and wonderful to see surgery thru his eyes. It’s also nice to have some camaraderie in the operating room as ‘media’.
The case went beautifully – another uniportal success story!
Dr. Gonzalez Rivas performing a surgical demonstration in Wenzhou, China
Goodbye Wenzhou – now off to Beijing!
**”I’m with the band” is my own lame joke because it says everything about my personality that I liken spending time in the operating room with a thoracic surgeon akin to traveling on the road with Mick Jagger back in his heyday.
the latest trailer about the documentary film on single port surgery and information about an upcoming training course.
For everyone that’s interested in learning more about the single port surgery technique, as taught by its creator, Dr. Diego Gonzalez Rivas – here’s another opportunity which may be closer to home for some readers.
Now, which way to Berlin?
The February conference takes place in Berlin, Germany on the 19th thru 21st. While Dr. Gonzalez Rivas, Dr. Delgado and Dr. Prado are headlining the event, other prominent thoracic surgeons such as Gaetano Rocco (Italy) and Alan Sihoe (Hong Kong) will also be lecturing at this event.
The conference includes live surgery demonstrations as well as a wet-lab for hands-on practice.
Deadline for registration is February 6th. Interested surgeons should contact:
R. Mette, M. Schmitt Charité – Universitätsmedizin Berlin Tel. +49 30 450 622 132 | Fax +49 30 450 522 929 E-mail: thoraxchiurgie@charite.de
In other news – the newest trailer for the documentary about Dr. Gonzalez Rivas and his work was recently released. I encourage all thoracic surgery personnel to see (and promote) this movie, which highlights the work of one of our own.
While Cirugia de Torax was unable to be in attendance and provide on location reporting and news, I would like to present some highlights from the recent event for our readers..
information about the upcoming VATS symposium in Cambridge, UK – with featured speakers Dr. Diego Gonzalez Rivas and Ian Hunt.
Another conference/ educational announcement for all residents, fellows and interested thoracic surgeons. This course is sponsored by the United Kingdom’s National Health Service and is being held in Cambridge, UK at Papworth Hospital this November. There is parallel content for nurses and other thoracic surgery personnel.
Internationally known Spanish surgeon Dr. Diego Gonzalez Rivas as well as native surgeon Mr. (Dr.) Ian Hunt of St. George’s Hospital in London, will be part of the faculty teaching this course.
Dr. Gonzalez Rivas will be discussing single port surgery in addition to performing a live case on the second day of the symposium.
Mr. Hunt will be discussing how to perform a total lymphadenectomy, as well as lymphadenectomies on more complicated cases.
Additional speakers will be discussing topics including issues in thoracic anesthesia, management of bleeding (in VATS and other minimally invasive surgery), and managing other operative complications.
Come to Boston this November and meet some of the Living legends and masters of thoracic surgery.
This November in Boston, MA
Unfortunately, due to time and financial constraints, Cirugia de Torax will not be in attendance. However, since this conference is the Who’s Who of Thoracic Surgery with Drs. D’Amico, Cerfolio, McKenna, Jones and Sugarbaker as featured speakers – I strongly urge interested thoracic surgeons, nurse practitioners, physician assistants, medical students/ residents/fellows and nurses to attend.
Attendees are also encouraged to submit photos and highlights from this event. All of the details have been copied from the original announcement below.
Dr. Alec Patterson and Dr. David J. Sugarbaker along with the entire Program Committee, invite you to attend the Focus on Thoracic Surgery: Novel Technologies in Lung Cancer meeting in Boston from November 21-22, 2014. The program includes a faculty of internationally recognized experts in lung cancer and applications of new technology for its surgical management.Register and reserve housing before October 23, 2014 and benefit from lower registration fees and a guaranteed hotel room in Boston.
Education is a key element of the AATS and providing reduced registration fees for residents and fellows helps strengthen our mission. We are committed to continuing high quality AATS educational activities. Take advantage of the reduced registration. If you register before October 23rd, the registration fee for residents/fellows/medical students is only $75. After October 24th the fee increases to $100.
Updates in multi-disciplinary care from the Foundation for the Advancement of Cardiothoracic Surgery at the 2014 Cardiovascular- Thoracic Critical Care conference in Washington D.C
Washington D.C.
While the majority of the 11th annual conference by the Foundation for the Advancement of Cardiothoracic Surgery was focused on cardiac surgery topics, Dr. Namrata Patil, the Director of the Thoracic Intermediate Care Unit (and thoracic surgeon) at Brigham & Women’s Hospital in Boston, MA gave an excellent presentation on the management of critically ill thoracic surgery patients.
Attendees at the Factscare conference
Early Intervention, Rapid Response versus Failure to Rescue
Rather than an exhaustive review of the literature, Dr. Patil’s lecture gave a much-needed bedside perspective on the care of these patients. She stressed the importance of remaining hypervigilant as well as the need for early identification and early, aggressive intervention in these patients.
While the majority of the conference focused on ECMO, LVADs and transplant patients, Dr. Patil’s presentation was a crucial reminder of the pitfalls of falling into complacency when caring for our vulnerable thoracic population. While these patients do not always attract the attention that patients with artificial life support mechanisms (like Heartmate II patients), it is a mistake to think that these patients are less fragile or critically ill. By definition, these lung patients, (who frequently have underlying lung disease and other serious comorbidities) are compromised – and acutely ill.
This means that clinicians need to shift their focus from the intensive care unit to the telemetry and floor units without losing their critical care perspective. Too often, when patients are transferred to step-down units, critical care concepts are relaxed because of preconceptions based on assumptions regarding patient acuity. But as anyone with thoracic experience knows, a ‘stable’ patient can easily descend into a downward spiral if not managed aggressively.
“Is this acceptable to me?”
As Dr. Patil reminds us, clinicians need to be vigilant when caring for patients of all acuities. She’s not asking us to chase ‘zebras’ but instead gently reminding clinicians not to dismiss important clinical findings. Instead of attributing low-grade fevers and cloudy X-rays to atelectasis, intervene early to prevent the next step in deterioration; pneumonia or respiratory compromise. Remain vigilant to detect later stage complications instead of racing to discharge on marginally functional patients.
She encourages clinicians to educate patients, providers and families; to teach as part of efforts to prevent complications. She also advocates for the increased development of protocols specific to the thoracic surgery population and better communication with all members of the care team; including the patients and their families.
Ethics and Advocacy
She also spoke on the ethics of caring for these patients and advocating for the rights of patients, particularly elderly patients. In an era of increased awareness of POAs, and Advance Directives, there is often a push (from the hospital administrators, nursing staff, and other medicine specialities) to advocate for a Do Not Resuscitate (DNR) code status. Unfortunately, many of the people pushing for this designation have forgotten that this is part of a patient’s right – and automatically assume it should be a decision based solely on age. This ageism is contrary to our duty to protect, to advocate and our patient’s right to self-determination.
This ageism also ignores one of the widely held truths in our society; that for many people, “Age is just a number” and that the patient’s functional status may not reflect their actual age. We’ve all met 50 year-old patients who have been debilitated by chronic and prolonged illnesses and may have a much poorer functional status than an active, alert 80 (or even 90) year-old patient. Assigning or encouraging a DNR status in these patients based on age is not only incorrect, but unethical.
In a time of an increasing push for standardized, ‘one-size-fits-all” care and ‘Angie’s List” style medicine with emphasis on short length of stay and rapid discharges, Dr. Patil’s more personalized approach will actually engender better clinical outcomes by reducing morbidity, mortality, and re-admissions. It also helps clinicians, like myself, sleep better at night – knowing we have been as aggressive as possible to prevent complications in our patients.
Using 3rd world skills to augment diagnostic technologies
Dr. Patil’s talk also highlighted the importance of clinical judgement and clinical skills in caring for these patients. While heart patients routinely have advanced life support and hemodynamic monitoring devices such as Swan Ganz catheters, NICO and telemetry, excellent clinical skills are needed when relying on less invasive measures such as physical exam and basic radiology. Her background, of practicing medicine in India (and the related limitations in resources) has added to her skills as a clinician and diagnostician without relying on expensive or extensive use of technology. In an era of rapidly expanding concerns regarding resource management and cost-containment, this skill is crucial, just at a time when new medical school graduates are focusing more on advanced diagnostics over basic clinical assessment skills.
Dr. Namrata Patil
Dr. Namrata Patel, thoracic surgeon
Dr. Namrata Patil is a polyglot (English, Urdu, Spanish, Hindi and Marathi) with extensive surgical and intensive care experience. Originally trained as an ENT surgeon, over the years she has added to her body of knowledge with residencies in Burn/ Trauma, Psychiatry, Thoracic Surgery and Surgical Critical Care.
She is an associate surgeon at the prestigious Brigham & Women’s Hospital in Boston, MA as well as a Professor of Surgery at Harvard Medical School.
Her most recent list of publications reflect her wide range of training and experience.
I have asked Dr. Patil for a copy of her presentation for use on this site. As soon as these slides are published at facts-care.org, I will provide a link for readers.
a new film showing the life-changing efforts of one thoracic surgeon.. It’s about time!
Dr. Diego Gonzalez Rivas
I am excited beyond words to hear that my long-time hero and champion of modern-day thoracic surgery, Dr. Diego Gonzalez Rivas, is featured in a new documentary film, “This is Life”. The film follows the life of a patient undergoing a single incision thoracoscopic lobectomy. The film is being released this December.
I eagerly await the film – and am happy to see thoracic surgery (and Dr. Diego Gonzalez Rivas) get their due. For too long, our humble specialty has been overlooked for the more ‘glamorous’ cardiac surgery. This oversight has led to a dire shortage of thoracic surgeons in many parts of the world.
Hopefully, this is only part of an ongoing effort to have thoracic surgery recognized as an independent and complex surgical specialty requiring extensive knowledge, advanced skills and training. It is not an ‘add-on’ for cardiac surgeons with insufficient cardiac consultations.
Dr. Gonzalez Rivas and single-port surgery in Shanghai, China
For those of you hoping to see – and learn from the best, Dr. Gonzalez Rivas will be spending much of the month of October in Shanghai, China at the “National Uniportal VATS Training Course & Continuing Medical Education Forum on General Thoracic Surgery” which runs from October 8th to November 8th, 2014 at Tongi University.
Alas! To my eternal regret, Cirugia de Torax will not be in attendance. However, I will have sources on the ground – and hope to post more information during the conference,
upcoming minimally invasive thoracoscopy course for my Spanish speaking readers at the Clinica Alemana in Santiago, Chile
Cirugia de Torax won’t be there this year – but Clinica Alemana, one of the highest ranked hospitals in Latin America is holding another course on Minimally invasive thoracic surgery this October.
The facility, which is in Santiago, Chile is also home to Dr. Raimundo Santolaya, who was one of our first interviews here at Cirugia de Torax.
Featured speakers include Dr. Miguel Congregado (Seville, Spain), Dr. Pablo Moreno de Santa Barajas (Vigo, Spain), Dr. David Smith (Buenos Aires, Argentina) and Dr. Patricio Varela of the University of Chile.
Course content is sponsored by the Chilean Society of Respiratory Diseases, The Chilean Society of Surgeons, the American College of Surgeons and the Faculty of Medicine at Clinica Alemana – University of Desarrollo.
Interested surgeons should contact the clinic at this address: dmedico@alemana.cl or cursosclinicos1@alemana.cl or enroll on-line at www.alemana.cl
The event is jointly sponsored by M. Kaplan, Johnson & Johnson, IMP, Solumed and Stryker.
Talking about the roles of traditional VATS, single port surgery and robots in modern thoracic surgery.
The Ethicon (Johnson & Johnson) sponsored session was by far, the best of the conference – and an excellent overview of modern technologies in thoracic surgery.
starting with Dr. Ricardo Buitrago (purple tie), Dr. Diego Gonzalez Rivas (blue tie) and Dr. Mario Ghefter (pink tie) are changing the future of thoracic surgery
Dr. Diego Gonzalez Rivas
“Is uni-port surgery feasible for advanced cancers?” Short answer: Yes.
The first speaker, was Dr. Diego Gonzalez Rivas of Coruna, Spain. He is a world-renown thoracic surgeon and innovator of uni-port thoracoscopic surgery. He discussed the evolution of single port surgery as well as the most recent developments with this technique, including more advanced and technically challenging cases such as chest wall resections (2013), sleeve resections/ reconstructions (2013), pulmonary artery reconstructions (2013) and surgery on non-intubated, awake patients (2014).
Experience and Management of bleeding
The biggest challenges to surgeons learning this technique is management of bleeding. But as he explained in previous lectures, this can be overcome with a direct approach. (these lectures and YouTube videos, Dr. Gonzalez explains the best ways to manage intra-operative bleeding.) In the vast majority of cases – this did not require deviation or conversion from the uni-port technique.)
As surgeons gain proficiency with this technique which mirrors open surgery, the only contra-indications for surgical resection of cancerous tissue (by single port) are tumors of great size, and surgeon discomfort with the technique.
Dr. Mario Ghefter
My favorite lecture of the series was given by Dr. Mario Ghefter of Sao Paolo, Brazil. While his lecture was ostensibly about video-assisted thoracoscopy (VATS), it was more of a retrospective vision and discussion of the modern history of thoracic surgery as seen through the eyes of a 22 year veteran surgeon.
He talked about the beginnings of VATS surgery and the contributions from such legends as Cefolio and D’Amico, including the 2005 paper – and modern-day thoracic bible, “Troubleshooting video-assisted thoracoscopic lobectomy (Demmy, James, Swanson, McKenna and D’Amico).
Dr. Ghefter also talked about how improved imaging and diagnostic procedures such as PET-CT and EBUS have been able to provide additional diagnostic information pre-operatively that helps surgeons to plan their procedures and treatment strategies more effectively.
Dr. Mario Ghefter
As a counterpoint to both Dr. Gonzalez and Dr. Buitrago, Dr. Ghefter acquitted himself admirably. He reminded audience members that even the newer technologies have some drawbacks – both as procedures and for the surgeons themselves.
He also successfully argued (in my opinion) that while the popularity of procedures such as multiple port VATS and even open thoracotomies have dropped drastically as thoracic surgeons embrace newer technologies, there will always be a place and time for these more traditional procedures.
Dr. Mario Ghefter is the Director of Thoracic Surgery at Hospital do Servidor Público Estadual – Sāo Paulo and on staff at the Hospital Alemão Oswaldo Cruz.
Dr. Ricardo Buitrago
Native Colombian (and my former professor), Dr. Ricardo Buitrago is acknowledged as one of the foremost experts in robotic thoracic surgery in Latin America.
During his presentation, he discussed the principles and basics of use of robotic techniques in thoracic surgery. He reviewed the existing literature surrounding the use of robotic surgery, and comparisons of outcomes between thoracic surgery and traditional lobectomy.
He reviewed several recent robotic surgery cases and the use of robotics as a training tool for residents and fellows.
While he mentioned some of previously discussed limitations of robotic surgery (namely cost of equipment) he cited recent studies demonstrating significant cost savings due to decreased length of stay and a reduced incidence of surgical complications.
He also discussed recent studies (by pioneering surgeons such as Dr. Dylewski) demonstrated short operating times of around 90 minutes.
Highlights from the first day of the ALAT conference in Medellin, Colombia: the size matters debate and personalizing chemotherapy for advanced cancers
Medellin, Colombia
It’s a multidisciplinary conference that attracts a range of specialists (critical care medicine, pulmonology, oncology, surgery, rehabilitation medicine) that includes doctors, nurses, respiratory and physical therapists from across Latin America.
Much of the conference is divided by discipline in lecture series: pulmonary medicine, critical care, sleep medicine ect.. Much of it is geared to pulmonary medicine but the are topics that appeal to everyone.
The first day is dedicated to discussions and debates on the latest research and development in chronic obstructive pulmonary disease (COPD), treatment of multidrug resistant Tuberculosis (MDR-TB and XDR-TB strains), tobacco cessation, ARDS and pulmonary rehabilitation.
Bypassing most of this for the thoracic surgery lectures series, Dr. Gustavo Lyons is moderating several discussions on thoracic surgery topics. Dr, Lyon’s is the Director of the Thoracic Oncology division of ALAT, and Assistant Medical Director at the Hospital Britanico de Buenos Aires (British Hospital of Buenos Aires).
Dr. Gustavo Lyons of Buenos Aires, Argentina
Dr. Rafael Beltran of the National Institute of Cancer gave the first lecture which was a discussion and presentation of research findings regarding the use of wedge resections (segmentectomies) versus lobectomies for cancer resection.
Dr. Rafael Beltran with Dr. Carlos Carvajal
Dr. Beltran discusses some of the discrepancies in cancer detection and treatment world-wide. Early diagnosis is a critical part of this In Colombia, only 1/20 patients is eligible for surgical treatment at the time of detection where as that number falls to 1/5 in the United States. (UK is 1/10 respectively).
The remainder of patients cancers are diagnosed at advanced stages when surgery is no longer a viable option.
During his talk, Dr. Beltran reviewed the literature surrounding lobectomy versus wedge resection (limited resection) for definitive cancer treatment. While the majority of the thoracic surgery community agree that a lobectomy or anatomical resection is necessary for larger lesions, Dr. Beltran reviewed the literature relating to small lesions (less than 2 cm) when surgeons are able to get substantial margins with segmentectomies.
However, as Dr. Beltran reminded the audience, smaller wedge resections did not have a lower morbidity and mortality in comparison with lobectomies.
These mixed results suggest that segmentectomies be reserved for patients who would otherwise be ineligible for surgical resection due to advanced age/ frailty (75+ years), poor functional status and poor respiratory function.
Dr. Claudio Martin, an oncologist from Buenos Aires, Argentina also spoke as part of the block section – about the personalizing cancer treatment therapies, particularly in advanced stage lung cancers. Personalization in this stance refers to the need to draw biomarkers and perform genetic testing. This allows doctors to use targeted therapies – which is very effective in treating oncogene driven cancers.
Biomarker testing allows oncologists to determine what mutations (if any) are present (such as the Kras mutation). This also helps the treatment team determine which chemotherapy agents will be the most effective (and least toxic) to patients.
A review of published literature shows that this approach – incorporating personalized therapies for cancer treatment based on the presence or absence of specific biomarkers or mutations shows a survival benefit of approximately 20 additional months when compared to patients receiving the standard regimen.
Cirugia de Torax criss-crosses the globe to bring you news about the latest and greatest in thoracic surgery
ALAT in Medellin
It’s shaping up to be an exciting summer at Cirugia de Torax. We will be heading to Medellin for the annual conference of the Latin American Association of Thoracics.. The Who’s Who of Latin American thoracic surgeons – so I hope to see some familiar faces and catch up on their ongoing projects..
HITHOC with Dr. Isik
After the conference, it’s a quick trip home before heading over to Turkey to interview Dr. Ahmet Feridun Isik to hear more about his HITHOC program.
Dr. A. Feridun Işık and his team perform cytoreductive surgery and the HITHOC (HIPEC) procedure
Dr. Isik and his colleagues have been very gracious during our correspondence – and I’ve been planning a trip to talk to him in person (and see his program) since I first read his work.
an upcoming conference on thoracic oncology in New York, New York
Mark your calendars and clear your schedules for the first weekend in October! The Advances in Thoracic Surgical Oncology course is October 3rd – 4th, 2014.
Unlike many of the association conferences – this conference is not geared at the thoracic surgery specialty or cardiothoracic surgery crowd in its entirety.
This course, offered by the internationally famous Memorial Sloan Kettering Cancer Center in New York, New York is focused on the use of thoracic surgery in modern cancer treatment, particularly in the treatment of lung and esophageal cancers*.
As a world-famous academic and cancer research center, Sloan Kettering has hundreds of educational offerings for practicing physicians, nurses and other health care professionals as well as Fellowships and doctoral programs in specialty focus areas.
The event is hosted by Dr. David R. Jones, a thoracic surgeon and recent transplant from the University of Virginia in Charlottesville, Virginia. Dr. Jones is the Chief of Thoracic Surgery, and the Surgical Director of the Thoracic Oncology Program at Memorial Sloan Kettering Cancer Center.
The conference will be held 31 July to 2 August 2014 in Colombia’s 2nd city at the Plaza Mayor.
Invited speakers include all of Latin America, Spain, the United States, the United Kingdom, Portugal and Italy. Invited lecturers include noted physicians such as Peter Barnes, Stella Martinez, Rafael Beltran and Dario Londono.
Topics include the treatment of multidrug resistant tuberculosis, pulmonary rehabilitation (and quality of life in COPD), COPD and Pulmonary fibrosis, along with more specialized content for thoracic surgery and endoscopy. These specialty segments include content on lung transplant, surgical treatment alternatives and ongoing research.
the latest from Dr. Diego Gonzalez Rivas and the masters of thoracic surgery.
Dr. Gonzalez Rivas and the Thoracic Surgery Unit in Coruna, Spain are hosting the “International Symposium on Uniportal VATS” this week (February 26th to 28th, 2014).
Dr. Gonzalez Rivas demonstrates uniportal VATS
While the in-person, on-site event is limited to just 100 attendees, the event will be offering real-time live streaming surgery for viewers worldwide.
With registrations from around the world, Dr. Gonzalez Rivas estimates that thousands of pairs of eyes will be watching; from Australia to Saudi Arabia, Hong Kong to Colombia, Brazil to Russia, and the United States.
If you’ve ever wanted to learn more about single port VATS, this is the time to find out.
For more information:
Livethoracic.com – link to the event and on-line registration. Registration is 500 Euros.
Article at Examiner.com with more details on this event.
Discussing the classification and treatment of lung cancer according to the latest revisions (7th edition).
Medical City, Dallas, Texas USA
Sometimes location and timing is everything. Since I can’t attend all of the great thoracic surgery conferences and events, sometimes I just have to wait for something closer to home. But then again, “home” is a relative concept.
As a locum tenens provider, I travel around the country working in various hospital surgical programs on short-term contracts. It’s an interesting and always changing life but one that allows me to pursue my love of thoracic surgery to the fullest.
For the next few weeks, Medical City in Dallas, Texas is my home, as part of the cardiothoracic surgery service. It’s a return trip so it was nice to renew my acquaintance with the surgeons and staff of the CVICU and step-down units.
Today, as part of an ongoing continuing medical education program series, Dr. Mitchell Magee, of Southwest Cardiothoracic Surgeons gave an hour-long lecture entitled, “Lung cancer staging and evolving less invasive surgical treatment alternatives.” The focus of the talk was the changes in lung cancer classification and staging in the 7th edition guidelines. These revisions were proposed to replace previous versions which were based on a very small, select sample of patients at a single site. In comparison, the new revisions are based on over 100,000 patients worldwide.
T, N, M
T – tumor
N – nodes
M – metastasis
This classification system has been in use since the 1940’s and has been revised several times to reflect our growing knowledge. The latest revisions (7th edition) were released in 2012 after several years of research and debate. (For more on this process, see “The science behind the 7th edition Tumour, Node, Metastasis staging system for lung cancer” by Marshall et al, 2012).
Dr. Magee discussed the most recent revisions and how these changes affect both the treatment recommendations and prognoses for our patients. After reviewing these changes, he talked a bit about obtaining sufficient diagnostic information for accurate staging, including the role of EBUS, the new CT scan screening guidelines and the gold standard, mediastinoscopy. He also discussed some of the limitations of PET/CT and other non-invasive diagnostic imaging.
Upstaged/ Downstaged
As part of these changes in the subclassification of tumors, 10 stages have been downstaged (meaning that previously in-operable cases may now be eligible for resection) and seven classifications have been upstaged – meaning that the cancers are now considered more advanced.
For example, patients with two separate tumors in the same lobe of the lung has been upstaged to T3. Two different tumors in the same lung, but a different lobe is now T4 classification.
More specific
Some of the classifications have changed to make findings more specific. For example, T1 staging has now been subdivided into T1a and T1b.
Any invasion of the pleura, including microscopic – is now T2 staging.
He concluded the presentation with a short overview of the history of surgical resection for lung cancer, and the evolution of surgical techniques from open thoracotomies with pneumonectomies to lung sparing procedures utilizing more minimally invasive techniques.
Despite these changes, the hallmarks of a successful cancer operation remain unchanged – the right operation for the individual patient, and the need to respect oncological principles, like surgical margins, and a through lymph node dissection.
Lymph node dissection/ node sampling
Node sampling remains a crucial part of the cancer staging process despite the advent of less invasive imaging studies due to it’s infaliable accuracy. (There is either tumor tissue in the node or there isn’t, where as PET scan results can be false positive or false negative).
For this reason, tissue samples remain the gold standard of treatment and are the most accurate way to predict and prognosticate the extent of disease.
General rules regarding lymph node sampling are:
– More nodes are better. The minimum acceptable number of nodes for accurate staging is at least SIX for at least THREE different stations.
A good way to remember the relationship between node stations and node status is that bode stations are determined by distance from mediastinum; meaning that node station 14 is more peripheral that node 2.
N1 nodes are stations 10 – 14
N2 nodes are the single digit nodes (2, 4, 7 etc.)
Lymph nodes used for diagnosis and staging. Copyright Memorial Sloan-Kettering Cancer Center. Used with permission.
References and additional suggested readingBaltayiannis N, Chandrinos M, Anagnostopoulos D, Zarogoulidis P, Tsakiridis K, Mpakas A, Machairiotis N, Katsikogiannis N, Kougioumtzi I, Courcoutsakis N, Zarogoulidis K. (2013). Lung cancer surgery: an up to date. J Thorac Dis. 2013 Sep;5(Suppl 4):S425-S439. Review. Free pdf. Nice review article discussing the importance of staging for determining optimal treatment for lung cancer, as well as the impact of the latest revisions to the (7th edition) TNM classification system.
IASLC Staging Handbook in Thoracic Oncology – a site-specific guide on the new TNM classification of thoracic malignancies. This publication is published in coordination with the 7th editions of the TNM Classification of Malignant Tumors/UICC and AJCC Cancer Staging Manual.
Goldstraw P, Crowley J, Chansky K et al. (2007). The
IASLC lung cancer project: proposals for the revision of the
TNM stage groupings in the forthcoming (seventh) edition of
the TNM classification of malignant tumours. J Thorac Oncol
2007; 2: 706-714. Figure 1. Powerpoint slides TNM classification revisions for the 7th edition.
Quick and easy summary of the 7th edition classifications for Lung cancer staging – 7th edition Lung cancer staging pdf from the American Joint Commission on Cancer.
Dr. Mitchell Magee, thoracic surgeon at Medical City – Dallas, Texas
Dr. Mitchell Magee is Surgical Director of Thoracic Oncology and the Minimally Invasive Therapy Institute for Lung and Esophagus at Medical City Dallas. While his partner, Dr. Dewey focuses exclusively on cardiac surgeries like cardiac bypass, valve replacement, TAVR, LVADS and cardiac transplantation, Dr. Magee is the thoracic arm of the two surgeon Southwest Cardiothoracic Surgeons practice. This means Dr. Magee is able to devote his time to a sizable portion of all of the esophageal tears, empyemas, mediastinal masses and lung pathology that a city the size of Dallas has to offer.
Dr. Mitchell Magee & Amber Bethea, PA-C
Dr. Magee is also part of the CLEAR Clinic at Medical City – which is the lung cancer screening center at the Medical City Dallas facility.
Some of the biggest names in thoracic surgery were in attendance, to present their research and surgical techniques to a crowd of over 600 Chinese thoracic surgeons. The lectures (and live surgery) were also broadcast across China.
World-renown thoracic surgeons at the 16th National Forum in Shanghai, China
Invited International Speakers included:
Dr. G. Alexander Patterson, thoracic surgeon/ lung transplant from the Washington School of Medicine in St. Louis, Mo. (USA). Dr. Patterson gave a lecture on clinical experiences and advances in Lung Transplantation. He also lectured on pancoast tumors.
Dr. Claude Deschamps, French Canadian thoracic surgeon and Chair of Surgery at the Mayo Clinic, Rochester, MN (USA). Dr. Deschamps talked about the use of anti-reflux surgery.
Dr. Gaetano Rocco, of the National Cancer Institute in Naples, Italy. Dr. Rocco talked about advances in chest wall reconstruction. He gave another lecture on uniport surgery.
Dr. Alan Sihoe from the University of Hong Kong discussed management of air leaks.
Surgeons from Taiwan and mainland China presented on a variety of topics including tracheal surgery, management of empyema, sympathectomy for hyperhidrosis and surgical treatment of tuberculosis. (The full list of speakers and topics presented is available here*.)
Conference Spotlight: Single port surgery
But the focal point of the forum was single port (uniportal) surgery. Saturday (the 19th) was devoted to lectures and demonstrations of the single port thoracoscopic technique, including live surgical demonstrations performed by Dr. Diego Gonzalez Rivas. His live surgery presentation was viewed by 500 surgeons at the conference as well as hundreds of other surgeons via a live feed.
Dr. Gonzalez Rivas demonstrates the single port (uniport) technique in Shanghai, China
Thank you to Dr. Gonzalez Rivas for his submission. We welcome reports, photographs and discussions on recent and upcoming thoracic surgery conferences. If you have a meeting, paper or presentation to share, please contact us at k.eckland@gmail.com
*Information is translated from Mandarin using google software with some obvious translational errors, particularly names of several of the Chinese surgeons.
the 2013 S.W.A.T conference, presented by Johnson & Johnson. Featured presenters Dr. Diego Gonzalez Rivas and Dr. Paula Ugalde discuss single port thoracoscopy and topics in minimally invasive surgery
Very pleased that despite the initial difficulties, we are able to provide information regarding the recent conference.
Talking about Single-port surgery in Bogotá, Colombia – 2013 S.W.A.T. Summit
Dr. Diego Gonzalez Rivas and Dr. Paula Ugalde were the headliners at the recent Johnson and Johnson thoracic surgery summit on minimally invasive surgery. Both surgeons gave multiple presentations on several topics. They were joined at the lectern by several local Colombian surgeons including Dr. Stella Martinez Jaramillo (Bogotá), Dr. Luis Fernando Rueda (Barranquilla), Dr. Jose Maineri (Venezuela) Dr. Mario Lopez (Bogotá) and Dr. Pardo (Cartagena).
Thoracic surgeons at the 2013 S.W.A.T Summit in Bogota, Colombia. Drs. Gonzalez-Rivas and Dr. Paula Ugalde are center, front-row
Target audience missing from conference
The audience was made up of thirty Latin American surgeons from Colombia, Costa Rica and Venezuela. This surgeons were hand-picked for this invitation-only event. Unfortunately, while Johnson and Johnson organized and presented a lovely event; their apparent lack of knowledge about the local (Colombian) thoracic surgery community resulted in the exclusion of several key surgeons including Dr. Mauricio Velasquez, one of Colombia’s earliest adopters of single-port thoracoscopy. Also excluded were the junior members of the community, including Dr. Castano, Dr. Carlos Carvajal, and current thoracic surgery fellows. It was an otherwise outstandingand informative event.
The Gonzalez – Rivas dissector, photo courtesy of Scanlon International
As discussed in multiple publications, previous posts as well as during the conference itself, it is these younger members who are more likely to adopt newer surgical techniques versus older, more experienced surgeons. More seasoned surgeons may be hesitant to change their practices since they are more comfortable and accustomed to open surgical procedures.
Despite their absence, it was an engaging and interesting conference which engendered lively discussion among the surgeons present.
Of course, the highlight of the conference actually occurred the day before, when Dr. Gonzalez- Rivas demonstrated his technique during two separate cases at the National Cancer Institute in Bogotá, Colombia. (Case report).
Dr. Gonzalez-Rivas and Dr. Ricardo Buitrago performing single port thoracoscopy at the National Cancer Institute
Featured presenters:
Dr. Diego Gonzalez – Rivas is a world-renown thoracic surgeon jointly credited (along with Dr. Gaetano Rocco) with the development of single-port thoracoscopic (uni-port) surgery. He and his colleagues at the Minimally Invasive Surgery Unit in La Coruna, Spain give classes and lectures on this technique internationally. Recent publications include three papers in July alone detailing the application of this surgical approach, as well as several YouTube videos demonstrating use of this technique for a wide variety of cases.
Dr. Gonzalez Rivas
Dr. Paula Ugalde, a Chilean-borne thoracic surgeon (from Brazil) who gave several presentations on minimally-invasive surgery topics. She is currently affiliated with a facility in Quebec, Canada.
Dr. Paula Ugalde
Refuting the folklore
Part of the conference focused on refuting the ‘folklore’ of minimally-invasive procedures. Some of these falsehoods have plagued minimally-invasive surgery since the beginning of VATS (in 1991), such as the belief that VATS should not be applied in oncology cases. The presenters also discussed how uniportal VATS actually provides improved visibility and spatial perception over traditional VATS (Bertolaccini et al. 2013).
However, Gonzalez-Rivas, Ugalde and the other surgeons in attendance presented a wealth of data, and publications to demonstrate:
– VATS is safe and feasible for surgical resection in patients with cancer. (Like all surgeries, oncological principles like obtaining clear margins, and performing a thorough lymph node dissection need to be maintained).
– Thorough and complete lymph node dissection is possible using minimally invasive techniques like single-port surgery. Multiple studies have demonstrated that on average, surgeons using this technique obtain more nodes than surgeons using more traditional methods.
– Large surgeries like pneumonectomies and sleeve resections are reasonable and feasible to perform with single-port thoracoscopy. Using these techniques may reduce morbidity, pain and length of stay in these patients.
– Rates of conversion to open surgery are very low (rare occurrence). In single-port surgery, “conversion” usually means adding another port – not making a larger incision.
– Learning curve fallacies: the learning curve varies with each individual surgeon – but in general, surgeons proficient in traditional VATS and younger surgeons (the “X box generation”) will readily adapt to single-port surgery.
– Bleeding, even significant bleeding can be managed using single-port thoracoscopy. Dr. Gonzalez Rivas gave a separate presentation using several operative videos to demonstrate methods of controlling bleeding during single-port surgery – since this is a common concern among surgeons hesitant to apply these advanced surgical techniques.
Additional References / Readings about Single-Port Thoracoscopy
Scanlon single-port thoracoscopy kits – informational brochure about specially designed instruments endorsed by Dr. Gonzalez Rivas.
Dr. Diego Gonzalez Rivas – YouTube channel : Dr. Gonzalez Rivas maintains an active YouTube channel with multiple videos demonstrating his surgical technique during a variety of cases. Below is a full-length video demonstrating the uniportal technique.
Additional posts at Cirugia de Torax about Dr. Diego Gonzalez- Rivas
Upcoming conference in Florida – information about registering for September conference for hands-on course in single-port thoracoscopic surgery with Dr. Gonzalez-Rivas
Youtube video for web conference on Single-port thoracoscopic surgery
Bertolaccini, L., Rocco, G., Viti, A. & Terzi, A. (2013). Surgical technique: Geometrical characteristics of uniportal VATS. J. Thorac Dis. 2013, Apr 07. Article from thoracic surgeons at the National Cancer Institute in Naples, Italy explains how the geometric advantages of uniportal VATS improves visibility and spatial perception over traditional VATS, and mimics open surgery.
Calvin, S. H. Ng (2013). Uniportal VATS in Asia.J Thorac Dis 2013 Jun 20. Article discussing the spread of uniportal techniques in Taiwan, China and other parts of Asia.
Rocco, G. (2013). VATS and uniportal VATS: a glimpse into the future.J. Thorac Dis. 2013 July 04. After coming across several articles by Dr. Gaetano Rocco, and actively pursuing several other publications by this Italian thoracic surgeon, I have become increasingly convinced that Gaetano Rocco, along with Dr. Gonzalez Rivas is one of the world’s leading innovators in thoracic surgery. Hopefully, cirugia de torax will be able to catch up to Dr. Rocco at some point for an in-depth discussion.
While I advance criticism of this event – it was a fantastic conference. My only reservations were to the exclusivity of the event. While this was certainly related to the costs of providing facilities and services for this event – hopefully, the next J & J thoracic event will be open to more interested individuals including young surgeons and nurses.
Looks like readers and cirugia de torax will be staying home, It’s a Johnson and Johnson invitation only event.
Since I received several inquires from surgeons in Latin America who were interested in finding out more about the conference featuring Dr. Diego Gonzalez in Bogotá, Colombia – I contacted the event coordinator, Cristina Barciona directly.
However, as Ms. Barciona explained – this is a Johnson & Johnson corporate event, that is invitation-only, so outside attendees such as interested surgeons (and this particular nurse) are not invited. In fact, several of Bogota’s well-known thoracic surgeons have confirmed that they have been excluded from the guest list for this event. This is certainly a very different response than I would have expected given Johnson & Johnson’s image in the United States, where they have the “Discover Nursing” and other high profile media campaigns..
I have to admit that’s very disappointing news – being such as big fan of Dr. Gonzalez – Rivas as well as the thoracic surgeons in Bogotá, Colombia, I was really looking forward to writing about the event.
Sorry, folks for getting your hopes up. So if you can – head to Florida for the Duke sponsored,”Masters of Minimally Invasive Thoracic Surgery ” course in September.
For thoracic surgeons interested in becoming more familiar with uniport surgery, this is your chance to learn from the pioneers of the technique.
Several new dates for Uni-port thoracoscopy with Dr. Diego Gonzalez Rivas. These events span across the Americas and Europe, so if you are interested in uni-port thoracoscopic surgery, then there is something nearby.
The first date is coming up soon – in August 2013, in Bogotá, Colombia.
Dr. Diego Gonzalez Rivas in Bogotá, Colombia
I am excited about this one, and hope to be able to cover the event for readers of CdeT. While I am currently in Medellin, I became familiar with, (and have a great deal of respect for) many of Bogotá’s finest thoracic surgeons in the past so it’s a great opportunity not just to hear more about Dr. Diego Gonzalez Rivas and uni-port thoracoscopy but to check in local surgeons and hear about some of their more interesting cases.
Dr. Gonzalez will be joined by Dr. Paula Ugalde, a well-known thoracic surgeon from Brazil (now practicing in Quebec, Canada).
As soon as I get some more details on the Bogotá event – I’ll post them here..
Split, Crotia – September 12th – 15th – 23rd Congress of the World Society of Cardio-Thoracic Surgeons.
This conference is being jointly sponsered by the Society of Cardio-Thoracic Surgeons of South Africa (SCTSSA). Dr. Diego Gonzalez will be talking about “Uni-port VATS major pulmonary resections in advanced lung cancer” in an afternoon session on September 13, 2013. (Obviously they don’t know much about him – since it’s only a 20 minute session – but as a CTS conference, only about 10% is thoracic topics (he is one of just a handful of thoracic speakers.)
Then in mid -September 2013, he will part of a roster of the greats of thoracic surgery (Dr. Robert Cefolio, Dr. James Luketich and Dr. Thomas D’Amico) at the Duke Center for Surgical Innovation for a course entitled, “Masters of Minimally Invasive Thoracic Surgery”.
The second event, is a meeting/ conference/ training course in Dr. Gonzalez’s home hospital in Coruna, Spain. The event, “Live Thoracic” will feature ‘live-surgery’ demonstrations and will be streamed for real-time viewing from around the world.
In a side note – I want to thank the nearly 6,000 students, interns, nurses, residents and thoracic surgeons who have downloaded one of my thoracic surgery apps for Android devices.
Interested in learning more about single port thoracoscopy, or talking to the inventors of this technique? This March – head to the 1st Asian single port surgery conference in Hong Kong.
It doesn’t look like Cirugia de Torax will be in attendance for this conference, but it’s another opportunity for practicing thoracic surgeons and thoracic surgery fellows to learn more about single port thoracoscopic surgery.
This March (7th – 8th), the Chinese University of Hong Kong, along with the Minimally Invasive Thoracic Surgery Unit (Coruna, Spain), and Duke University are presenting the 1st Asian Single Port Symposium and Live Surgery conference in Hong Kong.
This is your chance to meet the experts – and the inventors of this technique (such as Dr. Diego Gonzalez – Rivas, one of the new masters frequently featured here at Cirugia de Torax.)
Full listing of conferences (AATS, STS, European societies) available at CTSnet.org. They also post information on additional training courses (thoracoscopy, minimally invasive surgery). I’ve posted some of the highlights below.
an Interview with Dr. Diego Gonzalez Rivas – and coverage of ‘Videotoracoscopia y cirugia robotica en torax: Avances y perspectivas’ in Santiago, Chile
Santiago, Chile
I was a little intimidated to actually interview Dr. Diego Gonzalez Rivas after reading his articles and pestering him with emails for the last few years. But he was just as nice and patient with my questions as he’s always been.
Dr. Santolaya, Dr. Sales dos Santos, Dr.Berrios and Dr. Diego Gonzalez Rivas
Since publishing the last few articles on his single port technique, Dr. Gonzalez has been in high demand from thoracic surgeons wanting to learn more, and to train in single port techniques. In addition to traveling the world to teach – he continues to offer training at the Minimally Invasive Thoracic Surgery Unit at the Complexo Hospitalario Universitario de A Coruna, in Coruna, Spain.
Dr. Gonzalez reports that single port thoracoscopy doesn’t just provide patients with the least invasive surgery possible, but that single port thoracoscopy is superior to traditional VATS in the vast majority of cases. Single port thoracoscopy is defined by the creation of one 2cm to 4cm incision – with no rib spreading and utilization of video-assisted thoracoscopy.
“Forward Motion”
He states that using a single port approach gives much better visibility than traditional VATS. This visibility is equal to that of open surgery – versus the 3 or 4 port approach, which is constrained by the 30 degree movement / rotation of the thoracoscope. This visibility concept; called ‘Forward Motion,’ along with the ease of using instrumentation through the same port makes single port surgery amendable to most thoracic surgery procedures.
Learning curve? What learning curve?
He reports that members of the “Playstation Generation” as he terms the newest young surgeons, adapt more readily to the use of both traditional and single port thoracoscopy. In fact, he reports that the residents (in his program) are able to learn and use this approach with minimal assistance.
With the exception of lung transplantation (requiring the traditional clamshell incision), Dr. Gonzalez reports that he is able to successfully perform a wide range of surgeries from wedge resections and lobectomies to more complicated procedures such as pneumonectomies and sleeve resections.
In today’s lecture he debunks some of the myths regarding the ‘classic contraindications’ to video-assisted thoracoscopy (VATS) such as broncheoplasty, the presence of dense adhesions or the need for complete lymph node dissection. While he reports that dense adhesions may make the procedure more painstaking and difficult – it is still possible.
LymphNode Dissection
In cases of lymph node dissection – he reports that lymphadenectomy is actually superior by single port and other VATS methods, with the average surgeon actually harvesting more nodes, more easily.
While he initially believed that right upper lobe resections would be impossible with this method – his recent experiences (included in an upcoming paper on 102 cases) show that any anatomic complexities are readily overcome by an experienced VATS surgeon. Not only that, but he has been able to successfully remove very large (8cm or greater) lung tumors using this method – by slightly enlarging the port at the time of specimen removal. He has also successfully removed Pancoast tumors and performed chest wall resections with this procedure, as well as single port thoracoscopy after previous VATS or previous thoracotomy including completion pnuemonectomies and completion sleeve lobectomies.
One of the biggest obstacles for surgeons implementing the single port method is the dreaded complication of catastrophic bleeding. This often causes inexperienced single port surgeons to hasten to convert to open surgery without attempting to control the bleeding. Dr. Gonzalez presented several cases today to demonstrate the difference between controlled bleeding that can be managed with the speedy application of surgical staples, clips or sutures versus heavy uncontrolled bleeding, which requires quick recognition and prompt conversion to open thoracotomy.
He reports that in the over 500 cases he has performed by VATS (3 port, dual port and single port), conversion to open thoracotomy remains a very rare occurence. (He presented data on his outcomes today.)
In his own practice, he reports that prior to 2007 the majority of cases were by traditional thoracotomy. He began using 3 port VATS more heavily in 2007 – 2009. After training with Dr. D’Amico at Duke University in Durham, NC – he moved to dual port thoracoscopy in 2009. Since 2010, his practice is almost exclusively single port thoracoscopy.
The future of single port thoracoscopy
Dr. Gonzalez believes the future of single port thoracoscopy will be a hybridization of current robotic thoracic surgery (which now uses three and four port techniques) to using less invasive, smaller robotic arms that will allow surgeons to enjoy the micro-precision of robotic technology through a single port.
Not just a ‘single port surgeon’
While he is famous internationally for his innovations in the field of minimally invasive surgery, he is also a transplant surgeon. In fact, along with his partners, he performed an average of 35 – 40 lung transplants a year.* This makes the transplant program in Coruna the second largest in Spain, despite the relatively small size of Coruna compared to other cities such as Barcelona or Madrid.
For patients who are interested in Dr. Gonzalez-Rivas and his program, please contact him at Info@videocirugiatoracica.com
I published an article based on this interview over at Examiner.com
5 / Video-assisted thoracic surgery lobectomy: 3-year initial experience with 200 cases. Gonzalez D, De la Torre M, Paradela M, Fernandez R, Delgado M, Garcia J,Fieira E, Mendez L. Eur J Cardiothorac Surg. 2011 40(1):e21-8.
6 / Single-port Video-Assisted Thoracoscopic Anatomical Resection: Initial Experience. Diego Gonzalez , Ricardo Fernandez, Mercedes De La Torre, Maria Delgado, Marina Paradela, Lucia Mendez. Innovations.Vol 6.Number 3. May/jun 2011. Page 165.
Books/ Book Chapters
1 / Thoracoscopic lobectomy through a single incision. Diego Gonzalez-Rivas, Ricardo Fernandez, Mercedes de la Torre, and Antonio E. Martin-Ucar. Multimedia Manual of Cardio-Thoracic Surgery. MMCTS (2012) Vol. 2012 doi:10.1093/mmcts/mms007. Includes multiple videos demonstrating single port techniques.
2 / Tumores del diafragma. M. de la Torre Bravos, D. González Rivas, R. Fernández Prado, JM Borro Maté. Tratado de Cirugía Torácica. Editores L. Fernandez Fau, J. Freixinet Gilart. SEPAR Editores médicos SA. Madrid 2010. Vol 2, Sec VIII, Capitulo 87: 1269-78.
3 / Trasplante Pulmonar. C. Damas, M. De la Torre, W. Hespanhol, J.M. Borro. Atlas de Pneumología. Editores A. Segorbe Luís y R. Sotto-Mayor 2010. Vol 2, Capítulo 54 651-8.
4 / Doble utilidad hemostática y sellante de fuga aérea de tachosil en un caso de cirugía compleja por bronquiectasias. M. De la Torre, J.M. Borro, D. González, R. Fernández, M. Delgado, M. Paradela. Anuario 2009. Casos clínicos en cirugía. Accesit en la 3ª edición de los Premios Nycomed 2008.
5 / Cirugía Torácica videoasistida avanzada. D. González Rivas. Videomed 2008. Certamen internacional de cine médico y científico.
6 / Traumatismo Torácico. M. de la Torre, M. Córdoba. En « Manual de Urgencias en Neumología». Editado por Luis M Domínguez Juncal, 1999 165-78.
7 / Neumotórax. M. Córdoba, M. de la Torre. En « Manual de Urgencias en Neumología». Editado por Luis M Domínguez Juncal, 1999 139-56.
8 / Cirugía del enfisema. P. Gámez, J.J. Rivas, M . de la Torre. En « Neumología Práctica al Día». Boehringer Ingelheim 1998 77-102.
9 / Neumotórax. J.J. Rivas, J. Torres, M. de la Torre, E. Toubes. En « Manual de Neumología y Cirugía Torácica». Editores Médicos S.A. 1998 1721-37.
One of the world’s experts on sympathectomy and the treatment of hyperhidrosis reviews the evidence at the XVI Congreso Boliviano Sociedad de Cirugia Cardiaca, Toracica y Vascular 2012.
While there was no opportunity to speak with Dr. Jose Ribas de Milanez de Campos at length, Cirugia de Torax did have a chance to talk briefly with the world-renown Brazilian thoracic surgeon about his presentation on VATS sympathetectomy for the treatment of hyperhidrosis. He is one of the foremost experts on hyperhidrosis and the treatment of this condition. (He, along with other thoracic surgery legends, Cefalio and McKenna helped draft the STS statement of the topic.)
Dr. Jose Ribas de Milanez de Campos
Dr. Ribas reviewed the current literature as well as the most recent ATS Expert Consensus, and changes in international nomenclature for the ongoing research in the treatment of hyperhidrosis.
State of the evidence
At the 2009 American Thoracic Society expert consensus for surgical treatment of hyperhidrosis – a meta-analysis of the existing data was performed. Of the 1097 different papers, there were just 102 detailing clinical trials. Of these, only 12 studies met the criteria as randomized trials, and these studies were conducted by just three different groups of surgeons. Findings were based on this small pool of data.
Changes in nomenclature
Following the review of this data, several changes in surgical nomenclature were suggested to increase the clarity of data reporting among surgeons. One of the main points of confusion is the use of the ganglia level to report and describe procedures. This is problematic since multiple studies, including cadaveric studies, have shown that there are multiple anatomic variations in ganglia level. Also obese body habitus may obscure landmarks/ levels of ganglia in the fat tissue. Thus, the ATS now suggests that surgeons use “Rib Level” when reporting sympathectomy procedures. This is believed to allow greater precision and accuracy in data reporting.
Surgeons are also encouraged to classify surgical procedures as either sympathetomy, sympathiocomy or ramicotomy – mentioning the mechanism of sympathetic interruption; clipped versus cut, cauterised or otherwise removed. There is no clearly superior method but surgeons need to be sure that there is enough separation between the ends of the sympathetic chains. Dr. de Campos prefers dual port incisions over single port access for better visibility, and considers the harmonic scalpel much more precise.
The third major recommendation for surgeons performing sympathetectomies – is the recommended use of quality of life questionnaires for periodic follow-up with patients.
Treating hyperhidrosis
Level of sympathetic interruption should be related to patient’s primary symptomatology.
R2, R3 for patients with facial symptoms such as facial flushing.
R3 & R4 for patients with palmar symptoms.
R4 & R5 for patients with palmar and (severe) axillary sweating.
This is important because patients report greater satisfaction, less regrets and less side effects with the lower level blockages (R4 versus R2). Due to the inexactness of reports and poor follow-up, it is hard to know the incidence of compensatory hyperhidrosis (or compensatory sweating of lower extremities). Literature has reported the incidence at 3% – 98% of patients, making it difficult to quantify.
Patients who have sympathetic interruption of both R2 & R3 increases the risks of compensatory hyperhidrosis and Horner’s syndrome. This compensatory sweating is also more severe in warmer climates.
Best Candidates for the procedure
The best candidates for the procedure are patients who developed symptoms at an early age. Palmar symptoms often begin in young children (including toddlers). Axillary symptoms usually start during adolescence, with craniofacial symptoms beginning in young adulthood.
Surgery is most effective in younger patients (under the age of 25). Patients also need to be of normal weight for the best results with a BMI of 25 or less*. This is important because the greater the weight (or body mass index), the higher the incidence of compensatory sweating – which will prevent effective surgical treatment.
Common complications
The most common complications are compensatory sweating, and Horner’s syndrome. This occurs more frequently with higher level surgeries.
When to have surgery
Patients should consider surgery only after exhausting other treatments – as the expert consensus states sympathectomy should be considered a procedure of “last resort.”
However, oxybutynin treatment has shown promise for the treatment of hyperhidrosis. After 45 to 90 days of oxybutynin treatment, 80% of patients will respond favorably with noticeable improvement in symptoms. Surgery should be reserved for refractory cases.
*BMI of 28 or less in the United States, according to national guidelines.
References
Includes a limited list of publications by Dr. Rivas de Milanez de Campos on this topic.
M.A. Callejas, R. Grimalt, E. Cladellas (2010). Hyperhidrosis update.Dermo-Sifiliográficas (English Edition), Volume 101, Issue 2, March–April 2010, Pages 110-118.
Cameron AE, Connery C, De Campos JR, Hashmonai M, Licht PB, Schick CH, Bischof G; International Society of Symapathetic Surgery. Percutaneous chemical dorsal -sympathectomy for hyperhidrosis. Minim Invasive Neurosurg. 2011 Oct;54(5-6):290. Epub 2012 Jan 25 [letter].
De Campos JR, Hashmonai M, Licht PB, Schick CH, Bischof G, Cameron AE, Connery CP. (2012). Treatment options for primary hyperhidrosis. Am J Clin Dermatol. 2012 Apr 1;13(2):139. [comment].
de Campos JR, Kauffman P, Werebe Ede C, Andrade Filho LO, Kusniek S, Wolosker N, Jatene FB. (2003). Quality of life, before and after thoracic sympathectomy: report on 378 operated patients. Ann Thorac Surg. 2003 Sep;76(3):886-91. [full-text not available.]
Wolosker N, Yazbek G, Ishy A, de Campos JR, Kauffman P, Puech-Leão P. (2008). Is sympathectomy at T4 level better than at T3 level for treating palmar hyperhidrosis? J Laparoendosc Adv Surg Tech A. 2008 Feb;18(1):102-6. [full-text not available.]
For additional information on this topic:
Nauman, M., Davidson, J. R. T. & Glaser, D. (2002). Hyperhidrosis: Current Understanding, Current Therapy. Medscape. [Registration required for Medscape]. Click article title for pdf version. While this article is dated back to 2002, it gives a good overview of hyperhidrosis for people who are unfamiliar with this condition.
Notes from the day’s lectures at the XVI Congreso Boliviana de Cirugia Cardiaca, Toracica u Vascular in Santa Cruz de la Sierra, Bolivia
This afternoon’s thoracic surgery offerings were provided in a more relaxed, round-table style discussion.
Relaxed roundtable discussion – Latin American surgeons. (Dr. Fernando Bello is the second from the left)
Dr. Edwin Crespo Mendoza, thoracic surgeon, of Santa Cruz, Bolivia led the discussion on diaphragmatic hernia repair and reminded the audience that over 50% of traumatic diaphragmatic hernias go undiagnosed at the time of initial presentation after trauma. To illustrate this, Dr. Crespo presented several cases including a case of post-traumatic hernia diagnosed 13 years after initial auto accident.
successful diaphragmatic hernia repair – click to enlarge
Dr. Fernando E. Jemio Ojara, MD (cardiothoracic surgeon) here in Santa Cruz at the Clinica Folanini presented a fascinating case of bilateral lung injury after blunt trauma. In this case, the patient was preparing to undergo urgent repair of a right-sided bronchial tear but during attempted intubation saturations dropped dramatically to 60%. At that time, the patient was placed on ECMO by venous cannulation to maintain oxygenation during the case. The surgeons proceeded with a right posteriolateral thoracotomy. Patient had a short successful ECMO run of 85 minutes, with extubated within 36 hours of surgery, and had no further problems post-operatively,
Dr. Ojara also discussed the mechanism of these type of acceleration – deceleration injuries that most commonly affect the right middle lobe, and how stabilization with ECMO is an effective strategy to repair what is essentially a functional pneumonectomy (in this particularly patient).
Dr. Fidel Silva Julio, Thoracic Surgeon also talked on a similar theme in his overview of closed chest trauma. He reminded the audience that 75-85% of all closed chest trauma patients need some sort of surgical management from chest tube placement to urgent surgery. He reviewed the classic presentations and radiographic findings in some of the most common conditions after chest trauma such as tension pnuemothorax/ sucking chest wounds, flail chest, pneumomediastinum, cardiac tamponade and pulmonary contusions. There were several medical students in the audience, taking notes – so I have included links to the radiology signs mentioned in his lecture, as well as a basic radiology primer.
He also highlighted the need to prevent the typical trauma pitfall of massive volume resuscitation which can prove extremely detrimental in these patients.
talking about the incidence of carotid body tumors at altitude with the world’s experts
This is not one of our usual topics here but since carotid body tumors (CBT /carotid paraganglion) are often associated with increased altitude; we are pleased to bring more information about the condition from several of Latin America’s experts from Quito, Ecuador, Mexico City (D.F.), Bogotá, Colombia and La Paz, Bolivia. (Also given the level of expertise in this room, on this specialized condition – it would be almost criminal not to report this information.)
We have requested copies of the powerpoint presentations to include here, so please check back soon.
re-section of a carotid body tumor
Dr. Oscar Ojeda Paredes, MD – email: oscarle19@hotmail.com
discussed the incidence, presentation, diagnosis and treatment in Quito. He also discussed the different characteristics in carotid body tumors occurring at altitude versus sea level. While carotid body tumors have a genetic component related to abnormal mutations of Chromosome 11, tumors according at sea level occur more frequently in familial patterns and reach larger sizes. The majority of patients seen at altitude are less than 3 cm, and asymptomatic in nature with the exception of a palpable mass. (This mimics the case presented here at CdeT.)
Several of the cases were in young females (less than 40 years). Dr. Ojeda and Dr. Guerrero explained that this believed to be related to the increased incidence of hypoxia during pregnancy (due to hemodilution and vascular expansion) in women with the chromosomal mutation.
During a separate presentation, Dr. Ojeda also addressed the rare complication of ‘Syndrome of Insufficient Baroreflex’
This sydrome occurs after the afferent fibers serving the carotid sinus are damaged during surgery (usually for the removal of carotid body tumors.) The syndrome occurs most frequently in patients who have had bilateral surgery – and while uncommon is not limited to patients who undergo carotid body tumor resection – it has also been reported in the literature in carotid endarterectomy patients.
Dr. Valente discussed the incidence of carotid body tumors in Mexico City. Despite being at the lowest altitude of the respective cities – given the very large surrounding population – Dr. Valente reports a significant number of cases in his hospital, as well as the results of several studies conducted in Mexico City. As mentioned in the literature, Dr. Guerrero (and the other presenting surgeons) report a very low incidence of malignacy.
Dr. Alberto Munoz, MD – National Cancer Institute (NCI) in Bogota, Colombia
Dr. Munoz, vascular surgeon from Bogota, Colombia
Dr. Munoz reports that while the majority of these cases are referred to Head & Neck (ENT) surgeons – there is a fairly significant incidence of disease in Bogotá, with surgeons at the National Cancer Institute seeing 30 cases in 2008, and 48 cases in 2009. (If you’ve read some of the other literature, you’ll realize this is a larger sample that frequently reported – for example one study reported only 120 cases over a 30 year period.)
Dr. Munoz reports that at his facility 8 – 10% of these tumors occur bilaterally, and are found of 10 – 12% of all carotid ultrasounds performed at NCI. Dr. Munoz also reviewed the existing the existing body of literature, dating back to 1963 – which is surprisingly small (total of seven studies with a total 412 tumors – including a previous study with a 160 patients in Bogotá.)
Dr. Ivan Soto Vaca- Guzman, MD (La Paz, Bolivia) Email: isotovacaguzman@yahoo.com
Dr. Soto, Bolivian expert on carotid body tumors
Dr. Soto presented information regarding several of his cases, including a discussion of previous Bolivian publications on carotid paraglanglion, as well as more recent data from his institution. This included a total of 467 patients with 134 patients (2005 – 2012). In comparison with much of the previously presented data – in Dr. Soto’s experience and research, the majority of patients developed CBT on the left. Similar to the other presenters the majority of patients were asymptomatic, and intra-operatively were found to have a Shamblin classification of II.
His most recent work confirmed the previously demonstrated predilection for females – with a female to male ratio of 8:1.
He also discussed the use of a pre-operative grading system based on ultrasound results based on the Shambling classification system is limited as it is a surgical classification applied at the time of surgery. He discussed a new classification system, called UPEC developed by Dr. Alvaro Balcazar, Dr. Lopez and Dr. Ivan Soto, Bolivian vascular surgeons. The advantages of Balcazar’s classification system is the prediction of complications – since tumors with extensive invasion into adjacent structures have a much higher risk of significant (and potentially life-threatening) bleeding. Dr. Soto states that he rarely, if ever, needs to embolize the tumor prior to surgical removal.
The UPEC classification system – uses letters A – D to indicate the amount of tumor invasion.
Stage A: without invasion
Stage B: partial invasion – partial invasion into the carotid only.
Stage C: Extensive invasion – may extend laterally, or into cephalic or caudal areas.
One of the questions addressed at the conference was the absence of carotid body tumors in places such as Tibet (at significant elevation). However, these differences are theorized to related to the chromosomal mutations that cause carotid hyperplasia in response to hypoxia. So while hypoxia certainly exists at Mount Everest – people (particularly women) carrying this mutation may not.
It was a historic moment for vascular surgery; as it is the first time that the heads of vascular surgery societies, and other surgeons from so many Latin American countries have come together to collaborate; forge ties, and advance knowledge and technology in vascular surgery.
Dr. Balcazar welcomes attendees.
Most of the thoracic surgery program is on Saturday but there are some interesting altitude-related offerings all week; including an entire morning devoted to carotid body tumors – which coincides with my latest case report.
Surgeons – I tried to meet all of you – if you have a relavent citation or paper – please send it to me so I can add it here.
Highlights from the recent conference on Advances in Lung Cancer and Mesothelioma
Instituto Nacional de Cancero
Bogota, Colombia
Dr. Ricardo Buitrago and Dr. Juan Carlos Garzon, Thoracic Surgeons
This one day conference put on by the National Cancer Institute in Bogotá, Colombia highlighted the latest research and techniques of treating lung cancer and mesothelioma.
It was headlined by a trio of invited lecturers, Dr. Carlos Jimenez, MD, Pulmonologist (MD Anderson, Houston, TX), Dr. Garrett Walsh, MD, Thoracic surgeon (MD Anderson, Houston, TX) and Dr. Mark Dylewski, MD, Thoracic surgeon (Baptist Health/ South Miami Hospital – Center for Robotic Surgery).
Dr. Ricardo Buitrago (who readers will be hearing more about in the coming months) and Dr. Rafael Beltran were the moderators for the conference.
Dr. Jimenez spoke on the topics of endobranchial ultrasound and fine needle (Wang) aspiration for lymph node biopsy as an adjuvant of mediastinoscopy for cancer staging, as well as ‘medical thoracoscopy’ or pleuroscopy. (While I will never share his views of pleuroscopy being part of the role/ scope of pulmonology – it was an interesting presentation.)
The presentations of Dr. Walsh and Dr. Dylewski served as beautiful counter-balance to each other and demonstrated the spectrum and breadth of thoracic surgery in the treatment of thoracic diseases.
Dr. Garrett Walsh and Dr. Mark Dylewski, American thoracic surgeons
While Dr. Dylewski presented the latest data from his experiences performing over 355 cases by robotic approach, Dr. Walsh spoke about performing large open cases with an interdisciplinary team to treat later stage cancers (T3, T4 respectively) and the ability to resect cases that are often referred for medical treatment due to local metastasis to adjacent organs.
Dr. Walsh delivering presentation
Other notable speakers included Dr. Stella Martinez who debated the advisability of surgical treatment of Malignant Pleural Mesothelioma (MPM) in response to another presentation by Dr. Walsh, as well as a discussion by Dr. Humberto Varela of the utility of specific diagnostic modalities for the detection and staging of malignant pleural mesothelioma.
the XXIX Congreso Latinoamericano de cirugia vascular y angiologia in Santa Cruz, Bolivia this October.
The Sociedad Boliviana de Cirugia Cardiaca, Toracica y Vascular has an upcoming conference this October, the XXIX Congreso Latinoamericano de cirugia vascular y angiologia (ALCVA). While much of the conference focuses on cardiovascular topics, there is one day reserved for thoracic surgery topics.
I am attending in hopes of recruiting some of La Paz’s thoracic surgeons into our high altitude project, and will be giving a presentation entitled, “Las verdades esenciales y falsedades sobre el manejo del paciente diabético” on October 6, 2012.
As part of this, I will be bringing readers coverage of this event. If you are going to be Santa Cruz, and you want to talk thoracics -contact me.
continued coverage of the2012 (Mexican) National Conference in Cancun, Mexico with discussions by Dr. Rafael Andrade, Dr. Raimundo Santolaya and Dr. Enrique Guzman de Alba.
LXXI Congreso Nacional de Neumologia y Cirugia de Torax
Cancun, Mexico
Yesterday was such a flurry of activity – I didn’t get a chance to post Wednesday’s Conference highlights until now.
After sitting thru some lackluster presentations for most of Tuesday, today was definitely the best day of the conference so far; as the topics become more and more thoracic surgery related (versus Asthma, and other strictly pulmonary medicine topics). There were so many enjoyable and informative lectures today that is was hard to choose, even after deciding to pick more than one – I feel like apologizing to all the other great speakers – but I’ve narrowed it down to a trifecta of great speakers, with Dr. Raimundo Santolaya, Dr. Rafael Andrade, and Dr. Enrique Guzman de Alba.
Dr. Ramundi Santolaya, MD a Chilean thoracic surgeon gave a thoroughly enjoyable overview of the diagnosis and management of pneumothoraces. Whether it was due to innate charisma, a lively discussion and multi-media presentation on one of my favorite topics, or due to that fact that with his clear, unaccented Spanish – I didn’t miss a word – he was a standout star of the day – so much so that I chased him down later for a full interview.
Dr. Raimundo Santolaya, of Santiago, Chile discusses 'Actualidades en el manejo del neumotorax'
Dr. Rafael Andrade, from the University of Minnesota was also very informative, yet entertaining during his talk on the use of ultrasound for mediastinal evaluation (cancer staging). He explained that while mediastinoscopy remains the gold standard for staging lung cancer, that the new(er) ultrasound techniques including endobronchial (EBUS) and endoesophageal (EUS) ultrasound allow for tissue sampling (and biopsy) of lymph nodes that are normally inaccessible during mediastinoscopy including many of the more distal stations. These techniques do not replace mediastinoscopy, or mediastinotomy (Chamberlain) but offer complimentary information to assist in the staging of cancers to help determine the extent of disease when PET results may be inconclusive, or appear to show more extensive disease.
I had just finished reading some of his recent papers for another article I was working on, so it was both a surprise and a pleasure to see him and speak with him, in person. He sure didn’t seem to mind my questions (despite my chronically impaired Spanish.)
Dr. Rafael Andrade takes the time to speak with Cirugiadetorax.org
Of course, his English is impeccable but when in Rome, etc. so I did my best. Luckily for me, and all the readers here at Cirugia de Torax – my understanding of ‘surgical Spanish’ tends to be spot – on, particularly when there are overhead slides to assist with translation.
Dr. Rafael Andrade, University of Minnesota presents, 'Valor del ultrasonido toracico en las enfermedades pleurales
Dr. Enrique Guzman de Alba, a cardiothoracic surgeon gave two lectures, more of a part I and a part II on the current literature regarding the surgical treatment of lung cancers by staging as well as a review of the literature surrounding clinical outcomes comparing lobectomy versus segmentectomy (aka wedge resections.) As he explained, lobectomy remains the gold standard for any patient who is able to tolerate surgery, (including patients that are believed to be marginal candidates and would otherwise be relegated to wedge resection.) He reports that despite common beliefs regarding segmentectomies as ‘lung -sparing’ for patients with marginal baseline respiratory (or other functional) status – there has been no data to demonstrate that these patients perform better/ or better tolerate a wedge resection versus the more complete lobectomy. Therefore, given the increased incidence of cancer reoccurrence with segmentectomies – he advocates for the larger, but more effective lobectomy.
Dr. Enrique Guzman de Alba, cardiothoracic surgeon at INER, Mexico City, Mexico giving one of several presentations
There was also some interesting discussion on managing malignant pleural effusions and limitations of PleurX catheter use in Mexico due to prohibitive costs for many patients.
Dr. Cueto as our featured speaker today at the National Conference of the Mexican Society of Pulmonology and Thoracic Surgery talking about pulmonary embolism.
Cancun, Mexico
The highlighted speaker for the conference today is the dynamic Dr. Gullermo Cueto Robledo of the General Hospital of Mexico City. Dr. Cueto presentation was “Diagnostic opportunities in Pulmonary Embolism.”
Dr. Cueto at the 2012 Congreso Nacional de Neumologia y Cirugia de Torax
It was a standing room only crowd for his presentation on the incidence, mortality, diagnosis and treatment of pulmonary embolism.
Dr. Cueto reviewed the incidence of pulmonary embolism which occurs approximately 909, 753 times a year in the United States, with an estimated 296,370 deaths directly attributed to this phenomenon (2005, Journal of Thromboembolism & Hematology).
In a recent study at the Institute of Cardiology in Mexico City by Sandoval, 22.4% of all autopsies showed evidence of pulmonary embolism.
While many of the risk factors are well-known cardiovascular disease risks (obesity, hypertension, diabetes, smoking, elevated cholesterol) as well as traditional risk factors such as cancer/ malignant processes, venous stasis/ immobility, recent surgery and airline (or other travel) greater than two hours – Dr. Cueto discussed how pulmonary embolism is often overlooked. He reviewed the existing criteria for predicting embolism risk such as the Wells, Winky (Geneva) scores, as well as the shortfalls of each of these scores, which often rely on subjective criteria on the basis of the individual applying the criteria. He also talked about a recent paper suggesting a strong correlation between ST changes in aVR and presence of a right BBB in addition to the traditional S1Q3T3 finding on electrocardiogram.
He states that the strength of the D-dimer is not in it’s diagnostic capability but in it’s prognostic ability, as the elevated values at specific thresholds can be used to correlation both the location and risk of mortality.
Despite the advent of multi-modality imaging studies the gold standard remains the V:Q scan which is the only diagnostic tool to clearly rule out the presence of pulmonary emboli, along with the advantages and disadvantages of traditional and helical CT scans in addition to MRA (magnetic resonance imaging with angiography.) He reports that initial enthusiasm for MRA has dampened due to multiple limitations in use as well as poor picture quality in comparison to other modalities. The main limitations of the multi-detector helical CT scan remain the inaccessibility and unavailability of this modality at many facilities due to cost.
He also reviewed the recently published guidelines from the American College of Chest Physicians (Chest, 2012) include very specific recommendations including initiation of thrombolytic and anti-coagulant therapies prior to formal or radiographic diagnosis in patients at high risk despite their classification of evidence as 2C. These changes come due to recent studies showing adverse outcomes with delayed onset of treatment, with a marked shift around the twenty hour mark after the onset of the initial thrombotic event. As he mentioned previously, since the majority of patients may demonstrate either vague or absent symptomatology on the onset of massive pulmonary embolism, these guidelines attempt to streamline and advance treatment that may be otherwise delayed by diagnostic testing.
(2009). Air travel and risk of thromboembolism. Ann Internal Medicine 151 – 180: 190. Review of the literature showing an 18% increase for every two- hour interval of travel.
I’m here at the National conference for pulmonologists and thoracic surgeons this year to hopefully interview (and possible recruit some surgeons to the research project).
It’s already been an eventful day, with several excellent presentations this morning as attendees continue to arrive to the official beginning of the conference tomorrow morning. Extensive discussions on the multi-drug resistant tuberculosis started today and will continue for the rest of the week in addition to offering aimed at multiple specialties including surgery, nursing, respiratory therapy, pulmonology and general internists.
One of the featured presenters is Dr. Richard Light, MD who almost seems like family to me at this point, since I’ve been reading much of his previous work while I write a new case presentation about dual port thoracoscopy. He’s one of the many people I hope to catch up with for a few minutes over the next few days.
Wish me luck! I’ll continue to post about updates over the next several days.
Cirugia de Torax.org heads south of the border for the upcoming Sociedad Mexicana de Neumologia y Cirugia de Torax congreso (conference) this April. It’s also a chance for surgeons to find out more about the high altitude project.
The title of this post is apt in more ways that one. The Mexican Society of Pulmonologists and Thoracic Surgeons is meeting for their 2012 annual meeting this April, and yes, Cirugia de Torax.org is going to be there. We’re hoping to interview and talk to some of Mexico’s greatest innovators and researchers in thoracic surgery during our visit this year.
We will be also talking about the high altitude lung surgery project with interested and potential participants – including prospective timelines, data collection tools (and validity of measurements), and expected responsibilities/ duties of site participants.
This year’s conference is being held in Cancun, from April 9th thru April 13th, 2012. Check back in April for more news and conference coverage.
Cirugia de Torax and the role of social media in the promotion of specialty practice.
“Using social media & technology to promote specialty practice” is the title of the abstract submitted (and accepted) for presentation at the American Academy of Nurse Practitioners (AANP) national conference in June 2012. As part of this presentation, we will be talking about and presenting information about the Cirugia de Torax website and associated social media. We will be presenting information about the evolution from the first post last spring, to the development of our first (and basic) Android app to more sophisticated applications such as the STS General database application.
We will also be presenting statistics – website visits, numbers of subscribers, numbers of applications downloaded, emails received as well as where our readers come from. So I wanted to take a moment to thank everyone who has made this project a success; to all of the surgeons and thoracic surgery specialists (nurse practitioners, physician’s assistants, nurses, etc.) that invited me into their operating rooms, made time in their schedules for interviews, phone calls, and answered my many emails.
Thank you to all of my readers – especially the medical / nursing students and patients out there that requested or suggested topics or articles. (I never knew how fascinated we all are with RATS (robot-assisted thoracoscopic surgery) until I started receiving all of those emails. So thank you for the gracious and generous feedback.
Lastly, if you are in Orlando, Florida area this June – I’d like to invite you to stop by and introduce yourself. (I’ll be posting more details as the date nears.)
K. Eckland
Update: 23 June 2012
27th AANP conference
Social Media Handouts – with information about Cirugia de Torax and other web blogs, websites, and social media by health care professionals (primarily nurse practitioners).
Thoracic Surgery 