Dr. Marcelo Migliore, Dr. Stefan Hoffman and several other thoracic surgeons who spearhead large HITHOC (Hyperthermic intrathoracic chemotherapy) research programs have just authored an editorial for the latest December 2020 issue of the Annals of Translational Medicine.
In this thoughtful article, the authors comment on the absence of any mention or consideration of HITHOC for the treatment of malignant Pleural Mesothelioma (MPM) despite multiple studies showing as survival advantage for patients receiving HITHOC*.
Migliore et al. point out a couple of things in their arguments for inclusion:
Stating (paraphrasing for brevity) that given the current level of evidence for most of the existing treatments of MPM are rated as weak, it is difficult to understand why HITHOC remains excluded from consideration. This gives the erroneous impression that HITHOC is a new, untried/ untested experimental treatment with little to no evidentiary support. This is false. Even a cursory overview of the data shows this is clearly not the case.
Why is this important, you ask??
Doctors, (at least credible ones), don’t offer or refer patients for treatments that fall outside the approved guidelines. Referring patients for treatments outside of the approved guidelines is considered charlatanism at best, and medical malpractice at worst. It’s akin to giving your patient megavitamin supplements and sending them to a Laetrile clinic, instead of an oncologist. This is particularly unethical when dealing with cancer patients because the direness of their prognosis can make them susceptible to the worst medical scams in our society. But this also means that doctors are hesitant to send their patients for legitimate treatments such as HITHOC because it isn’t “recommended.”
-And.. and it’s not a small AND.. the current “recommended” treatments don’t have strong evidence supporting their use (or a lot of good outcomes.)
Now as the editor of thoracics.org, I am going to take argument this a little bit farther than the authors did in their article.
Migliore and his fellow authors are European.. So they and the majority of their patients don’t fall victim to the “American medical insurance conundrum”, where Americans pay enormous sums of money to insurance carriers who then turn around and deny payment for necessary medical treatments. But, most of my patients are American, so inclusion matters a lot to me, because inclusion or specifically, the lack of inclusion drives a lot of insurance payment decisions.
One of the ways insurance companies save money is by denying payment for any treatment that is considered experimental. (What an insurance company deems experimental can also be controversial but that’s another conversation). Whether that so-called experimental treatment has a high probability of saving or prolonging your life is not important to the insurance company. (In fact, for decades after bone marrow transplant was shown to be a very effective form of treatment for several types of cancers, insurance companies continued to deny coverage – because bone marrow transplant is expensive.)
In fact, this scenario was the basis for a very popular 1997 movie based on the John Grisham novel, “The Rainmaker.”
(In the movie, Danny Davito and Matt Damon are in my hometown of Memphis, fighting for a client whose insurance has denied him a life-saving bone marrow transplant. )
As mentioned by the authors in the editorial, the omission of HITHOC from the guidelines suggests that it’s experimental. But as we’ve shown in multiple reviews of the data surrounding HITHOC, it’s been around for over 20 years and has a lot of data to support it’s use.
Even when a treatment isn’t deemed “experimental”, insurance companies don’t have to cover it. They routinely deny payments for treatments that are not part of standard treatment guidelines, so Inclusion in clinical guidelines is the first step to having the treatment included as part of Medical coverage.
In the case of HITHOC, inclusion in the clinical guidelines is critical. Patients with malignant pleural mesothelioma (and other cancers that are treated with HITHOC), don’t have a lot of time – and frankly, without HITHOC, their prognosis, and estimated survival time are both measured in single digits.
Without inclusion – patients never make it from their doctor’s office to the research program. Even if they somehow did find their way there (thru google, word-of-mouth or other means), most patients don’t have the means to pay for it, if insurance won’t help. (Even European programs, which are much more affordable than American programs, HITHOC can cost from 40,000 to 80,000 dollars. In the USA, the cost has been quoted as around a quarter of a million dollars.) So, inclusion matters.
For more information about any of the things we’ve talked about above: (about criteria for recommendations, current malignant pleural mesothelioma guidelines and all things HITHOC)
If you’ve never read a paper reviewing the guidelines for treatment of a medical condition, then you should know a couple of things first.
in these papers, multiple strategies or treatment options are listed
each of these treatments is then given a letter grade of A, B, or C based on the amount of scientific evidence that it works. (For more about the levels of evidence, see this article on the evidence pyramid).
A treatment with a high level of evidence (lots of scientific data, meta-analyses, double-blinded studies with large numbers of participants, etc.) would be ranked as 1A.
If we had another treatment, that seemed really effective, but maybe the evidence wasn’t quite as strong for that exact circumstance, it might be listed as 1B. As the supporting evidence for the treatments is reduced, treatments are graded as B, C and X. Level B recommendations are still things we still might consider using for patients, but less so for level C. Level X means that the treatment may actually cause harm. (Level X is often applied to treatments that were used historically, but are later found not to work. This happens quite a bit if you look at treatments used in the 1960’s versus now.)
So the authors are asking for HITHOC be mentioned in these guidelines, to be then ranked based on evidence. Since the evidence is graded, as we explained above, the authors aren’t asking for HITHOC to replace other treatments. They are merely asking for it to be listed as an option.
What are the current guidelines for treatment of MPM?
The current European guidelines for treatment of MPM are here. (In this guideline, they dispense with the standard grades of A, B, C and basically skip to palliative treatments in most cases. For example, they “recommend” talc pleurodesis as the first line surgical treatment – which as readers know, is a palliative treatment based on symptom management only.
The American recommendations also eshew the standard grading nomenclature, but A, B, C are merely substituted with srong, moderate and weak.
What about HITHOC? What is HITHOC?
*Many of those studies have been reviewed here at Thoracics.org: we have a whole section dedicated to cytoreductive surgery and hyperthermic intrathoracic chemotherapy (HITHOC).
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.
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!)
Multi-modality approach for anxiety/ nausea/ vomiting / pain
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.
Immediate extubation (once the specimen is out of the chest)
“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
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.
Dr. Ming-Hui Hung & Dr. Jin-Shing Chen at National Taiwan University Hospital talk about their work in nonintubated and awake thoracic surgery.
After attending multiple recent thoracic surgery conferences, where the topic of nonintubated thoracic surgery sparked murmurs and outspoken criticism, thoracics.org conducted a brief review of the literature to attempt to discern if this criticism and skepticism was warranted. As part of this review, we reached out to several of the leaders in the field, including Dr. Ming-Hui Hung, a well-respected Taiwanese anesthesiologist and widely acknowledged expert on this topic.
Thoracics.org asked for Dr. Hung’s commentary as well as his response to several specific questions on nonintubated thoracic surgery. Here is his response in it’s entirety (re-formatted to fit the Question and Answer format posed by our correspondence).
Question: Would you tell me more about your initial research in this area. What lessons have you learned (overall) in patient selection for non-intubated thoracic surgery? What additional tips or advice would you offer interested thoracic surgeons/ members of anesthesia?
As we had discussed in our publications, we are facing more and more aging and frail patients with minor thoracic procedures. As surgical approach evolves toward a minimally invasive thoracoscopic technique, we expect that there would be a need for less invasive anesthetic management (i.e. nonintubated VATS) as well. Traditional intubated one-lung ventilation does offer a safe and quiet surgical environment for surgery; however, we still suffer occasionally to have patients complicated with intubation-related adverse effects, not to mention the consuming procedures for successful one-lung ventilation. Actually, there was a short-stature elderly lady complicated with pneumo-mediastinum because of tracheobronchial laceration after a double-lumen tracheal intubation. We was driven by this case we suffered to find a solution and whereas we developed our nonintubated techniques since 2009. As you noted, now nonintubated VATS is a routine part of our armamentarium for thoracic surgery.
To summarize, there are important steps that we learned from our experiences:
Thoracic epidural anesthesia (TEA) vs internal intercostal nerve blocks (INB)
In the beginning, we applied TEA. It does provide satisfying analgesia but it is time-consuming and carries more risks for neurological complications. Once again, we had a nonintubated case coincidentally complicated with acute transverse myelitis after surgery. Although we excluded the epidural procedure per se, to be the direct cause of the regretful complication, we were still bothered by a legal suit against us. Then we learned that internal INB is equally effective as a thoracic epidural catheter. It saves time and risk free to do it as we do it under a direct vision by scope, and no touching on any spinal structures. Now INB is our routine part of nonintubated VATS. TEA is considered for those doing a bilateral VATS. We think this is important because it makes nonintubated VATS more safe and even more less invasive, for which our patients would accept this approach more. We Taiwanese are mostly reluctant to have someone doing anything on our spines, as we usually call them the “dragon bones”, the most important part of our bodies.
Intrathoracic vagal block
Since cough reflex is a visceral part of autonomic nerve, which is not blocked by TEA or INB, unpredictable cough reflex during surgery could quietly bothering and even dangerous. We soon learned that we could block the cough reflex via intrathoracic vagal nerves. It really works. It alleviates the tension upon surgeons who working on a spontaneously breathing lung and enable them more manipularity of lung parenchyma and hilar structures. Surgeons are still needed to be as gentle as possible for that excessive traction still can trigger cough reflex from the dependent side where vagal nerve function is intact.
Sedation and titration of its depth
We know there is an “awake, or not awake” issue on nonintubated VATS. We prefer to sedate our patients just because our patients do not want to be awake during surgery. Lateral decubitus position is not a confortable position. Most of our patients undergo surgery because of lung cancer or potential lung cancer. It usually takes 1-2 hours to have a diagnosis first and complete the definite treatment upon the final pathological result. We believe no one would like to be anxiously awake for the result with an open chest in an awkward position. In addition, the initial phase of iatrogenic pneumothorax would cause the patient dyspneic and tachypneic for a while, giving patient sedated with supplemental opioid is useful to alleviate the respiratory disturbances and accelerate the operated lung to collapse. By applying bispectral index EEG monitor, we can observe the BIS index increasing during the initial phase of open pneumothorax, it could be caused by inadequate analgesia, or just because of a dyspneic response. We may give the patients some more anesthetic and it usually recovered after effective vagal block. Carefully observe the respiratory pattern (from the video, or using an noninvasive end-tidal capnography) is of importance. Anesthesiologists should keep vigilant on the respiratory pattern and airway patency of the nonintubated patients, including a plan B for intubation conversion.
We operate on spontaneous breathing lungs (most of the time, the operated lung collapses well because of positive pressure introduced into the chest cavity). The remaining opposite lung is sufficient to maintain satisfactory oxygen saturation, despite unavoidable hypoventilation. However, a vigorous diaphragm would jeopardize the balance. For surgery, it causes excessive movement of the operated lung and makes hilar manipulation dangerous or even impossible. For respiration, CO2 rebreathing (an to-and-fro phenomenon between the dependent and the non-dependent lung) would further exacerbate the breathing pattern and decrease the alveolar oxygen fraction of the nondependent lung, leading to oxygenation desaturation. It is the most common scenario of our difficult cases and we changed to intubation conversion in some of them, especially in major resections (i.e. lobectomy) for lung cancer. We learned that obese patients tend to be an abdominal breather because of an elevated diaphragm and they are usually associated with excessive diaphragmatic movement during nonintubated surgery. Other contraindications for nonintubated VATS are also listed on the literature. We suggest that are mostly at the discretions of the caring surgeon and anesthesiologist as their good clinical practice routines.
Question: How have your findings of your work been received internationally? At several recent conferences, there has been a lukewarm or even critical response towards nonintubated thoracic surgery. Is this a frequent response?
A typical unfriendly tone from other colleagues is “just because it can be done, should it be done?” We have the same feelings as you experienced in those meeting. Nonetheless, our findings are relevant and robust that nonintubated VATS is feasible and safe in selected patients with a variety of thoracic procedures. They were published in well-known surgical journals in cardiothoracic field, including Annals of Surgery, Journal of Thoracic and Cardiovascular Surgery, Annals of Thoracic Surgery and the European Journal of Cardio-Thoracic Surgery. Still, there are surgeons and anesthesiologists enthusiastic about less invasive alternative for their caring patients visiting our hospital for nonintubated VATS, including Korea, China, Switzerland internationally and other hospitals nationally.
We believe it is human nature being anxious and doubtful to do something you do not get familiar with, especially when intubated one-lung ventilation is nearly an unbreakable only golden standard for thoracic surgery for decades, and almost all thoracic surgeons in current generations would request a fully collapsed lung to operate upon. But at this time, we are approaching a 1000 nonintubated VATS case volume, and all thoracic anesthesiologists and thoracic surgeons in our hospital are dealing with nonintubated VATS if this is appropriate for their patients. We think it is quiet a milestone in our program.
Five years ago, I asked one of my colleagues, a nursing anesthetist [emphasis mine] whether she would choose nonintubated technique if she needs a VATS procedure.
She said, “Well, I need to think about it. You better give me an double lumen even though I know how big it is.”
One year later, her answer to the same question is a “Yes, please, no tube.”
Question: Are there any other obstacles for researchers in this area? Do you have other on-going research programs at your facility?
Obviously, nonintubated patients recover from surgery fast. They can shift to the gurney on their own from the surgical table. They experience less pain and less PONV in PACU, which enables them to recover oral intake sooner with oral analgesics and early ambulation, not to mention those common adverse effects after double lumen intubations, such as a sore throat and a change of voice quality. Currently, we are drafting our manuscripts about nonintubated VATS pulmonary resection in patients with compromised lung function. Meanwhile, a randomized trial is under investigation to compare the recovery differences of nonintubated VATS vs. intubated VATS. There are also several more nonintubated trials in Clinicaltrial.org in different countries.
Question: Do you know of any programs that have adopted your techniques and protocols?
To our knowledge, Dr. Jianxing He from the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China, is also an enthusiastic advocator and pioneer in nonintubated VATS. He is also leading journals such as Journal of Thoracic Disease andAnnals of Translational Medicine as an open forum to accelerate the impact of nonintubated VATS. He is going to publish a state-of-the-art monograph dedicated to nonintubated VATS in the near future. We believe you can get useful information regarding nonintubated VATS in China and different perspectives from him.
As always, we keep doing our best to satisfy our patients’ need during their curing and recovery processes, just because “our patients, first.”
Ming-Hui Hung, MD, MS
Anesthesiologist, Department of Anesthesiology
Jin-Shing Chen, MD, PhD
Professor, Department of Surgery
National Taiwan University Hospital
Thoracics.org would like to thank Dr. Hung and his colleagues for their continued work in this area. Thoracics.org would also like to thank Dr. Hung for his willingness and frank candor in addressing some of the other issues in this area.
Readers: Thoracics.org has highlighted a key phrase in Dr. Hung’s response that also, unintentionally but directly addresses one of the criticisms recently advanced by a noted American thoracic surgeon who challenged Dr. Martinez as to whether he would ever delegate the care of a nonintubated patient to a nurse anesthetist. When Dr. Martinez hesitated in his response, the surgeon claimed victory, stating, “See? That would never work in American hospitals, [where certified nurse anesthetists oversee the majority of cases]”. This was his rationale for dismissing this technique, even when it might make otherwise inoperable patients eligible for life-saving surgery. That dismissal of both his American colleagues and the needs of the more fragile subset of our thoracic surgery population demonstrates some of the limitations in our so-called “masters” or “giants” of thoracic surgery. While great, and influential surgeons, they are not infallible. Their experiences carry wisdom, but their opinions shouldn’t carry more weight than any other published study.
Thoracics.org is committed to giving a voice and forum to all specialties and members of the thoracic surgery community.
Single port thoracoscopic surgery and awake anesthesia: the micro-invasive thoracic surgery? The current research and use of these state of the art techniques to bring minimally invasive surgery to complex surgery and high risk patients.
Instead of being greeted with enthusiasm or professional interest, the great majority of well-known giants in thoracic surgery dismissed the idea with a few, repeated sarcastic, albeit joking remarks about the inconvenience of having conscious patients in the operating room. This attitude seemed perplexing given the results of Pompeo et; al.’s (2014) survey of the European Society of Thoracic Surgeons, in which a large number of respondents (59%) reported using nonintubated thoracic surgery (NITS) procedures. These mixed attitudes led thoracics.org to perform an in-depth literature search to determine the state of non-intubated thoracic surgery.
What is the current status of non-intubated thoracic surgery (and the literature surrounding it)?
Is it a wild, unsustainable idea promoted by a few dynamic but misguided surgeons? Is it a well-researched and promising developing technique that is being rejected by surgeons who may lack vision? Or does it fall into that gray area where we suspect that this technique has real value and benefits for a special subset of patients but there isn’t quite enough high level clinical evidence to demonstrate that to the surgical community?
Is non-intubated thoracic surgery destined to fall to the same fate of VATS – a game-changing technique that emerged in the early 1990’s, has been clinically demonstrated to be superior to open surgery with an overwhelming preponderance of evidence, but still being discussed by many surgeons as the ‘new kid on the block’**? Will people still debate the merits of non-intubated surgery ad infinitude thirty years from now, even when clinical guidelines have made it the standard of care (like VATS and oncology surgery)? Will there be the same reluctance to set firm standards for training in these techniques?
“Not a new concept”
As it turns out – non-intubated thoracic surgery is not a new idea or concept. It was developed early in the 20th century and was used successfully for many years for even the most complex thoracic cases such as esophagectomies until the development of double lumen intubation in the 1950’s made the use of single lung ventilation possible (Gonzalez-Rivas et. al. 2015, Pompeo 2015, Kiss & Castillo 2015). Since its rediscovery in the last several years, many of the problems that plagued this technique during its inception over a century ago have been addressed through better understanding of human physiology. Now, this seemingly fringe technique has been shown to be a feasible approach for treating the very margins of the thoracic surgery population (the extreme elderly, patients with advanced respiratory disease or other serious medical co-morbidities) that are often deemed inoperable using current techniques.
The dreaded complication (spontaneous pneumothorax) of early use of this technique by pioneers in thoracic surgery has now become one of the main advantages. Surgically created pneumothorax results in almost perfect deflation of the operative lung, achieving better results than even the most experienced of anesthesiologists using traditional single lung ventilation. Surprisingly to many observers, instead of creating a ventilatory emergency, this process is readily tolerated by most patients, even those with poor baseline pulmonary function (David, Pompeo, Fabbi & Dauri, 2015).
The majority of the current series of research on this topic are being performed by a small group of surgeons which includes Dr. Diego Gonzalez Rivas (Spain), Dr. Eugenio Pompeo and the Awake Thoracic Surgery Research Group in Italy and Dr. Ming-Hui Hung and colleagues (Taiwan). Pompeo’s group (Drs Benedetto Cristino, Augusto Orlandi, Umberto Tarantino, Tiziana Frittelli (General Director of the Policlinico Tor Vergata), Leonardo Palombi, Paola Rogliani, Roberto Massa, Mario Dauri) has been especially prolific in 2015 after several of their works were published in a special issue of Annals of Translational Medicine.
In multiple studies, these researchers have reported successful thoracic surgery outcomes in non-intubated patients, thus eliminating the majority of risks related to general anesthesia as well as uni-lung ventilation via mechanical ventilation and intubation. In several of these studies, the authors were also able to successfully perform these surgeries in fully awake patients (versus consciously sedated), making surgery possible for even the frailest of candidates. These studies included a small number of comparisons between traditional and non-intubated surgeries. While the numbers of patients enrolled have been small, and there are few randomized studies, the results have been encouraging.
Chen et. al
Chen et. al’s 2012 study has been one of the largest studies to date, with 285 cases. In this study, patients underwent lobectomies, wedge resections and segmentectomies with 4.9% requiring conversion with tracheal intubation. Lung resection was undertaken with traditional (3 port) VATS or a needlescopic approach.
The authors report the biggest problem they encountered was increased bronchial tone and airway hyper-reactivity during manipulation of the pulmonary hilum during lobectomies and segmentectomies. This was effectively treated without significant alteration in hemodynamics via intrathoracic vagal blockage which eliminated the cough reflex in these patients.
The authors caution judicious patient selection to prevent emergent conversion (intubation) particularly while surgeons are initially attempting this technique. Chen et al. also believe that non-intubated thoracic surgery is best suited for petite or small-sized female patients because the small tracheal size of these patients predisposes them to a higher rate of complications and potential tracheal injury with traditional surgery and intubation.
Awake anesthesia and lung volume reduction surgery
Pompeo et. al’s review of the literature surrounding of the use of this technique in patients with severe emphysema undergoing nonresectional lung volume reduction surgery (LVRS by awake anesthesia) showed significant treatment advantages for patients undergoing lung volume reduction surgery without intubation or administration of general anesthesia.
With an average mortality of 5% and a morbidity of 59% for traditional lung volume reduction surgery as reported during the National Emphysema Treatment Trial, findings from Tacconi et al.’s 2009 study of 66 LVRS awake patients (matched with 66 patients undergoing traditional surgery) appears promising. The authors report a reduced incidence of prolonged air leaks (18%) versus 40% in the traditional surgical group as well as a decreased length of stay. In this study, 3 patients required conversion to general anesthesia – one patient due to an elevated paCo2 of 83% and the remaining two patients for anxiety attacks.
Rate of intubation/ respiratory failure/ mortality in Tacconi et al.
Mortality in both non-intubated and the traditional surgical group was the same, with one patient from each group. In both cases, the patients had developed massive airleaks following surgery. In the non-intubated group, the patient developed acute lung injury requiring intubation of POD#12 and died POD#38.
In the traditional surgical group, 4 patients were unable to be extubated at the end of the case, with one patient requiring an additional day of mechanical ventilation. Another patient was reintubated on POD#3 for respiratory failure and died on POD#67.
Pompeo et. al, over the course of over eleven years, have also investigated the use of non-intubated (and awake) thoracic surgery for a wide variety of cases including urgent /emergent cases, wedge resections, decortications, talc pleurodesis as well as nonintubated anesthesia combined with single (uniportal) thoracoscopic approaches (aka “microinvasive thoracic surgery”).
Anesthesia for non-intubated thoracic surgery
The role of anesthesiologists in caring for patients undergoing non-intubated or awake thoracic surgery is more challenging than general anesthesia. While thoracic anesthesia already requires specialized skills for initiating, managing and maintaining uni-lung ventilation, the switch to non-intubated patients with either localized anesthesia or conscious sedation adds a new set of complexity to managing these often frail patients. Kiss & Castillo (2015) in their review of the literature, provide an excellent overview of the pros and cons of non-intubated anesthesia as well as guidelines for patient selection and eligibility criteria for use of this technique. Special populations who may benefit from this technique include patients with severe respiratory disease (and a high risk of ventilator dependency with intubation), patients with severe but stable dyspnea, or multiple cardiovascular and respiratory co-morbidities.
Kiss et. al also reviews the contraindications to use of this technique including: phrenic nerve paralysis on the non-operative side, patients at risk for difficult intubation, or patients who are unwilling to undergo awake thoracic surgery. Wang & Ge (2014) expand on these complications to include ASA status 4 or higher, bleeding disorders, decompensated heart failure, extreme obesity, unfavorable airway or spinal anatomy as well as specific respiratory conditions including bronchiestasis, asthma, sleep apnea, clinically significant sputum production and strict contralateral lung isolation.
Wang & Ge also give specific anesthesia dosing guidelines for conscious sedation, local anesthesia and regional blocks in additional to monitoring parameters.
Alterations in oxygenation and ventilation
David et. al. (2015) describe the pathophysiology and alterations in oxygenation and ventilation in surgical pneumothorax including hypercapnia, hypoxia and the associated hypoxic pulmonary vasoconstriction that occurs along with the development of intrapulmonary shunt as the deflated (and unventilated lung) maintains perfusion. The authors also explain how this effect can be either exacerbated or minimized thru the choice of anesthetic agents, and the administration of supplemental oxygen, which further demonstrates the importance of involving the thoracic anesthesia team in preparation for non-intubated cases.
This “permissive hypercapnia” has been reported in multiple articles as having minimal to no clinical effects and is easily treated with supplemental oxygen by nasal cannula or facemask.
Editor’s note: In advance of this article, Dr. Pompeo, Dr. Gonzalez Rivas and Dr. Min-Hui Hung were contacted for their additional comments and insights on non-intubated thoracic surgery. This and subsequent articles may be augmented, as applicable with their replies.
Should we really abandon pursuit of better patient outcomes, faster mobility, recovery and reduced length of stay in lieu of the security to tell off-color jokes with our patients safely under general anesthesia? Should we abandon all hope in treating patients previously deemed inoperable due to our own fears and hesitations to embrace newer techniques and procedures?
Or as Mineo et al, suggests, should we enlist our colleagues to design and devise several large scale studies at multiple institutions so that we can move to the next level of investigation and answer the question: “Should my patient be awake for this?”
Mineo TC, Tacconi F. (2014). Nonintubatedthoracic surgery: a lead role or just a walk on part?Chin J Cancer Res. 2014 Oct;26(5):507-10. doi: 10.3978/j.issn.1000-9604.2014.08.11. No abstract available. Very enjoyable, almost conversational article with the authors sharing their experiences with non-intubated thoracic surgery while calling for larger clinical research studies on the topic.
Pompeo, E. (2015). Non-intubated thoracic surgery: nostalgic or reasonable? Annals of Translational Medicine, 2015; 3(8): 99. Review of the historical development on non-intubated thoracic surgery and techniques in regional anesthesia for complicated thoracic surgery procedures including esophagectomies in the era predating the development of double lumen intubated and unilung ventilation. A timely reminder that some of the greatest developments in medicine and surgery are ‘rediscoveries’ of our predecessors.
Pompeo E; Awake Thoracic Surgery Research Group (2012). To be awake, or not to be awake, that is the question. J Thorac Cardiovasc Surg. 2012 Jul;144(1):281-2; author reply 282. doi: 10.1016/j.jtcvs.2012.01.083. No abstract available. Comment on article by Noda et. al.
Note: This is not an exhaustive list of literature available on this topic but a select listing of the most recent and relevant citations (and are available as free full text).
**Long time readers of thoracics.org may have noticed that we no long cover or report on ‘debates’ or discussions as to whether VATS can be used in oncology cases, or whether an adequate lymph node dissection can be performed using VATS. The literature clearly demonstrates that it can – and clinical guidelines reflect this, making the discussion one-sided, tedious, out-dated and repetitious.
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?
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
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 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.
 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.
updates on the on-going HITHOC project, war surgery, foreign body obstructions and bronchoscopy for infants
Gaziantep, Southeastern Anatolia
It’s been over a year since I first read Dr. Isik’s work on treating pleural mesothelioma. Since that time, Dr. Işik has continued his research into HITHOC and has now enrolled over 79 patients into the hyperthermic treatment group including one of the patients I met during my visit. (There are 29 surviving patients in the study, 13 in the mesothelioma group, the remainder are secondary pleural cancers.).
(If you are a patient seeking treatment, or would like more information about Dr. Isik (or Dr. Gonzalez Rivas, Dr. Sihoe or any of the other modern Masters of thoracic surgery), we are happy to assist you. Contact me at firstname.lastname@example.org
First impressions are deceiving
I don’t know what I expected Gaziantep to look like as one of the world’s oldest cities, but from the moment the airplane begins its descent into a beige dust cloud, to the desolate brush and dirt of the airport outside the city, it isn’t what I expected. Much of the antiquity of the biblical city of Antiochia has been replaced by a bustling modern city. Historic ruins and ancient Roman roads marking this as part of the original Silk Road are conspicuous, only by their scarcity.
There are a handful of museums and monuments to the area’s rich history, but like the new name of Gaziantep (replacing Antep after the first world war), Turkey’s sixth largest city is modern; a collection of traffic and squat square buildings of post-modern architecture.
The city is also a mosaic of people. There are groups of foreign journalists in the lobby of our hotel, and convoys of United Nations vehicles cruising the streets. Crowds of Syrian children play in the park, calling out in Arabic to their parents resting on the benches nearby. There is a smattering of Americans and English speakers interspersed, many are college students and other foreign aid workers on humanitarian missions to help alleviate the strain caused by large numbers of people displaced by the Syrian civil war.
But like a mosaic, there is always more to see, the closer you look. For me, as I look closer, I just want to see more. I feel the same about Dr. Elbeyli’s thoracic surgery department.
The border (and the largest Syrian city of Aleppo) lies just to the south – and the impact of the Islāmic militants is felt throughout the region. No where is this more evident than at the local university hospital, where I meet Dr. Ahmet Işık and the Chief of Thoracic Surgery, Dr. Levent Elbeyli.
Dr. Ahmet Feridun Işık
I like Dr. Işık immediately. He is friendly and appears genuinely interested by my visit. He’s from Giresun in the Black Sea region of northern Anatolia of Turkey. He attended medical school at Ankara University and completed his thoracic surgery training in Ankara before going to Adiyaman State Hospital in the bordering Turkish province of Adiyaman in southeastern Turkey.
He was an associate professor of thoracic surgery at Yuzuncu Yil University in the far eastern province of Van, Turkey before coming to Gaziantep in 2005. He became a full professor at the University of Gaziantep in 2013. In additional to authoring and contributing to his own publications, he also served as a reviewer for the Edorium series of open access journals.
It helps that his English is miles better than my non-existent Turkish. (Reading about the Turkish language in phrase books is one thing, pronouncing words correctly is another.)
He doesn’t seem to mind my questions tumbling out one after another. I’d like to be the cool, sophisticated visitor, but I’ve been waiting so long to ask some of these questions – and frankly, I am just excited to be there.
Dead-ends in medicine
There are a lot of “dead ends” in medicine – treatments that at first appear promising, but then end up being either impractical or ineffective. In fact, for the first ten years of HIPEC, most surgeons dismissed it as a ‘dead-end’ treatment; the surgery was too radical and mortality too high. But researchers kept trying experimental protocols; tweaking medications (less toxic) and procedures – and finding the right patients (not too frail prior to surgery) – and the literature shifted; from a largely useless ‘last ditch’ salvage procedure to a large, but potentially life-saving treatment. HITHOC is HIPEC in another color…
So I fire away –
Since our last post about Dr. Işık – he has performed several more cases of HITHOC on patients with pleural mesothelioma, pleural based cancers and advanced lung cancers. He now has 79 patients in the HITHOC treatment group. He has been receiving patients from all over Turkey, including Istanbul to be evaluated for eligibility for this procedure. While the majority of patients are referred by their oncologists, others come to Gaziantep after reading about Dr. Işık on the internet.
None of the original patients (from 2009) are still alive, but their survival still exceeded all expectations, with 13 patients (of 14 HITHOC patients) living 24 to 36 months after the procedure. (I don’t mean to be vague – but I was asking some of these questions in the operating room and I forgot to stuff my little notebook in my scrub pocket.)
While much of the literature surrounding the procedure cites renal failure as one of the major complications of the procedure, Dr. Işık has had one case of renal failure requiring dialysis. Any other instances of elevated creatinine were mild and transient. He doesn’t use any chemical renal prophylaxis but he does use fluid rehydration to limit nephrotoxicity.
He reports that while many surgeons consider sarcomas to be a contraindication to this procedure, he has had good outcomes with these patients.
He does state that diaphragmatic involvement in mesothelioma is an absolute contraindication because while the diaphragm can be resected / patched etc, it is almost impossible to guarantee or absolutely prevent the seeding of microscopic cancer cells from the diaphragm to the abdominal cavity – which increases the risk of disseminated disease.
He still uses Cisplatin – since that is what the original HITHOC researchers were using, but he uses a slightly higher dose of 300mg. He’d like to do some prospective studies utilizing HITHOC (these have all been retrospective in nature – comparing today’s patients with past patients that received PDD and pleurodesis for similar conditions). Prospective studies would allow him to better match his patients and to compare treatments head to head. It would also allow him to compare different techniques or chemotherapeutic agents.
Unfortunately, as he explained, many of these types of studies of ineligible for government funding in Turkey because the government doesn’t want to pay for experimental / unproven treatments for patients even if there are few or no alternatives for treatment. He is hoping to appeal this regulation so that he can continue his research since there is such a high rate of mesothelioma, that disproportionately affects rural Turkish patients.
The University Hospital is one of several hospitals in Gaziantep. The academic institution has over 900 beds and 20 operating rooms spread out over three floors. There is a large 24 bed surgical ICU which includes 4 dedicated thoracic surgery beds.
Thoracic surgery may not be the advertised superstar of the hospital but it is the backbone of patient care. There are three full-time professors of surgery; Dr. Ahmet Isik, Dr. Levent Elbeyli and Dr. Bulent Tunçözgür, along with an associate professor, Dr. Maruf Sanli, several thoracic surgery fellows and research assistants. Together the thoracic surgery team performs over 1000 cases a year.
Dr. Levent Elbeyli is the driving force for thoracic surgery. A Gaziantep native, he founded the department in 1992, and has seen it grow from a few scattered beds to a full-fledged program with a full-time clinic, 2 dedicated operating rooms, 4 ICU beds and 15 to 20 cases a week.
For the thoracic nurse, the department of Thoracic Surgery is a dream come true; tracheal cases, surgical resections, esophagectomies, thoracic trauma – all of the bread and butter that makes our hearts go pitter-pat. But then there is also plenty of pediatric cases, pectus repair, foreign body removal (oro-esophageal) and on-going surgical research. They do a large amount of pediatric and infant bronchoscopies (for foreign body obstructions, tracheal malformations etc).
There is the slightly exotic hydatid cysts and the more mundane (but my personal favorite) empyema thoracis to be treated. Cancers to be staged, and chest wall resections to undertake. I feel almost overwhelmed in my own petite version of a candy store; everywhere I turn I see opportunities to learn, case reports to write and new things to see.
My non-medical readers might be slightly repulsed by my glee – but it is this intellectual interest that keeps me captivated, engaged and enamored with thoracic surgery and caring for thoracic surgery patients. And then there is the HITHOC program. With a large volume of mesothelioma and pleural based cancers due to endemic environmental asbestos in rural regions of Turkey, there is an opportunity to bring hope and alleviate suffering on a larger level. (Dr. Isik sees more cases here in his clinic in one year than I have seen in my entire career).
In this study, Dr. Isik and hs team looked at 73 patients with malignant pleural mesothelioma (MPM) who were in three different treatment groups. Group 1 received surgery only (extrapleural pneumonectomy). Group 2 received palliative treatment only. Group 3 received lung sparing surgery with hyperthermic chemotherapy (HITHOC). Lung sparing surgery included pleural decortication.
While the treatment groups are small, the results show a clear survival benefit to the patients receiving HITHOC. Surprisingly, the palliative group lived longer than the surgery alone group.
Survival based on treatment modality:
Surgery only: 5 months average surgery. 15% survival at 2 years
Palliative treatment only: 6 months average survival 17.6% at 2 years
HITHOC group: 27 months average survival 56.5% at 2 years
Selected Bibliography for Dr. Işık
Işık AF, Sanlı M, Yılmaz M, Meteroğlu F, Dikensoy O, Sevinç A, Camcı C, Tunçözgür B, Elbeyli L (2013). Intrapleural hyperthermicperfusion chemotherapy in subjects with metastatic pleural malignancies. Respir Med. 2013 May;107(5):762-7. doi: 10.1016/j.rmed.2013.01.010. Epub 2013 Feb 23. The article that brought me to Turkey, and part of our series of articles on the evolving research behind HITHOC.
Isik AF, Tuncozgur B, Elbeyli L, Akar E. (2007). Congenital chest wall deformities: a modified surgical technique. Acta Chir Belg. 2007 Jun;107(3):313-6.
Er M, Işik AF, Kurnaz M, Cobanoğlu U, Sağay S, Yalçinkaya I. (2003). Clinical results of four hundred and twenty-four cases with chest trauma. Ulus Travma Acil Cerrahi Derg. 2003 Oct;9(4):267-74. Turkish.
Sanli M, Arslan E, Isik AF, Tuncozgur B, Elbeyli L. (2013). Carinal sleeve pneumonectomy for lung cancer. Acta Chir Belg. 2013 Jul-Aug;113(4):258-62.
Sanli M, Isik AF, Zincirkeser S, Elbek O, Mete A, Tuncozgur B, Elbeyli L. (2009). The reliability of mediastinoscopic frozen sections in deciding on oncological surgery in bronchogenic carcinoma. J Thorac Cardiovasc Surg. 2009 Nov;138(5):1200-5. doi: 10.1016/j.jtcvs.2009.03.035. Epub 2009 Jun 18.
Sanli M, Işik AF, Tunçözgür B, Arslan E, Elbeyli L. (2009). Resection via median sternotomy in patients with lung cancer invading the main pulmonary artery. Acta Chir Belg. 2009 Jul-Aug;109(4):484-8.
Sanli M, Isik AF, Tuncozgur B, Elbeyli L. (2010). Successful repair in a child with traumatic complex bronchial rupture. Pediatr Int. 2010 Feb;52(1):e26-8. doi: 10.1111/j.1442-200X.2009.03000.x
Sanli M, Işik AF, Tunçözgür B, Meteroğlu F, Elbeyli L. (2009). Diagnosis that should be remembered during evaluation of trauma patients: diaphragmatic rupture]. Ulus Travma Acil Cerrahi Derg. 2009 Jan;15(1):71-6. Turkish.
Readers here know that thoracics.org doesn’t shill for anyone.. We are a proudly independent website with no outside funding (as painful as this is sometimes). But we are happy to share the following information:
The Environment Litigation Group, which is a law firm specializing in lawsuits related to asbestos and other toxic exposures is offering complimentary gift baskets for cancer patients. Asbestos is recognized world-wide as a dangerous cancer causing chemical, and has been banned from use in 67 countries*.
Thoracics.org is posting the information here since this law firm works with many of the people with mesothelioma to assist them to obtain the financial assistance that was promised to them – as part of a huge financial settlement that was set aside for this purpose. In the United States, patients often need legal assistance due to a pattern of aggressive defensive tactics used by multiple corporations to shield themselves from liability. This has been aided by a former president who aimed to please his corporate sponsors.
This is a particularly egregious abuse when you consider that the link between asbestos and disease has been well-known since the 1920’s.
So we are pleased to share this link for complimentary gift baskets for cancer patients. (This is the same firm that offered free face masks during the face mask shortage). And – if they can help someone access the financial resources they are entitled to, all the better..
*It remains in prevalent use in places like India where the are few effective controls to prevent it’s use. This has implications for both Indian workers in the manufacturing sector, as well as consumers – in both domestic and international markets.
Migliore et. al at the University of Catania, Italy have just published the first randomized pilot study that directly compares hyperthermic intrathoracic chemotherapy with VATS pleurectomy / decortication with VATS talc pleurodesis. This is important because it represents a shift in the thinking surrounding treatment of Malignant Pleural Mesothelioma (MPM). For too long, too many surgeons have automatically shunted these patients into the palliative care treatment algorithm, which includes talc pleurodesis.
As we have discussed on multiple previous posts on this topic; treatments like talc pleurodesis are mainly performed for symptom relief. (The instillation of talc into the pleural space does nothing to treat the underlying cancer, but the talc pleurodesis slows the re-accumulation of pleural effusions which are a common cause of shortness of breath in these patients). HITHOC is different; it’s an active treatment aimed at treating the mesothelioma. A related treatment, called HIPEC (which is the same treatment aimed at cancers in the abdominal cavity) has rapidly become the standard of care for carcinomatosis, malignantperitoneal mesothelioma and other abdominally-based cancers.
Another important difference between this study and prior work in this area is the use of minimally invasive surgery for both groups. In several prior research studies, the use of large open operations in combination with HITHOC is believed to have contributed to an increased morbidity and mortality.
Multiple small studies (featured on this site) have shown increased survival and longevity for patients receiving HITHOC but these studies were not randomized. Randomization (while sometimes seeming to be cruel to enrolled patients) is important to eliminate conscious or unconscious treatment bias, and randomized control trials (RCT) are considered the highest level of evidence.
Treatment bias is when researchers consciously or unconsciously select patients that they think will do better to place into one treatment group versus another. Sometimes this treatment bias is built into the study (ie. sicker patients enrolled into a palliative care arm of a study).
As you can imagine, if all of the high functioning, ambulatory, well-nourished patient with earlier stage cancers go into the treatment arm, and all the cachectic, bedridden patients with advanced cancer go into the other arm of the study, the results are more likely to favor the first group. Surprisingly, this sort of sorting strategy is not uncommon, and is sometimes used along with ‘non-inferiority’ trials to push expensive treatments and technologies. Migliore et al. lessen this by using patients at 3 separate study sites and randomizing them into two groups.
However, some selection bias will usually still exist, particularly when involved in a study in a specialized area like this – meaning that patients have to be referred to the study center in the first place. Hopefully, if the program is large enough and well-publicized in the local medical communities, referring physicians will send any and all of their patients with malignant pleural mesothelioma to be evaluated for enrollment. Once the researchers start receiving the referrals, then they use standardized inclusion criteria to enroll patients. This way, the patients selected are similar to each other, in cancer staging, functional status, age etc. Apples to Apples, so to speak.
How is a pilot study different from a ‘regular’ study?
As a pilot study, the main aim of the study was to recruit patients (to see if a larger future trial is practical or feasible). If you can’t get eligible patients into your studies, it doesn’t matter what medical breakthrough you might be working on.
This pilot study also have secondary goals; determining statistical significance (how many patients do we need to treat to show a statistically significant difference aka Number Needed to Treat (NNT), Survival rates at specific fixed intervals, length of stay, rate of peri and postoperative complications.
Who could participate (aka inclusion criteria)
In this particular study, all of the participants had to have a pleural effusion along performance status equal or below 2. This means that the patients had to be fairly functional and independent.
0: Fully active, no restrictions on activities. A performance status of 0 means no restrictions in the sense that someone is able to do everything they were able to do prior to their diagnosis.
1: Unable to do strenuous activities, but able to carry out light housework and sedentary activities. This status basically means you can’t do heavy work but can do anything else.
2: Able to walk and manage self-care, but unable to work. Out of bed more than 50% of waking hours. In this category, people are usually unable to carry on any work activities, including light office work.
3: Confined to bed or a chair more than 50 percent of waking hours.Capable of limited self-care.
4: Completely disabled. Totally confined to a bed or chair. Unable to do any self-care.
In addition to this, and patient participant consent, the participants had to agree to undergo VATS pleurodesis. (This last inclusion criteria may sound obvious, but if all your enrollees only agree to take the ‘experimental’ treatment, then the study isn’t random).
Patients with advanced disease, and patients who were too sick/ debilitated to undergo surgery/ anesthesia were excluded.
Potential limitations to randomization with this study design
In this pilot study, the randomization strategy is one of limited utility. In this study, recruited patients were ‘randomized’ based on which medical center they presented to. Now, that probably worked just fine when they were only recruiting 3 to 5 patients per year but this presents a potential problem for future, larger studies. Imagine, dear reader, after reading numerous articles here at thoracics.org, your loved one, family member, or even a neighbor is diagnosed with malignant pleural mesothelioma. Well, as an educated reader, and patient advocate, you are going to send your loved one to the treatment center that you know does the procedure you want. Depending on your oncologist, they might do the same. (We do it all the time in medicine when we refer patients to specific hospitals for “a higher level of care”/ surgical evaluation etc.). It wouldn’t take very long or very many patients for much of the medical community and the educated public to know patients enrolled in the trial at the University of Catania are in the treatment arm of the study, and getting HITHOC (Group B) and that the patients at Morgagni Hospital and University Hospital of Palermo (Group A) receive palliative treatment with talc pleurodesis. But given the relative scarcity of published information on HITHOC for the general public and in Italian, we can argue that for this small pilot study, this strategy worked. As long as the patients in the treatment groups look about the same, it shouldn’t affect the outcomes (that’s where performance status, and degree of disease comes in.)
Also, I would like to point out – that in this study, all of the patients continued to receive adjuvant therapy, which I think is really the only ethical option available. (If you know that talc pleurodesis is only of palliative value, it’s very questionable to require study participants to discontinue adjuvant chemotherapy, which may help slow the spread of their disease. We already know adjuvant chemotherapy doesn’t work that well, (hence the need for discovery of new treatments) but it seems almost punitive to make participants discontinue chemotherapy. So, while some many argue that this adjuvant treatment may impact results, the authors opted to take the more ethical route. Since everyone in the study was getting the adjuvant treatment, it can be factored into the study results.
As a pilot study, comparison groups are small. As we discussed before, one of the primary aims of this study was the recruitment of eligible patients – and it took several years (almost six) for the authors to recruit enough patients to be able to extrapolate data and publish this study. In this study, Group A had 14 people, group B had 13. As a pilot study, that is a respectable size (many pilot studies have groups in the single digits). However, this study size highlights one of the biggest limitations of pilot studies – and it’s also the reason that these authors don’t suggest changes to the treatment algorithm based on their results. Pilot studies are not designed to change treatment regimens – they are designed to see if there is enough of a reason to investigate further. (aka Is there something there? )
It’s just not enough people to make broad statements or changes to current treatment. The authors of this study acknowledge this.
A word about study size
Readers need to be careful to make sure they don’t fall into the trap of forgetting the importance of study and treatment group size. (This commonly occurs when the general media reports on medical findings. One of the best examples is the widespread reporting in the early 2000’s on the use of cinnamon as a treatment for diabetes. Millions of people at home adopted this as a more ‘holistic’ alternative, despite the fact that the preliminary studieshad very few patients in the treatment (cinnamon arm). It wasn’t until 2013, that the first meta-analysis was published showing many of these claims to be misleading and exaggerated, and this meta-analysis was still based on multiple small size studies (see figure below)
So now that we’ve discussed study size for this pilot study, let’s look at their findings and determine, Is there something there – an apparent difference in outcomes between the small groups important enough that a larger study should be conducted.
What were the actual treatments performed?
The patients in Group A had a talc pleurodesis via the Uniportal VATS approach that included a surgical biopsy for final diagnosis and tissue type.
Patients in group B underwent tissue biopsy prior to the procedure to confirm the diagnosis of Malignant Pleural Mesothelioma and tissue type. These patients then underwent pleurectomy / decortication via the VATS approach with mini-thoracotomy followed by the instillation of chemotherapy. The surgeons removed all of the parietal and visceral pleural as well as any visible tumor tissue (debulking). Then cisplatin, diluted with 2-3 liters of saline was heated to 41 degrees in temperature, and then circulated through the chest cavity for 60 minutes.
Since I’ve included the link to the reference article, I am going to skip a lot of the discussion of group comparisons, (they were very similar), hospital stay (very similar) and the rates of post-operative complications were very similar (group A 8 patients, group B 7 patients).
Let’s look at the big question for the participants in the study and their families – and the real reason Dr. Migliore and all of his colleagues are investigating HITHOC as treatment.
Look at the last column – at 36 months (3 year survival):
4 patients in the HITHOC treatment group were still alive versus just one in the talc pleurodesis cohort. The authors note that this survival for the HITHOC group might even be skewed a little, in that some of the patients in the HITHOC group didn’t receive treatment until SIX months after diagnosis (and all survival rates are calculated as length of survival after diagnosis).
So, yes, even with these small, small numbers, these findings are important enough for researchers to continue investigate in this area. It certainly warrants a larger study, research grants/ and other financial support.
However, it also needs to be noted, that researchers in this study found that the tumor tissue type had a major impact on outcomes. Patients with epithelioid MPM lived on average of 15 months after talc pleurodesis ( 9 patients) versus 45 months after HITHOC ( 9 patients). Patients with biphasic tumor type, or sarcomatoid type were less frequent in this study, but it appears to carry a poorer prognosis.
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
Thoracics.org has received a request from a U.S. based law firm that specializes in Environmental Law (asbestos, toxic exposures, and other medical harm). They are offering free face masks for all of our American readers with cancer, or caring for loved ones with cancer, during the Covid-19 pandemic.
The Environmental Litigation Group (ELG) is based in Birmingham, Alabama.
While we appreciate their generous offer to our readers, this is not an endorsement of their services (which we have no way of evaluating.) Thoracics.org receives no additional financial or other support from this company.
However, on behalf of patients everywhere, we say Thank you.
It’s our ten year anniversary of thoracics.org! It’s an amazing milestone for us.
Ten years of interviews, case reports and the latest research and developments in thoracic surgery.. Ten years of trying to connect patients with the information they need – ten years of sharing information from around the globe.
We have worked very hard to remove many of the barriers that hinder the widespread reporting of new developments; whether due to language barriers or a long-standing western bias in publishing.
We have also tried to put the human faces on this work, work that is done by individuals, and people around the world, for the purpose of helping others. We need to know the names and faces of our heroes. We need to know about the long hours, all-night surgeries, skipped meals, lost times with families and all the other personal sacrifices that these people undertake willingly, on a daily basis.
While we have been quiet for the last several months, during the Covid-19 pandemic, that doesn’t mean that thoracic surgery has. Surgeons around the world, have continued to operate, take care of patients, conduct research and advance the field, in the midst of one of the worst global pandemic in modern times.
So we will be highlighting some of this work in the coming days. We will also pay homage to the brave healthcare workers and surgeons during this pandemic.
This 2019 article from the Indian Journal of Surgical Oncology covers a very tiny group of patients undergoing HITHOC during an 8 1/2 year period has serious limitations (with a total of only seven patients having HITHOC) but it’s still worth a few minutes of our readers time, particularly if the reader’s interest in HITHOC hasn’t translated into practice yet.
Patel et. al. do a very nice job of describing their inclusion criteria, as well as the surgical techniques utilized in this study, where patients underwent either pleurectomy/ decortication (P/D) or extrapleural pneumonectomy (EPP) with/ without HITHOC.
In fact, it’s one of the better overviews of the procedure that’s been published in recent years. This praise must be tempered by the fact that HITHOC is paired with two very high morbidity/ mortality procedures in this study. P/D and EPP alone are difficult-to-tolerate procedures, and for that reason, are limited to a small subset of eligible patients. Multiple studies by the leaders in the area of HITHOC such as Reid,Isik etc. have already demonstrated that HITHOC can be effective without EPP.
For readers, there are some other serious limitations in their study. Despite having a tiny sample size, the HITHOC and non-HITHOC groups are not comparable. It is figuratively; apples to oranges.
The non-HITHOC group was primarily made up of pleural mesothelioma patients, and based on that diagnosis alone – would have been expected to do worse post-operatively. Yet, we don’t know if they did (do worse or not).
One of the reasons that we don’t know if the pleural mesothelioma patients outlived the HITHOC treatment group is that measurements were discordant as well. The authors talk about 24 month and 36 month survival in the non-HITHOC group, but apparently, didn’t even follow the HITHOC group after 9 months. (Or chose not to present their data after nine months, which is, worse. )
The authors do acknowledge this, in their discussion, but also point out that two of the HITHOC patients (one a 40 year old female*) had extensive, infiltrating disease processes and poor pre-operative functional statuses.
It’s an interesting read for the most part, but it begs for follow-up so we will reach out to Patel etl. al. and update readers with any response.
*There are two charts that nicely display all the characteristics of patients in both groups. Interestingly, in this HITHOC group, both of the female patients presented with more advanced disease many, many months after initial diagnosis. The 40F patient is clearly a last ditch ‘salvage’ patient, so her six month survival time after surgery would be better measured against more palliative procedures.
– 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)
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.
This fear of thoracotomies dwarfs the very real risks of prolonged illness and debility.
The story of empyema is as old as surgery itself. Hippocrates himself describes treating empyema with chest tube placement. However, over the years – the urge to treat this condition with the expediency and urgency it requires, has waned. With the advent of antibiotics came the idea of a “wait and see” philosophy. When the alternative was a thoracotomy, this could be forgiven. In the age of uniportal VATS, it is not.
Current treatment algorithm (with basic variations)
Patient w/ parapneumonic effusion/ empyema –> antibiotics –> still sick –> more antibiotics –> still sick –> chest tube (or pigtail placement) –> fibrinolytics then —-> If treatment fails, consult thoracic surgery
The current treatment algorithm, which often starts as several weeks of outpatient antibiotics, (usually initiated for treatment of community acquired pneumonia that develops into a parapneumonic effusion), that engenders an even longer period after subsequent follow up chest x-rays, then CT scan fail to show improvement.
A pneumonia in late September, becomes an effusion in October, then progresses to empyema as various strategies are attempted and fail. One antibiotic is switched to another, a pigtail is placed in radiology (with partial results), then perhaps, a larger tube, and fibrinolytics. Then, only then – is the thoracic surgery service consulted.
At this point, the patient has been sick for several days to weeks. As they remain sick, there is a decline in both nutritional and functional status. The “spry” and youthful 75-year-old becomes a mostly bedridden and frail elderly patient. This too, works against the patient and their recovery, as internal medicine physicians and pulmonologists are reluctant to refer this now frail patient due to the perceived rigors of surgery. This fear of thoracotomies dwarfs the very real risks of prolonged illness and debility.
For most modern-day practices, thoracotomies for decortication are a thing of the past. Minimally invasive surgeries such as VATS or uniportal VATS have replaced the large incisions of the 1980’s and reduced, if not eliminated, the incidence of morbidity and mortality related to this procedure. But our treatment algorithms haven’t kept up with surgical advances.
Proposed treatment algorithm:
Patient sick –> CT scan showing effusion –> thoracic surgery consultation with uniportal VATS for any effusion/empyema
Uniport VATS, (which is basically a glorified tube thoracostomy with anesthesia and a camera) allows for more than drainage of fluid from the pleural cavity. It also allows visualization, for better evacuation of infected material. Surgeons are able to target areas of loculation; and complete a full decortication, if necessary. While the use of anesthesia may add a degree of risk for the frailest of patients, it is the anesthetic/ and analgesic effects that allow for optimal patient positioning, and instrument manipulation, allowing for better results that bedside tube thoracostomy alone.
Why then, are we, the thoracic surgery service still only receiving consultations at the 23rd hour? Why isn’t the literature pushing for a change in perspective, or a change in practice?
Current literature on empyema
Chin, Redden, Hsu and Driel (2017, 2013) published a Cochrane review of multiple randomized control trials comparing outcomes for tube thoracostomy versus VATS. However, this review, which found in favor of VATS, was primarily based on pediatric studies.
Notably, this Cochrane review (which did not include uniportal VATS), showed decreased mortalityand length of stay in the thoracotomy and multi-port VATS groups compared with the tube thoracostomy group.
Another Cochrane study, Cootes et al. (2009), which also demonstrated a decreased length of stay, and decreased duration of chest tube placement with VATS) was withdrawn due to questions about inclusion criteria.
The remainder of the existing studies
The remainder of studies published since the Cochrane database review had similar limitations. A German study published in 2017 (Segerer et al.) that reviewed 645 children throughout the country that presented with empyema and showed no different in the length of stay. But only 7% of these children underwent surgical procedures compared to 46.9% that underwent lesser procedures (thoracentesis or chest tube placement).
A more recently published study, Tanbrawarsin et al. (2018) showed a decreased incidence in recurrent bacterial empyema in patients who underwent surgery, but it is difficult to apply these findings to our algorithm, since it was based on just 34 patients, and was not randomized. Furthermore, all advanced empyema patients received open thoracotomies. Some patients also underwent thoracoplasties, which is a procedure not commonly used in many parts of the world, including the North America.
Patients deserve better
While the published data appears to remain undecided on the algorithm, it is clear, our patients deserve better. They deserve an approach that is timely, and effective. There is significant data that demonstrates that early surgical intervention improves outcomes. But unless thoracic surgeons present an overwhelming mountain of evidence [at pulmonary and internal medicine conferences] that uniportal VATS is superior to lesser therapies, patients with empyemas will continue to receive lesser therapies, first, before we receive the thoracic surgery consult.
They deserve the opportunity to rapidly return to health and full function. For that, we need to commit to performing and reporting more research aimed at looking at the most effective treatment for empyema. We, in thoracic surgery, know that that the answer is not more of the same; increasingly ineffective antibiotic regimens and a long convalesce. Now, we have to prove it, and publish it, over and over, to get past the persistent belief that risk of surgery outweighs the risk of continued illness.
Now, we need to conduct and publish studies, and reviews that comparenonsurgical treatment with uniportal VATS (excluding the dread thoracotomy) and looking for meaningful end points beyond mortality. Studies need to look at the length of stay, chest tube duration, morbidities related to either treatment (deconditioning, blood transfusions, DVT, malnutrition, etc. ) as well as both the 30-day recurrence and re-admission rate.
Surgeons, this is your call to action.
References (with links to full text articles when possible)
Shresthra et. al. (2011). Evolving experience in the management of empyema thoracis. KUMJ 2011 Jan-Mar 9 (33) 5-7. In this study, 82% of patients treated with tube thoracostomy eventually needed thoracotomy. Full text link not available.
Tanbrawasin, A. et al. (2018). Factors associated with recurrent bacterial empyema thoracis. Asian J. Surg 2018 Jul, 41(4) 313-320.
There are multiple studies showing early surgical intervention improves outcomes in empyema, but only a single selection was placed within the editorial above.
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.
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).
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.
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.
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.
A look of HITHOC in two programs in Germany, Freiburg and Regensburg
While there are a reported 17 centers in Germany performing the HITHOC procedure, this, dear readers, is the tale of two cities.
Over the years, finding information and making contact with surgeons performing the HITHOC procedure has been a long, expensive and time-consuming affair. Emails, interview requests and research questions frequently go unanswered. Expensive trips abroad for in-person interviews sometimes end up with all-too-brief meetings with disappointing results. But illuminating, and informative interviews and in-depth discussions about HITHOC are worth the inconvenience.
After the publication of a brief English language abstract for a larger article in German that hinted at research outcomes for multiple facilities, thoracics.org reached out several times to the authors (Ried et al, 2018) for further comment.
Now, thoracics.org is in Germany to talk with Dr. Hofmann as well as another thoracic surgeon at a different facility in southwestern Germany.
Our journey starts just a few hours south of Frankfurt, in the picturesque city of Freiburg im Breisgau, in the Black Forest region of Germany best known for Cuckoo clocks, the Brothers Grimm fairy tales chocolate cake, and thermal spas. Freiburg is the largest city in this region. It’s a charming locale with a history that extends back to medieval times despite Allied bombing in a more recent century.
Frieburg is also home to a University Hospital and the Robert Koch clinic of thoracic surgery. Dr. Bernward Passlick is the Director and head surgeon of this department.
Dr. Passlick is the reason thoracics.org has come to this charming but sleepy college town. After several months of written correspondence, thoracics.org arrived in Freiburg to here more about the HITHOC program from Dr. Passlick himself.
However, from the first initial comments from the department secretary who lamented that the length of HITHOC cases was “a waste of operating room time” [because multiple other cases could be done in the time it takes to perform one HITHOC case], to the actual meeting with Dr. Passlick, nothing proceeded as expected. Dr. Passlick was uninterested, and unwilling to discuss HITHOC. He reported that he did approximately 15 cases a year, retains no outcomes data and has no interest in publishing any results from these cases. However, despite the apparent lack of any documentation or statistics on HITHOC cases performed at the facility in Freiburg, he states that the ‘average’ survival is 2 to 3 years with some long-term survivors at six years or more, post-procedure. [When asked when he had no interest in publishing data showing six year survival, Dr. Passlick had no answer. We sat in silence for a few minutes, until I thanked him for his time and left.]
He briefly mentioned that his real interest lay in the area of treating multiple pulmonary metastasis using laser assisted resection via open thoracotomy. The laser resection technique allows for greater lung sparing in patients with multiple (and presumably, bilateral) pulmonary metastases from other primary cancers such as advanced colon, renal or breast cancer. He uses this technique for patients with five or more pulmonary metastasis, and reports he has operated on patients with as many as 20 to 25 metastatic pulmonary lesions. He didn’t have any statistics on this procedure to share, but did offer that he has a paper scheduled for publication soon. So, a bit disheartened, and thus unenlightened, it was time to leave Freiburg.
Leaving the Black Forest, we head east – into Bavaria with miles of rolling hills dotted with windmills, vineyards and solar panels, past Munich and then north into the area where the Danube, the Naab and the Regen rivers meet. This is Regensburg, a city that was founded by the Celts. The Romans later built a fort here in 90 CE. The remains of a later Roman fort are readily seen in the historic city center.
But as charming as the city of Regensburg is, we aren’t here for sightseeing. Our next stop is another HITHOC program. It’s not the biggest in Germany, not by far, but it is a very well established program that is grounded in evidence-based practice, protocols and on-going scientific inquiry and research.
We are here to interview Dr. Hans – Stefan Hofmann, the head of the thoracic surgery department at both the University hospital and the large, private Catholic hospital in town. Dr. Hofmann along with his colleague, Dr. Michael Reid.
Re-assuredly, the interviews were more familiar territory. Dr. Hofmann was very friendly, and forth-coming. Dr. Hofmann reports that their HITHOC volumes are fairly small, and attributes this to plateauing rates of pleural mesothelioma. (The majority of the HITHOC cases were initially performed for pleural mesothelioma, but there have been an increasing number of cases treating advanced thymomas (stage IV) with HITHOC as well as limited cases of pleural carcinosis.
In some of these thymoma cases, the patient undergoes a staged procedure, with mediastinal exploration performed as the first step. In some cases, the Regensburg facility receives patients after they have undergo mediastinal lymph node dissection at another facility.
His program has been performing HITHOC for over ten years, using a combination of cisplatin and doxirubin with a cycle time of 60 minutes. He reports a low rate of complications and points to the multiple publications by his colleague, Dr. Reid for outcome data. Dr. Reid has another couple of articles in press including another paper, that explains their renal protection protocol, [in addition to Reid’s earlier work in 2013, listed below].
Of course, the visit wouldn’t be complete without a trip to the operating room. While it wasn’t a HITHOC case, Dr. Hofmann was performing a robotic -assisted thoracoscopic surgery on a patient requiring lung resection for adenocarcinoma. As the patient was already medicated when I entered the operating room – there are no operating room photos. The case proceeded quickly, efficiently with no intra-operative complications and minimal EBL.
We won’t talk about that a lot here – it’s not the right forum, but for readers who would like more information about Dr. Hofmann, or are interested in surgery with Dr. Hofmann (or Dr. Gonzalez Rivas, Dr. Sihoe or any of the other modern Masters of thoracic surgery), we are happy to assist you. Contact me at email@example.com
Both surgeons are widely published on multiple thoracic surgery topics. This is a limited selection of citations related to HITHOC.
Today’s recommended read is for all of the thoracic surgeons out there that are interested in establishing their own nonintubated uniportal programs. This is a interesting article if you’ve taken a masterclass on uniportal technique, reviewed the literature around nonintubated surgery, but haven’t yet taken the next step to start performing this procedure at your hospital.
Thoracics.org has reached out to the corresponding author, Sook Sung for more information about their experiences with nonintubated uniportal VATS including some updates, but let’s review the primary article while we await a reply.
In the article, Nonintubated uniportal video-assisted thoracoscopic surgery: a single center experience, Seha Ahn et al. discuss their experiences over a six month period after initiating this technique in January 2017.
During this period, 40 patients underwent this technique. Pre-operative patient selection was important with multiple exclusionary criteria.
Exclusionary criteria for initial cases: General
Obesity (BMI greater than 30
Anticipated/ expected difficult airway
Persistant cough/ or high amount of secretions
At increased risk of gastric reflux
Exclusionary criteria: Cardiopulmonary
Expected/ anticipated to have extensive adhesions
Prior pulmonary resection
N2 stage lung cancer
Severe cardiac dysfunction (exact definition not defined)
Anesthesia and Intra-operative Monitoring
Prior to the procedure, patients received dexmedtomidine. At the time of the procedure, patients were maintained with infusions of remifentanyl and propofol.
No patients were intubated. Patients did receive supplemental oxygen by mask at a rate of 6 to 9 liters/ min. Oxygenation was monitored with botha small single nostril end-tidal CO2 monitor and pulse oxymetry. Anesthesia monitoring including a BIS monitor. General hemodynamic monitoring consisted of continuous EKG/ telemetry and serial blood pressure cuff measurements.
As part of the surgical technique, the authors administered an intercostal nerve block for additional analgesia. In the majority of patients (35 of 40), intrathoracic vagal nerve blocks were also performed to reduce / prevent coughing during the procedure.
The procedure was carried out using a single 3 to 4 cm incision. The main surgical instruments used were a 10mm 30 degree scope, a harmonic scalpel and a curved suction tip catheter.
There were 40 total patients in this study, which spanned a period of six months. More than half of these patients (57.5%) were women. The mean age was 60.
The vast majority of these patients (72.5%) had lung cancer. Seven patients (17.5%) had surgery for pulmonary metastasis. The remainder of patients had surgery for either benign lung disease or pleural disease.
Over half of the patients underwent lobectomies (57.5%). 10 patients (25%) had wedge resections, with six patients having segmentectomies (15%) and a solo patient undergoing a pleural biopsy.
There were several intra-operative conversions. The majority of these conversions were related to anesthesia, with 3 patients requiring conversion to standard intubation. The authors are a little unclear with the reasons for this – with one sentence saying it was not related to hypoxia (with all patient sats greater than 90%). The authors then attribute the conversions to excessive respiratory movements, but then report that all three of the patients’ hypoxemia resolved with intubation. This is better explained in a later portion of the paper, but it is still a bit confusing as to whether excessive respiratory movement was a contributing cause for the reason to intubate mid-procedure.
There was only one conversion for surgical technique, which occurred after the dread pulmonary artery injury, with the authors converting to multi-port VATS. There were no conversions to open thoracotomy.
Seven total post-operative complications (17.5%)
3 patients with prolonged air leaks
1 delayed pleural effusion
Interestingly enough, outcomes based on traditional criteria, (chest tube days, and overall length of stay) were not significantly different that results published for more traditional types of thoracic procedures.
The average post-operative chest tube time was 3.2 days (range: 1-13 days)
The average hospital stay was 4.4 days (range 1 – 18 days).
There was one notable outlier listed, a patient with a prolonged airleak that resulted in a 20 day hospital stay.
This article is note worthy of several reasons, in that the authors both describe their techniques and the initial results of the initiation of a new surgical approach (nonintubated and uniportal) in their facility. The authors are to be commended for reporting research results that show a (17.5 %) high rate of complications, which is presumably related to the learning curve of adopting a new surgical protocol.
However, this article would have been much more informative if there had been more of an in-depth discussion of the challenges involved in initiating and managing a nonintubated uniportal program, instead of a general review of the literature. While the article notes that there was a solo surgeon involved in these 40 procedures, there is little discussion of the prior experience of that surgeon or the anesthesia team(s) involved. What the surgeon previously experienced in uniportal VATS? If so, what was the level of experience?
The same goes for the anesthesiologists involved in this study, since a large portion of the procedure (ie. the nonintubated portion) as well as the highest level of conversions (to standard intubation) occurred under their guidance. A short discussion about intra-operative intubation would have been a helpful addition for readers as well, such as a discussion of the difficulties (or lack thereof) of intubating a patient after they have been secured into a lateral decubitus position.
While the traditional outcomes measures appear fairly unchanged in comparison to standard VATS with general anesthesia and intubation, what was the difference in related outcomes?
Was there a difference in/ would they anticipate a difference in (with larger numbers of patients):
Post-operative intubation? How man patients required urgent/ emergent intubation during the post-operative period?
Post-operative pneumonias and other respiratory complications? While the authors cite one post-operative pneumonia, there appear to be few other respiratory complications cited in this study.
Post-operative anesthetic complications such as hemodynamic compromise (requiring prolonged use of pressors, for example). What about post-operative nausea/ vomiting or gastric ileus?
Since nonintubated and uniportal techniques have been proposed as a alterative to standard surgery for high risk patients (patients with poor respiratory reserve/ cardiovascular disease), the presence or lack of these complications in patients (even specially selected patients) is important.
When reviewing the lack of clear-cut advantages such as shorter length of stay, were there other reasons for it, such as post-operative nursing care? Are there changes that need to be implemented/ have been implemented since this study was published that have resulted in fewer chest tube days, or a shorter overall length of stay?
In the time since this study was concluded, what have been this group’s continued experience? Have there been any unexpected outcomes or observations? What changes continue to need to be addressed?
Are there any other observations that the authors would like to share? While traditional journals have size and article length limitations, we don’t here at thoracics.org.
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)
We’ve come along way when discussing Mesothelioma and the use of hyperthermic intrathoracic chemotherapy (HITHOC) since this site was started back in 2010. In fact, for our first discussions about this technique, we had to travel to Ganziantep, Turkey
Back then, Dr. Isik was one of very few researchers to be actively looking, investigating and performing research in this area. So, when thoracics.org wanted to report about HITHOC – we had to go to the source. There were a few other researchers, in scattered locations across the globe, such as the Nara experiment in Japan, a couple of case reports out of Germany, but otherwise, it was a barren landscape in thoracic research.
Then came Dr. Marcello Migliore and the Italian research teams.. and then everyone else. HITHOC has expanded from the treatment of malignant pleural mesothelioma to a viable treatment for malignant pleural effusions from almost any kind of primary cancer (including lung, breast, thymoma).
So now that Thoracics.org is preparing to return to Italy for VATS International 2018 – it’s time to check in one the state of HITHOC in 2018.
It seems the Germans have the answer. Unfortunately, they are keeping it to themselves, because Reid et. al’s most recent article that sums up state of HITHOC in over 116 German institutions is published only in german. Thoracics.org has attempted to contact the lead author for more details, but at the time of this publication, we are still awaiting a reply.
The English version abstract gives us a tiny sliver – of the results of the authors survey of german thoracic surgery practices. Ried et al. reports that of the 116 facilities they surveyed, 17 thoracic surgery departments in Germany are performing HITHOC. All of these facilities perform HITHOC for malignant pleural mesothelioma, with 11 facilities including patients with thymoma with pleural metastasis. Only 7 facilities report performing HITHOC on patients with other secondary pleural carcinosis. While the inclusion criteria doesn’t appear to be the same throughout Germany, the procedural protocol appears to be fairly universal – hyperthermic (42 centigrade) application of cisplatin or cisplatin combinations for a 60 minute cycle. But that tiny scrap of an abstract still leaves thoracics.org with so many questions. Enough in fact, that we promise the authors their own feature article, if we get a reply.
Migliore’s recent editorial, while interesting, doesn’t really add much to our current landscape. On the thoracics.org wishlist instead is a more step-by-step discussion of the Catania University thoracic surgery department’s HITHOC treatment algoriths and review of research results.
Luzzi et al. out of Siena, Italy published a small-scale study on the physiologic effects of HITHOC after pleurectomy and decortication. Notably, these patients are undergoing an more extensive operation than HITHOC alone, and there are part of a smaller subset of patients with a more aggressive cancer than some of our other studies, namely malignant pleural mesothelioma (MPM). While the authors followed 41 patients undergoing HITHOC at their facility, only ten patients were enrolled in their study looking at hemodynamics.
This study which included 10 patients, looked at the hemodynamics of patients before, during the HITHOC procedure, and the early post-operative procedure. The authors were trying to address possible causes of the high rate of complications cited in previous researchers studies. These studies also showed that adequate fluid hydration intra-operatively reduced many of these complications such as hypotension and acute renal injury. The authors hypothesized that microvascular changes (namely systemic vasodilation and with a capillary leak syndrome) contributed to the development of these operative complications. They used both vasopressors and specific fluid volume resuscitation recipes to reduce these microvascular changes during and after the procedure but also observed that colloid and blood transfusions had similar effects. The authors call for the adoption of hemodyanamic monitoring parameters similar to those used in cardiac surgery (Swan Ganz, SvO2 monitoring) for better detection and treatment of these microvascular changes to limit the development of complications.
Chinese authors offer us the most comprehensive view of HITHOC up-to-date. Not through newly published results or an original work, but through a comprehensive meta-analysis of previously published works. Zhou et. al do a nice job of reviewing the existing research and discussing the different applications of HITHOC (outside of malignant pleural mesothelioma for malignant pleural effusions of any underlying etiology. Unfortunately, Thoracics.org has covered many of these articles before – so while it’s a good overview article for HITHOC novices, long-term readers already know the in-depth details of the Isik study, Zhang’s results, and several of the other major studies discussed in Zhou et. al. But the authors make a very salient point – that while several of the programs have formalized and standardized HITHOC protocols, these protocols often differ from hospital to hospital, with no set universal chemotherapeutic regimen in place. A universal protocol would make it easier to conduct additional meta-analyses and RCTs to determine if HITHOC for malignant pleural effusions are as promising as they appear to be. A HITHOC registry, anyone?
Migliore, M. (2017). Debulking surgery and hyperthermic intrathoracic chemotherapy (HITHOC) for lung cancer. Chinese Journal of Cancer Research, 2017, Dec; 29 (6): 533-534. Editorial.
Reid, M., Hofmann, H. S., Dienemann, H. & Eichorn, M. (2018). Implementation of hyperthermic intrathoracic chemotherapy in Germany. [article in german]. Zentralbl Chir. 2018 Jun, 143 (3): 301-306. Ried et al. are also the authors of that 2014 article, we discussed in a previous post about anesthesia during HITHOC.
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.
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.
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.
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.
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.
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”
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.
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.
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.
New Brunswick, one of Canada’s eastern maritime provinces is struggling to maintain their thoracic surgery service line within the small province of an estimated 800, 000 inhabitants. While a local hospital is interviewing candidates in Moncton, New Brunswick, there is currently only one thoracic surgeon for the entire province, after two other surgeons were forced to go on emergency medical leave. While the current surgeon is a board certified thoracic surgeon, general surgeons have previously served in this position. In an article published in Canadian Broadcast News (CBC), administrators within the province reached out to potential applicants while attempting to reassure local citizens.
This comes after a local outcry over the lack of access to care for New Brunswick patients needing thoracic surgery. Lead by a local nurse, the shortage of thoracic surgeons in the region has received extensive press. Even more so, when it was revealed that neighboring Nova Scotia will not be accepting patients from New Brunswick. (As we’ve written here before, Canada has been particularly hard hit by the thoracic surgeon shortage.
However, with this shortage, comes opportunity; for new thoracic surgeons, foreign medical graduates and other surgeons from outside the Maritime region.
To apply for the position at The Moncton Hospital: click here.
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 firstname.lastname@example.org
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.
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.
Dr. Marco Scarci – Dr. Scarci is a thoracic surgeon at the University Hospital of London and the founder of VATS International.
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:
-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: email@example.com
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 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 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 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 firstname.lastname@example.org
Ever had a clip slip in surgery? New vascular clips to help prevent massive hemorrhage and loss of vascular control from clip slippage.
There is a big push towards cost-saving measures in many operating rooms – by changing back from clips to suture, or using existing energy devices (such as the harmonic scalpel electrocautery device) to replace GIA staplers, clips, and other closure devices. Despite the pressure from financial departments, vascular clips and staplers continue to be popular in thoracic resections. For many surgeons, the idea of using a harmonic device alone for vascular control is an uncomfortable one. (The rule of thumb for using energy devices is to avoid using these devices on any vessels with a diameter larger than one-half the length of tip of the device.)
In other cases, such as large caliber arterial vessels such as the pulmonary artery or control of acute hemorrhage, cautery devices are often contraindicated.
During the recent conference in Peru, Marc Moneaux of Grena, Ltd. gave a presentation on the newest generation of vascular clips designed to address some of the problems with the existing clips, mainly clip dislodgement. The new clip, called with Click aV Plus clip has been endorsed by several prominent thoracic surgeons including Dr. Diego Gonzalez Rivas and Dr. Alan Sihoe.
In this post, we present a new video byTurkish thoracic surgeon, Dr.Cagatav Tezel on VATS decortication for tuberculosis.
There’s a new video over at VUmedi by Turkish thoracic surgeon, Dr. Cagatay Tezel. In this video, as well as a related article over at CTSnet, Dr. Tezel talks about modern day surgical treatment for tuberculosis related complications. Tuberculosis, unlike measles, polio or other diseases associated with the 19th (and earlier centuries) has not faded into the past, despite the availability of a (partially effective) tuberculosis vaccine. Tuberculosis continues to carry a heavy morbidity and mortality burden globally. In fact, for all of the news media surrounding Ebola, HIV, SARS and Bird/ swine and various flu, Tuberculosis is the real killer; and is responsible for 1.8 million deaths a year*.
Complicated multi-drug regimens and poor patient adherence have resulted in the development of new strains of resistant TB. Decreased immune resistance in specific populations such as diabetics, or patients with HIV infection has resulted in a greater number of people with active disease. This means, that thoracic surgery remains a critical component in the treatment of this deadly disease.
Surgical treatment of Tuberculosis and TB related complications
As long time readers know, Thoracics.org has been following the rise of multi-drug resistant (MDR-TB) and extreme/ extensive drug resistant (XDR-TB) versions of the age-old scourge of the ‘white plague‘ as well as the evolution of the surgical treatment of this disease, from the early era of thoracoplasty, as well as more modern treatment of TB related empyemas such as VATS.
In fact, the surgical treatment of tuberculosis is the foundation on which the thoracic surgery specialty emerged, out the operating theaters of TB sanitariums around the world. However, as the development and successful use of antibiotics spread from the late 40’s thru the 50’s and 60’s – surgery took a backseat to drug therapy. The development of these drug resistant strains means that it is imperative that the thoracic surgery community continue to research, innovate and operate on patients with tuberculosis.
We welcome articles and video submissions on this topic from our colleagues around the world.
*Several statistics give the annual death toll at 2 to 3 million.We have cited the most recent WHO figures above.
The Tuberculosis Vaccine: information about the vaccine, and who should get it (according to current CDC recommendations).
Freixinet JG1, Rivas JJ, Rodríguez De Castro F, Caminero JA, Rodriguez P, Serra M, de la Torre M, Santana N, Canalis E. (2002). Role of surgery in pulmonary tuberculosis. Med Sci Monit. 2002 Dec;8(12):CR782-6.
If you can only attend one thoracic surgery conference, shortlist 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.
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. 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.
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.
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.
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.
Talking to Dr. Benny Weksler about Minimally invasive esophagectomies, robotic surgery, lung cancer screening and life in the mid-south.
Memphis, Tennessee USA
Recently, I had the great pleasure and privilege to have a sit down interview with one of the thoracic surgeons whose work I have long admired. Loyal readers will certainly recognize the name, Dr. Benny Weksler, one of the modern masters of esophageal surgery.
Minimally invasive esophagectomies (MIE)
He is best known for his minimally invasive esophagectomies which take much of the pain (literally) out of the traditional surgical resection for esophageal cancer. The minimally invasive esophagectomy is the VATS approach to esophagectomy, using smaller 2 to 3cm ‘ports’ instead of large incisions.
In classic thoracic surgery, large open incisions such as the Ivor Lewis esophagectomy were the best way to optimize survival for patients with this aggressive cancer. However, the traditional open surgery itself is particularly arduous and has been likened to the “open heart surgery” of the thoracic specialty. The Ivor Lewis in particular is two full-sized surgeries; a full thoracotomy combined with a transverse laparotomy. While it has been utilized for decades for excellent visualization, staging and resection, the recovery is a long, painful process.
Dr. Weksler in the mid-south
It’s been just over three years since Dr. Benny Weksler was recruited to start a new thoracic surgery program at The University of Tennessee – West Cancer Clinic – Methodist Hospital System here in Memphis, Tennessee. It’s been a big change, and a bit of an eye-opening experience for the Brazilian native and famed thoracic surgeon who has spent much of this career in the northeast. Prior to this, he was part of the renowned University of Pittsburgh Medical Center under the famed Dr. James Luketich. Since Dr. Weksler’s move, he’s still adjusting to the warmer weather here, which is one of the things he likes best about the area along with the traditional Memphis music scene, which the city is famous for.
It’s also been a time of great changes and innovations for Memphis and the University of Tennessee, as well. Dr. Weksler started the first thoracic surgery service line for the UT – Methodist Hospital system, which is actually the first real dedicated thoracic surgery service line in the Memphis area – which extends across a tri-state area that also covers parts of northern Mississippi and western Arkansas.
Why is this important and what does it mean for Memphis?
Prior to Dr. Weksler’s arrival, patients were either referred to private cardiothoracic surgery practices in Memphis, they went to larger cities with bigger academic centers or they unwittingly trusted their health to a non-specialty surgeon. Neither of those options were ideal, but now patients in the northern Mississippi delta – metro Memphis area can receive state-of-the-art, surgical excellence close to home. For some patients, this is a matter of life or death.
Now the program is growing; so much so, that Dr. Weksler has two full-time thoracic surgeons and is actively looking for a third. With the addition of the third surgeon, Dr. Weksler hopes to expand the UT program to serve local veterans at the Memphis VA.
While Dr. Weksler doesn’t embrace the principles of uniportal surgery, his work on esophagectomies more than makes up for it. In fact, Dr. Weksler is one of the leading surgeons in the United States for minimally invasive esophagectomies. As discussed in previous posts, an experienced esophageal surgeon is critical for patient survival. (Bare Minimum competency for any esophageal surgeon is 25 cases a year – it’s not a surgery for your ‘average’ thoracic surgeon or any general surgeon).
Memphis’ newest secret weapon against cancer (too bad no one knows that he’s here)
In fact, his presence here in Memphis, among otherwise limited surgical services, is like finding a diamond while scavenging for supper in a metal dumpster in a hundred degree heat. In addition to being one of the foremost surgeons for esophageal disease (cancer and benign esophageal disease like achalasia), Dr. Weksler is also an experienced robotic surgeon.
As a newcomer to town, Dr. Weksler is having to re-build his practice volumes. As he explains, “We do about 30 esophagectomies a year, and I also see approximately 60 patients with esophageal cancer that cannot be operated on. 100% of our esophagectomies since I have been here were done minimally invasive”.
I can only speculate as a knowledgeable outsider that these surgical volumes reflect the lack of the general public and referring physicians knowledge about Dr. Weksler’s presence in the mid-south. Dr. Weksler is the type of surgeon that patients will travel across the country to see. My guess is that many of these potential patients are still traveling to Pittsburgh.
New ideas, new programs and new service lines
Dr. Weksler brings with him new ideas and new programs aimed at treating all Memphians. This includes community programs aimed at underserved and at-risk communities. One of these programs focuses on the diagnosis and treatment of lung cancer in African -American communities, which are disproportionately affected by advanced lung cancer, particularly in middle-aged males. By creating and implementing screening programs in these communities, Dr Weksler and his team are able to diagnose and treat lung cancers at earlier stages and improve patient survival. Despite being in its infancy, the program (which does not have a formal name) has screened over 100 patients and diagnosed eight cancers.
If you are a Memphis resident and would like information on this screening program or lung cancer screening: Contact the Lung Cancer Screening Navigator at Dr. Weksler’s office at 901-448- 2918.
Changing the art of Medicine & Surgery in Memphis
Dr. Weksler has been instrumental in creating at atmosphere of multidisciplinary collaboration. For example, programs have been streamlined and designed with patients in mind, to be the most effective, informative and efficient. This means that patients receive a “one stop shopping” experience as Dr. Weksler describes it. Patients are able to see their medical oncologist, thoracic surgeon and radiation oncologist on the same visit. All patients and their cases are presented at tumor board, to determine that treatment is individualized to the patient’s condition, functional status and tumor type which adhering to the clinical guidelines and evidence-based practice to optimize patient outcomes and long-term survival.
Q & A with Dr. Weksler – What patients should expect
Dr. Weksler talked to me at length about this multidisciplinary team approach as well as what patients should expect when they come to Methodist/ West Cancer center for care.
Question: What is the general process/ timeline for patient who has been referred to your clinic for evaluation?
Dr. Weksler: When patients come into the multidisciplinary clinic, patients / families with esophageal cancer will leave the office with a pretty good idea of what is going to happen. Depending on the work up done before they see me [which includes identification of tumor/ cancer staging], we will do the radiation therapy simulation the following
week, and start chemotherapy and/or radiation therapy the next week.
Question: What diagnostics/ medical records should they bring with them?
Dr. Weksler: We would like to see all available records, including previous surgeries, all scans, PET/ CT scans, barium esophagram, endoscopy report and all biopsy reports.
Question: What should patients anticipate? (will they get feeding tubes prior to surgery, etc)?
Dr Weksler: Most patients will get a port for chemotherapy*. We place feeding tubes in patients that loss more than 10% of their weight, or if they suffer from severe dysphagia. Patients can expect a 5 week course of chemotherapy and/or radiation therapy, followed by an interval of 6 to 8 weeks, followed by surgery.
*Editor’s note: A port is a long-term but temporary and completely removable central intravenous access for chemotherapy administration. It is placed underneath the skin with no cords, or lines visible externally. Feeding tubes are also temporary tubes that are easily removed/ reversible but help the patient to maintain adequate nutrition necessary for healing.
He has multiple offices including the West Cancer Center. For an appointment, please contact 901-448-2918.
Unfortunately, while Dr. Weksler and his thoracic surgery program are state-of-the-art, the Methodist website is not.
Additional references and resources (this is a selective list)
1. Oncologic efficacy is not compromised, and may be improved with minimally invasive esophagectomy.
Berger AC, Bloomenthal A, Weksler B, Evans N, Chojnacki KA, Yeo CJ, Rosato EL. J Am Coll Surg. 2011 Apr;212(4):5606; discussion 5668. doi: 10.1016/j.jamcollsurg.2010.12.042. PMID: 21463789
2. Outcomes after minimally invasive esophagectomy: review of over 1000 patients.
Luketich JD, Pennathur A, Awais O, Levy RM, Keeley S, Shende M, Christie NA, Weksler B, Landreneau RJ, Abbas G, Schuchert MJ, Nason KS. Ann Surg. 2012 Jul;256(1):95103.
doi: 10.1097/SLA.0b013e3182590603. PMID: 22668811 Free PMC Article – attached. Recommended reading. If you are only going to read one article on MIE, this is a nice project looking at a large number of patients.
3. Major perioperative morbidity does not affect long-term survival in patients undergoing esophagectomy for cancer of the esophagus or gastroesophageal junction.
Xia BT, Rosato EL, Chojnacki KA, Crawford AG, Weksler B, Berger AC. World J Surg. 2013 Feb;37(2):40815. doi: 10.1007/s0026801218236.
4. The revised American Joint Committee on Cancer staging system (7th edition) improves prognostic stratification after minimally invasive esophagectomy for esophagogastric adenocarcinoma.
Zahoor H, Luketich JD, Weksler B, Winger DG, Christie NA, Levy RM, Gibson MK, Davison JM, Nason KS. Am J Surg. 2015 Oct;210(4):6107.
doi: 10.1016/j.amjsurg.2015.05.010. Epub 2015 Jun 26. PMID: 26188709
5. Minimally invasive esophagectomy in a 6 year-old girl for the sequelae of corrosive esophagitis.
Majors J, Zhuge Y, Eubanks JW 3rd, Weksler B. J Thorac Cardiovasc Surg. 2016 Jun 22. pii: S00225223(
16)305657. doi: 10.1016/j.jtcvs.2016.06.011. [Epub ahead of print] No abstract available.
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.
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. 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.
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.
While working on a recent interview with one of the New Masters of Thoracic Surgery, I talked about one of his biggest contributions to his local community, which was establishing the first dedicated thoracic surgery program in that city. Then I realized that maybe readers wouldn’t know what that was important.. This article came from that interview
Big hospitals, little hospitals. Major health systems and community facilities battle it out of our insurance dollars. Private wings, VIP suites, catered meals and fancy robots all try and lure patients in the doors. As a writer of several books based on the business of medical tourism – I’ve seen that the appeal of glistening marble floors, free fancy coffees and an aura of exclusivity can trump the principles of safe and effective patient care when it comes to attracting paying patients. This is acutely evident in the surgery wars; the wars to attract referrals between private practice and academic medicine (which usually, but not always – has less glamorous facilities**). But for a person facing a large, and possibly life-saving thoracic surgery, we need to explore the differences that are more than just skin-deep.
Subspecialty interest and skill
The difference between a true thoracic surgery program and a cardiothoracic surgery private practice group is often marked by the degree of continuing competence, subspecialty interest and skill in minimally invasive techniques. (For more about the overall differences between general thoracic and cardiothoracic surgery, read here.) This post is discussing the pitfalls of the private practice medical group and surgical referral patterns. Surgical partners in a lucrative practice don’t have continuing education requirements, but residencies do. In order to teach surgical residents, the attendings themselves need to be well-versed in the latest operating techniques and surgical outcomes research.
Where the patients come from
Private practice groups get their patients thru an ‘old boy network’ particularly in cities with few strong ties to university medical centers. Patients don’t just walk thru the door to see a thoracic surgeon – they are referred to one. Most people have never even heard of a thoracic surgeon before they or a loved one needs one.
As we talked about in one of our very first posts, “Who is performing your thoracic surgery?” – just because you need thoracic surgery, that doesn’t guarantee that a patient will see an actual board certified thoracic surgeon.
In a referral based system, patients are often not referred based on the skills or merits of the surgeon in the operating room, his rates of post-operative infection or even the health system affiliations – but by his charm, wit or connections on the social scene. In a city like Memphis, which is awash in old money, southern tradition and the Junior League, this means that patients are referred to the surgeon based on the friendships amongst wives, college fraternity friendships or 6 am tee-off times.
Often times, the surgeon is not particularly gifted or even interested in modern lung or esophageal surgery techniques, meaning that the surgeon is most likely to revert to large thoracotomies or median sternotomies because that’s where his comfort lies. There is no standard or requirement to master minimally invasive techniques, so often these surgeons don’t. It’s not a criticism of cardiothoracic surgery, but a basic reality. A heart surgeon wants to be a heart surgeon. He doesn’t necessarily want to do lung or esophageal surgery, but he might not turn away these cases either, because everyone likes to make a living.
In comparison, a dedicated thoracic surgery program, particularly in an academic setting; is made up exclusively of thoracic surgeons who live and breathe general (noncardiac) thoracic surgery. This is what they do, this what they want to do, this is what they have always wanted to do. Academic settings also have more stringent requirements (in general) regarding maintaining clinical and educational competencies. These surgeons are learning or teaching the newer techniques, reading and writing the literature and actively pursuing advances in the field. This dedication is important for more than the most obvious reason – sure, you want your surgeon to be competent in the operating room – but you also want him to be knowledgeable and skilled outside of it.
Academic centers with general thoracic surgery programs are more likely to have a protocol based, formalized multidisciplinary approach to thoracic disease. This means that patients are treated by a team of specialists in a cooperative fashion. There are no conflicts between what the oncologist wants to do and what the surgeon wants. If the patient needs pre-operative radiation or chemotherapy, it’s coordinated in conjunction with surgery, so that the patient receives care in a timely and organized fashion based on the current treatment recommendations and clinical research**.
But American medical care is the best in the world, right?
Multidisciplinary approach, evidence-based practice, ongoing academic research and continuing surgical education: All of these themes don’t sound extraordinarily unusual to readers because I have been discussing and presenting surgeons who work within these types of programs for years here at Thoracics.org.
Not the norm
But it’s actually not the norm in the United States, which means that many American patients get woefully inadequate, outdated or just plain uncoordinated care. These patients have more pain, more suffering, longer lengths of stay, more complications and less quality of life than any of the patients who have been cared for by just about any surgeon ever mentioned on this site. Patients at the University of Pittsburgh, Duke, University of Virginia or John Hopkins were getting great care, but patients here in Memphis, Las Vegas or any of the other cities or regions without these types of specialized programs, weren’t and often still aren’t.
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 : email@example.com
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.
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).
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
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.
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.
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
Thoracics.org follows up with Dr. Marcello Migliore from the University of Catania, on his work in the area of HITHOC and malignant pleural mesothelioma
As discussed in a previous post on HITHOC and Mesothelioma, Dr. Marcello Migliore and his colleagues in Catania, Italy have published results from a small pilot study on the use of HITHOC (cytoreductive surgery and intrathoracic chemotherapy) to treat malignant pleural mesothelioma.
Thoracics.org contacted Dr. Migliore to find out more about that study as well as his on-going research in this area. He was also kind enough to offer his opinions on Hope and the diagnosis of malignant mesothelioma.
On-going research on HITHOC
Thoracics.org: Dr. Migliore, woud you tell us more about your current research on HITHOC and mesothelioma?
Dr. Migliore: We are conduction a pilot study to compare pleurodesis with talc vs HITHOC in mesothelioma patients. Goals are quality of life and survival.
Thoracics.org: How many more patients are you hoping to enroll ?
Dr. Migliore: we hope to enroll at least 12 patients (unfortunately in almost 2 years we enrolled only 6 patients)
Thoracics.org: Would you tell us more about eligibility criteria?
Dr. Migliore: All patients with mesothelioma will enter the study protocol except those who cannot undergo surgery for poor performance status.
Thoracics.org: Would you describe the procedures for our readers?
Dr. Migliore:Talc pleurodesis is performed using the uniportal VATS technique (2 cm skin incision), which is a concept that was introduced by us already in 1998 (and published in 2001 and 2003). As you know, Gonzalez- Rivas is now well known worldwide for using the concept of uniportal technique to perform major lung resection. Pleuerectomy and decortication with HITHOC is performed using the bi-portal VATS technique but with an skin incision of around 8 cm.
Thoracics.org: In your preliminary paper on your last pilot study, there were a couple patients with lung cancer who were included in the HITHOC trials. Is that the same for your current study?
Dr. Migliore: While I feel that some patients with lung cancer could have benefited from HITHOC, for this study, the indications must be strictly limited [to patients with malignant mesothelioma only].
As you know, the largest group of patients with lung cancer are patients with more advanced cancer; stage IV lung cancer patients, and because survival is dismal, the standard practice is no surgery except palliative procedures. But, there are selected patients in whom there is some evidence that surgery could help. For this reason my personal reaction is that, in the near future, we should aim to prolong survival in stage IV lung cancer patients also by surgery. We are in mind to start a new study on the role of surgery in selected stage IV lung cancer patients.
Technical Aspects on HITHOC
Thoracics.org: Does previous pleurodesis make surgery more difficult?
Dr. Migliore: Yes, due to the development of adhesions between parietal pleura and the chest wall, as well as between the parietal and the visceral pleura, which are really difficult to remove. It requires delicate work using the fingers ( at the end of the operation you can have pain in fingers and fingertips!)
Thoracics.org: Does it lead to increased operating room time, or increased bleeding from adhesions?
Dr. Migliore: While is certainly increases operating time but there is no evidence of increased bleeding but air leaks are more frequent. Intraoperatively, it is imperative to put attention to every single detail to avoid postoperative complications.
Thoracics.org: Do you find that patients with diaphragm involvement develop more post-operative complications or are more likely to develop disseminated disease ?
Dr. Migliore: That has not occurred in this group of patients but the number of patients is small, and therefore it is impossible to answer.
Thoracics.org: What has been the biggest obstacle in your research?
Dr. Migliore: Certainly living in a “rural” region with cultural dogmas and financial restriction for research are probably the most common obstacles to speedy clinical surgical research.
On Hope & Malignant Mesothelioma
[During a related study] “We operated two patients and one is alive after 3 years. She was 40 y.o. lady with a 15 year-old child. She had malignant pleural effusion with a peripheral lung tumor and was treated elsewhere with talc pleurodesis alone, and 6 months survival was given. We performed a parietal and visceral pleurectomy with HITHOC. She is alive (with recurrence) and her son is now 18 yo. This simple case give an explanation that an operation although “experimental, gives hope (we should not give false hope) and permits to these unfortunate patients to see light in the dark”.
Dr. Marcello Migliore, MD
Section of Thoracic Surgery
Department of General Surgery & Medical Specialities
University of Catania, Policlinico Hospital
Editor’s note: Some minor edits have been made for the sake of formatting. Thank you to Dr. Migliore and his team.
Is there hope? Thoracics.org discusses hope and mesothelioma along with the most recently published work in the area of cytoreductive surgery and intrathoracic chemotherapy (HITHOC).
Is there hope?
In a recent article in Future Oncology, Dr. Maat and his colleagues explore the question of whether hope exists for patients with malignant pleural mesothelioma (MPM). The authors acknowledge the difficulties for patients and providers alike in maintaining hope when the odds are against it. Dr. Maat also discusses the differences between offering false hope and belief in the possibilities of emerging therapies.
“Dismal” prognosis of malignant mesothelioma
This brings to the forefront one of the biggest failures in thoracic surgery and oncology; malignant mesothelioma. While great strides have been made in the last fifty years in the treatment of many other cancers, malignant mesothelioma continues to carry a dismal prognosis with a lifespan measured in months. Not only that, but even the great “wins” in this area, like pleural decortication, are often only viewed as such when measured against palliative treatment (Zahid, Sharif, Routledge & Scarci, 2011).
This is one of the reasons Thoracics. org has taken such an interest in emerging therapies and research in areas such as HITHOC, and will continue to do so. Sometimes even the most promising data takes a dead-end, like in the case of Dr. Isik in Ganziantep, Turkey, where HITHOC and mesothelioma research have been forced to take a backseat to ISIS and the Syrian refugee crisis. This along with financial limitations (unfunded research) have threatened a promising program.
In situations like Dr. Isik’s, it is easy for readers and other researchers themselves to lose hope. If programs showing favorable results like Dr. Isik’s can not survive, how can we expect support for additional research in this area? But just as Dr. Maat advocates for hope among patients, and providers, we here at Thoracics.org continue to advocate for a hopeful future in the area of HITHOC; not just for malignant pleural mesothelioma, but for a whole spectrum of cancers that remain frustratingly difficult to treat.
Migliore et al.
As such, Thoracics.org would like to highlight some of the most recent HITHOC publications. Two of these studies are from Dr. Migliore and his colleagues at Catania, Italy. The first paper, describes their preliminary experiences with eight patients (6 patients with MPM and 2 patients with lung cancer). The authors discuss inclusion criteria, methodology and surgical technique (uniportal VATS/ and mini-thoracotomes) including one hour of chemoperfusion with cisplatin at 42.5 degrees centigrade. Interestingly, in this tiny subset of patients, the surgeons included one patient who underwent diaphragmatic resection, which is usually considered a contraindication to the procedure according to most researchers*. When we review the post-operative survival of these patients in this and the subsequent publication, it is worth asking about the specific survival time of the patient with diaphragmatic resection, and whether disease recurred in this specific patient.
The authors also included 2 patients with adenocarcinoma of the lung with pleural metastases in their priliminary series. One of these patients had previously undergone talc pleurodesis.
Consistent with other recently published reports, mortality for this limited study was 0% (or much lower than what was previously reported during the “first generation” of cytoreductive surgery with hyperthermic chemotherapy in the early 2000’s). Additional post-operative complications included 2 cases of post-operative nausea/ vomiting and one patient with acute kidney injury (post-operative creatinine 2.0).
The second publication by Migliore et al., also in Future Oncology is an expanded discussion of the six malignant pleural mesothelioma patients with better survival outcomes as 4 patients survival extended past the time of publication (one death at 6 months post-operative, one death at 24 months).
Anesthesia and HITHOC
While this article dates back to mid 2014, Kerscher et al. is one of the only authors to investigate and describe the unique challenges for anesthesiologists managing these patients during the intra-operative and post-operative period. Kerschner and colleagues report on their experiences with 20 patients undergoing cytoreductive surgery and HITHOC at the University Medical Center in Regensberg, Germany from 2008 to 2013. In addition to describing the intra-operative anesthetic and post-operative analgesic techniques used as their institution, Kerscher et. al also delve into the specific management strategies related to the use of HITHOC, such as the addition of ventilatory peep during the cycling of hyperthermic chemotherapy to increase the amount of lung surface area exposed to the chemotherapeutic agents (cisplatin in this study).
Their discussion of the management of intra-operative challenges caused by the infusion of chemotherapy such as low cardiac output, hypotension, pulmonary edema and coagulopathies along with an in-depth look at hemodynamics, volume resuscitation, challenges in ventilation and normothermia make this paper recommended reading for any surgeons or institutions interested in piloting their own HITHOC program. This article also serves as a reminder that while many small studies report minimal complications, there can and are serious and potentially fatal intra-operative complications in patients undergoing HITHOC.
Like Dr. Hung and Dr. Chen, this paper serves an important reminder that all advancements and discoveries in thoracic surgery require a cohesive, teamwork approach.
*Most surgeons who perform HITHOC / HIPEC exclude patients with diaphragmatic involvement because this is believed to make it impossible to prevent widespread dissemination of disease – since the diaphragm is the physical, tissue barrier that separates the chest cavity from the abdomen.
Learn Uniportal VATS from the masters – with a hands-on wet lab..
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’.
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.
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
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.
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.
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.
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!
Dr. Giuseppe Aresu of the University Hospital of Udine, Italy presents a case of thymectomy by subxyphoid approach
Article originally published October 31, 2015
We report the case of a thymectomy performed through a subxyphoid vertical single incision port carried out in a 51 years old female myasthenic patient presenting a Masaoka stage I thymoma.
The subxhyphoid approach permits an excellent view of the mediastinal anterior region and of the two pleural spaces giving the surgeon the possibility to perform a very radical and safe dissection of the thymic and peri-thymic fatty tissues.
Considering the position and the 3.5 cm length of the port, it is esthetically excellent. Without a sternal incision, or VATS – associated intercostal nerve injury, the recovery can be faster and less painful than the sternotomy approach or other vats approaches carried out through the intercostal spaces.
We performed extended thymectomy through a uniportal subxiphoid approach in a 51 years old female presenting a thymoma of 2.5 cm and myasthenia gravis.
The patient was informed about the risks and the benefits of the procedure and the consent to carry on with the operation was obtained.
Under general anesthesia, the patient was intubated with a double-lumen endotracheal tube and artificial ventilation was applied.
The patient was placed in a supine position with a silicon roll positioned below the lower part of the chest in order to lift the subxiphoid region.
The operating surgeon stood on the right side of the patient, the assistant stood on the patient’s left side and operated the endoscope. The monitor was positioned at the right side of the patient toward the cranial side of the bed.
A 3.5-cm longitudinal muscle sparring incision was made below the xiphoid process between through the linea alba.
The xiphoid process was exposed, the inferior part of the sternum was lifted up with a retractor and a blunt dissection was carried out in order to find the pericardial plane.
A SILS port (Covidien, Mansfield, MA) was then inserted into the port, and CO2 was insufflated at a maximal pressure of 8 mm Hg. The CO2 insufflation within the mediastinum generates a very useful amount of extra working space within the anterior-superior mediastinum allowing an easier dissection and a better visualization of the mediastinal structures especially toward the cranial part of the mediastinum cephalad to the left innominate vein including the upper poles of the thymus.
Under visual guidance provided through a 10-mm EndoCAMeleon® Telescope, the operator utilized grasping forceps designed for single-incision surgery with his left (SILS Hand Instruments Endo Clinch™ II (Covidien) and performed dissection, coagulation, and division of tissue mainly using the Sonicision™ cordless ultrasonic dissection device (Covidien, Mansfield, MA) and occasionally using a normal straight hook cautery.
The bilateral phrenic nerves and the bilateral mammary arteries and veins were always under optimal control as well as the cranial part of the mediastinum permitting a safe dissection en bloc of the thymus, thymic tumor, and surrounding fatty tissue anterior to the phrenic nerves.
The operation time was about 2 hours and 30 minutes, and blood loss was minimal.
No complications occurred during or after the operation, the drain was taken out after one day and the patient was discharged home 2 days after surgery.
Postoperative pain was very low requiring just 1 g X 3 daily of paracetamol during the hospital stay, and no analgesic administration after the discharge.
This case was later published (Dec 14, 2015) at CTSnet. Congratulations Dr. Aresu!
Suda, T. (2016). Single-port thymectomy using a subxiphoid approach-surgical technique. Ann Cardiothorac Surg. 2016 Jan;5(1):56-8. doi: 10.3978/j.issn.2225-319X.2015.08.02. Review. Free fulll text discussion of a similar case by Japanese surgeon. This article includes a video presentation and a in-depth discussion of technical aspects of the case such as surgeon position and camera access.
the second annual Cambridge VATS : uniportal VATS, nonintubated thoracic surgery and the masters
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.
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.
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.
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.
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
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.
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.
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).
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.
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.
from the Journal of Thoracic Disease and Dr. Chin Hao Chen (one of our favorites here at thoracics.org), advances in chest tube management
While chest tube placement (tube thoracostomy) is one of the more simple and straight-forward procedures in thoracic surgery, chest tube management can be fraught with frustration for both patients and providers. While the system itself is relatively uncomplicated, it is area that often brings stress to nurses and other axillary providers who do not work with chest tubes on a daily basis.
Ambulating with chest tubes is an exercise in logistics
Chest tubes can be knocked over, dislodged or accidentally removed from suction before the lung is completely healed. Chest tubes also make any sort of ambulation just a little bit more complex. The logistics of ambulating patients with one (or more pleurovacs) in addition to IV pumps, poles, foley catheters and other devices, particularly if the patient is weak or unsteady more of a chore than many can image. A ten minute walk make take upwards of fifteen minutes in preparation, as supplies are gathered and additional personnel are summoned for assistance.
Is there an air leak?
But this is only one of the frustrations of chest tube management. The main point of contention and frustration for providers and patients alike is monitoring chest tubes for the presence / absence of an air leak, and calculating drainage. While neither of these tasks is particularly arduous, accuracy is critically important. Both the miscalculation of drainage as well as the report of a newly developed air leak (or an previously undetected but continued air leak) can cause significant delays in chest tube removal. Or, if the chest tube is removed too early, it can cause a pneumothorax or re-accumulation of a pleural effusion.
The first problem can be readily addressed with use of an orange (or other non-standard color) sharpie marker. The second problem can require a bit of ingenuity, especially since the development or detection of an air leak can occur during the course of the day -after the thoracic surgery team has been in to evaluate the patient (for example). In fact, it’s one of the frequent calls we field on a daily basis.
Nurse: Ummm.. did this patient have an air leak this morning? (Or with more experienced nurses): “Mr. X developed a small air leak about an hour ago after walking in the hall.”
Then the question becomes one of whether or not the chest tube (which may have been previously scheduled for removal) can be removed. Often, it delays chest tube removal by another day to ensure that the lung is adequately healed.
Why can’t I just cross my fingers and pull it anyway?
Or we can proceed at our own peril – and risk taking out the chest tube. Sometimes the lung stays up, but often – the patients develop a pneumothorax, requiring another chest tube to be placed. Replacing the chest tube is not just an otherwise unnecessary procedure (and all the risks entailed), it’s painful for the patients, as well as being very demoralizing for the patient.
Several thoracic surgeons have attempted to solve this problem using a myriad of devices – from portable suction machines to more novel ideas like computerized chest tube systems such as the device developed by Dr. Gaetano Rocco. Dr. Rocco’s device was a computer that allowed patients with prolonged air leaks to be discharged home with real-time monitoring. (It was essentially a laptop computer, and requires use of a specialized chest tube system). It’s still a great development, but fairly expensive for use in hospitalized patients.
Additionally and unfortunately, most of these devices have failed to gain mainstream attention, or use – which means that despite all of the new technologies and techniques, many of our patients are still chained to their rooms (to the suction module) while waiting for their lung to heal. This puts the patients at risk for additional complications in addition to prolonging their hospital stay.
Now Dr. Chin-Hao Chen et al. have designed a new device that can be used with the existing pleurovac systems to perform real-time pressure monitoring. The paper, published in a recent issue of the Journal of Thoracic Disease demonstrates how surgeons can add this device to existing closed systems to detect air leaks and chest tube tidaling. This type of device allows surgeons to adopt state-of-the-art technologies using the standard equipment already available in their hospitals with minimal modifications. It eliminates the question of when the is lung healed, and when can the chest tube be removed.
Dr. Chin Hao “Roy” Chen – inventor of the Chen esophagectomy, now presents his latest creation, the wireless thoracoscope. More about our recent article at Examiner.com
Our readers get the first glimpse of Dr. Chen’s newest device. The wireless endoscope is currently undergoing animal trials at MacKay Memorial Hospital in Taipei, Taiwan.
The battery operated devices are more flexible and portable for ease of use, in and out of the operating room. Disposable shafts attach to reusable battery units, eliminating tangled cords, and concerns about the sterility of the thoracoscopic set up.
The STS Task force takes on credentiallng in minimally invasive surgery but shouldn’t they be looking at advanced specialty certification instead?
The term “minimally invasive surgery” gets tossed around a lot these days; it’s on advertisements for surgery clinics, hospital billboards and countless CVs. But what does that term really mean? And who has earned the right to claim this skill set? It’s an issue that is becoming more relevant in thoracic surgery as many surgeons become trained in increasingly complex procedures. It’s also part of a shift in referral patterns, as patients increasingly seek and even self-refer to surgeons who advertise expertise in less invasive procedures. But right now, there is no way to designate or delineate between surgeons trained in these procedures and other general thoracic (and general surgeons). So I was excited to see that the STS was finally going to address this area. Or at least, I thought they were, when I saw the recent draft, entitled, “STS Expert Consensus Statement: A tool-kit to assist thoracic surgeons seeking credentialing for new technology and advanced procedures in general thoracic surgeon.”
Sharp eyed readers probably already see some of the problems with this draft. But first, a little background.
Currently, the primary certification in the United States for the thoracic surgery specialty is the American Board of Thoracic Surgery examination (ABTS) which is the entry-level requirement for thoracic surgeons after completing their surgical fellowship in thoracic surgery. While, the ABTS certification requires a biannual re-certification to maintain credentials, this certification only covers the minimum requirements for thoracic surgery. It doesn’t address the newest technological advances in this specialty. This is problematic for consumers seeking surgeons specially trained and experienced in performing techniques such an uniportal surgery. It also creates difficulties for surgeons seeking this skill set since there is no clearly defined coursework required to obtain these skills.
Certification versus credentialing
But, certification and credentialing are not the same thing. Certification is generally a national or internationally recognized achievement, whereas credentialing is a more local process, from hospital to hospital or organization to organization. Credentialing is done not to recognize surgical skills or achievement but to protect the healthcare facility from the kind of liability that arises when imposters impersonate medical personnel, physicians with suspended licenses continue to practice, and similar such circumstances. Being credentialed within a healthcare network, or hospital facility isn’t an achievement per se, it’s a requirement for most of us to receive a paycheck. It’s also extremely variable, as this draft details, and subject to the whims of the Joint Commission.
STS focuses on credentialing – not certification..
STS focuses on credentialing: “The purpose of this consensus statement is to serve as a reference and resource for surgeons and hospitals as they plan for the safe introduction and implementation of new technologies and advanced procedures in general thoracic surgery.”
But this is thoracics.org – so we don’t have to. We have the luxury of considering the bigger picture.
But whether institutional credentialing or national certification – It’s a good excuse to examine the issues more closely. So instead of looking at credentialing, we’ll use the principles advanced by STS as part of consideration for a system of certification; by a national /international organization like STS or by the American Board of Thoracic Surgery itself. (While STS is focusing on facilities, they need to think bigger and be bigger. This draft has the potential to serve as guideline for an advanced specialty certification, but it would need some drastic changes.)
But regardless of whether we talk about certification or credentialing, we need to first define what we are referring to when we use this terminology.
What is minimally invasive surgery?
Does traditional (3 or more port) video assisted thoracoscopy qualify? What about robotic assisted surgery? A new document by the Society of Thoracic Surgeons Task force on General Thoracic Surgery Credentialing attempts to define minimally invasive thoracic surgery. In the document, the authors propose set definitions to replace this vague terminology to better clarify these distinctions. In this, they partially succeed.
How does a surgeon become a minimally invasive surgeon?
What are the qualifications for performing minimally invasive surgery? Does a weekend conference with lecture-only content qualify? What about more extensive wet-lab courses? Is there a case minimum for surgeons claiming competency in this surgical technique?
In their pursuit of credentialing guidelines, Blackmon et. al outlines a complicated set of checklists, proficiency levels and other suggestions for hospitals seeking to credential and privilege surgeons to perform these procedures.
Not a mandate, just suggestions
The authors claim that the purpose of this document is not to mandate the training requirements for a proposed credentialing process. In contrast, any proposal for a certification process in minimally invasive thoracic surgery techniques, by definition, would require mandates and strict requirements.
Not only that, but I disagree with their premise regarding credentialing. Credentialing should be equally arduous and less ‘historically’ defined.
These mandates would be a useful and valuabletool to guide and aid both consumers and surgeons. Surgeons and residents in thoracic surgery would have a clear cut curriculum to use as a road map for obtaining training and surgical proficiency. Consumers would have a guarantee that surgeons with these certifications had completed the minimum standards for training.
The authors propose a complicated set of proficiency levels to account for differences in regional and facility specific criteria. The task force does such to prevent an undue burden on each surgeon to conform to a rigid set of minimum criteria, thus ‘grandfathering’ in surgeons who may have obtained their training outside of traditional frameworks. While I understand this consideration, in this aspect, I disagree.
Five levels of proficiency
While the authors intentions are sincere, a less complicated, but more strict set of qualifications would better serve the specialty. Instead of having multiple levels of qualifications, a uniform approach would be less self-serving and more easily understood by consumers. In this case, greater transparency is needed to protect the public, and maintain public trust. Surgery, like every other service industry, is becoming more and more consumer-driven every day. Using levels of proficiency that read as, “Has taken VATS training, lecture-format only” or as cited by Blackmon et al. “the clinician has learned VATS lobectomy at our course, completing an animal skills model assessment and achieving level 3 skills verification” places too great of a burden on the consumer. It is also serves as a disservice to thoracic surgeons and the thoracic surgery specialty in general. By trying to be “all-inclusive,” the task force has weakened the value of this ‘credential’. If a hospital wants to privilege a surgeon to perform a procedure after the surgeon has watched it on Youtube, that’s something for their risk management department to take on – but an advanced specialty certification would eliminate a lot of these shenanigans, (but maybe that’s what STS is hesitant to take on). It certainly won’t be popular politically among many of the more traditional surgeons that serve as much of the general body of STS.
Traditional VATS as advanced technology?
Lastly, I find it discouraging that as a specialty, thoracic surgery is still talking about traditional VATS as an advanced surgical technology. It initially emerged in the early 1990’s and by now, should be standard fare for all thoracic surgery fellows of the past decade. The most recent guidelines consensus statements (of 2013) recommend VATS as first line treatment for a multitude of conditions. Three-port VATS is no longer something out of science fiction, for today’s surgeons, it should be bread and butter. By that criteria alone, standard VATS shouldn’t even be in consideration for inclusion as minimally invasive surgery. That title and definition should be reserved for the more advanced, and more specialized techniques, whether robotic or uniportal.
Blackmon et al. (2015). STS Expert Consensus Statement: a tool-kit to assist thoracic surgeons seeking credentialing for new technology and advanced procedures in general thoracic surgery. Read draft here. You have until 5/27/2015 to send STS your opinion.
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. 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
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.
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. 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.
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.
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.
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).
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.
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.
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.
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.
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 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.
aka, “Why we should be nice to plastic surgeons”. This case study highlights the need for close interdisciplinary partnerships among surgeons and also asks the question, “Are we addressing the emotional and psychosocial needs of our patients and their families?”
Bronchopleural fistula: an abnormal communication between the exterior environment and the pleural cavity, often caused entry of bacteria, fluids and other substances into the chest cavity by way of the bronchial tree, for example: bronchial stump breakdown. BPF most commonly occur after large thoracic surgeries such as pneumonectomy but can occur for other reasons such as infection or trauma.
Bronchopleural fistulas (BPF) are a dread complication of thoracic surgery that has (thankfully) become rare in most countries in the last few decades. Treatment of a large bronchopleural fistula can be massive undertaking requiring collaboration and cooperative from multiple specialties including radiology, infectious disease, pulmonology, wound management and plastic surgery.
Patients often endure several months of surgical and wound care treatments prior to undergoing definitive surgical management for this condition. This treatment includes the surgical creation of large open wounds to facilitate drainage of purulent materials, repair of the fistula tract and bronchial stump and debridement / revascularization for proper tissue healing. The case presented today illustrates the devastating emotional, physical and financial costs of bronchopleural fistula as well as the need for interdisciplinary collaboration for definitive surgical repair.
Surgical repair itself carries an elevated risk of morbidity and mortality primarily from respiratory complications, infections/ sepsis and hemorrhage.
More than physical consequences
Bronchopleural fistulas carries more than just the physical consequences of pain and disability for patients and their families. There are also devastating emotional and social effects. Patients can experience a myriad of psychosocial effects from this chronic wound and related treatment. The resultant deformity from many drainage and wound management techniques, in particular, can lead to depression and social ostracism. The development of a bronchopleural fistula can contribute to relationship and intimacy issues. Several of the surgeons interviewed including Dr. Boxiong specifically mentioned both divorce and suicide as being a risk in numerous cases.
Dr. Boxiong Xie, thoracic surgeon
Dr. Dong Jiasheng & Dr. Zheng, Reconstructive/ Plastic Surgeons
The patient is a young male in his early forties who had undergone a right upper lobectomy for cancer several years prior at a facility in a far away province. He then presented with a large empyema. Initially, conservative treatments were attempted. The patient underwent several drainage procedures, by both open and closed methods. These measures along with attempts to repair the bronchial stump failed due to extensive infection and tissue destruction.
Following the failure of more conservative measures, the patient presented to this facility for specialty care. He had heard about this program, and travelled a long distance to be here at significant difficulty and expense. As his surgeon explained, “it’s his last chance at a normal life.”
Over the continuing course of his treatment, a large opening on the anterior chest was created surgically. Due to the extent of necrotic tissue, this required the removal of anterior sections of ribs #2, 3, 4 and 5, leaving the patient with a very large open cavity, as seen in CT slices (pulmonary and tissue windows).
This large cavity was left open for a period of around two years, while infected material was debrided and evacuated, and aggressive wound management was continued. At the time of his presentation to the operating room, the wound bed is dry and pink with a small amount of slough. An opening to the bronchus is visible (with bubbling on respiration at the site of the wound). The wound measures approximately 6 cm X 4 cm. As seen from the CT images above, the wound was also several centimeters in depth.
The wound tracks up towards the shoulder, making it deeper and larger than it initially appears on gross visualization. There is a visible pulsation from the border of the cavity, (which may add to the patient and family’s distress).
After the wound is cleaned and prepared with betadine solution, the anesthesiologist introduces a bronchoscope into the airway, for illumination and visualization of the airway. The light from the scope is immediately visible to observation within the chest. At that point, amplatzer patch was inserted into the bronchial stump.
After placement of the patch was confirmed, the patient was re-prepped, and draped. Dr. Boxiong expands the existing wound, and dissects down to healthy bleeding tissue, removing yellow eschar. The wound is lightly packed with moist gauze.
Then Dr. Dong and his assistant surgeon arrive, to start their portion of the operation. Dr. Dong starts another incision approximately 3 cm below the wound area. The incision is extended to the left side of the chest. The surgeon dissects down through skin, adipose and fascia to free the right internal mammary artery to use to ensure that the graft is well vascularized.
Next step: Flap harvesting
Once the IMA was free, it was temporarily secured, and the wound was dressed. The patient was re-positioned, and re-prepped to allow access to the posterior aspect of the left chest. Due to muscle devascularization from the multiple previous surgeries on the right anterior chest, the surgeon harvests the left latissimus dorsi, using a large diamond-shaped incision.
Once the flap was harvested, the patient was left with a large open defect, without enough surrounding skin to cover the area. The surgical site is dressed with a temporary dressing while Dr. Dong moves on to his next surgical site.
Next step: Skin Harvesting
After preparing the patients right thigh, Dr. Dong applied a Padgett dermatome to shave off a thin layer of skin.
After multiple passes, the surgeons have enough skin to cover the defect from the flap site.
Next step: Skin Grafting
The thin strips of skin were applied to the flap site and sutured into place.
Once the sutures were completed, the wound was re-dressed and the patient was re-positioned for the last steps of the operation.
Next step: Anastomosis of mammary artery to flap
Following re-positioning to supine position, the flap was placed within the right chest wound. The flap was loosely sutured into place to maintain a proper position while the painstaking vascular anastomoses were performed. Once the anastomoses were completed, the remaining incisions were carefully closed.
Total surgical time was greater than ten hours.
As discussed by Lois and Noppen (2005), BPF management has traditionally been performed in a piece meal or stepwise fashion, with surgical interventions reserved as a last resort. Unfortunately, for some patients, this means that BPF becomes a chronic illness. As a chronic illness, (and all that chronic illness entails such as chronic malnutrition, chronic inflammation, long-term antibiotic therapy), the morbidity and mortality of this condition continues to increase for the duration of the illness. In the case study above, a relatively young, now cancer-free patient had now developed much of the disabilities associated with elderly patients due to the chronic nature of his illness (BPF after a lobectomy ten years prior). This certainly places the patient at significant risk for major complications once a large-scale definitive surgery is performed. Van Schill et al. (2014) notes that better understanding regarding the need for interdisciplinary management including aggressive physical therapy and nutritional support have reduced some of these complications.
While the impact of bronchopleural fistulas are usually discussed in terms of mortality, financial costs (surgical costs) and length of stay,and for this case, we would like to take a closer look at morbidity and quality of life issues raised by the development of this complication.
While BPF is rare, it truly can be a life-altering and destructive diagnosis. In addition to pain, physical debility, there may be gross deformity coupled with chronic wound care. Deformities caused by extensive tissue destruction and removal of several ribs can cause significant emotional and psychological anxiety and stress in both the patient and family members. The visible pulsation (cardiac movement) seen within the wound may exacerbate this anxiety. The stress of this wound combined with additional stressors related to this diagnosis have been observed to lead to a higher rate of marital discord and patient suicide. Patients may also feel a loss of sexuality and personal identity in the presence of this type of disfigurement, similar to some women after radical mastectomy (particularly in female patients).
To add insult to injury, unlike many conditions which can be readily corrected surgically, the creation of myocutaneous flap (and subsequent skin grafting) itself causes additional disfigurement. This patient required a lengthy (ten hour) surgery which resulted in the creation of three new surgical sites in addition to the patient’s original right-sided chest wound. While this is a drastic example, it does serve to highlight the on-going need to consider the psychological and emotional well-being of this patient (and all our patients).
BPF and professional relationships?
This case also reminds of the need for good interdisciplinary relationships. In thoracic surgery, cosmetic outcomes (other that pursuing minimally invasive options when possible) are not usually one of our primary considerations. This leaves us at a disadvantage when managing patients with such a drastic complication. We don’t always have a strong network or relationships with other surgical or medical disciplines outside of oncology or oncology-related fields. We need to take the opportunities available to become more familiar with our local reconstructive surgeons, as well as the latest techniques in reconstructive surgery. It’s not “good enough” to know the name of one of the plastic surgeons we brush elbows with in the surgical waiting lounge. It is not just about referrals and compensation. It is about having an open and free dialogue with surgical colleagues, so that when we do require their assistance, we can work together smoothly and coördinate care.
Consider the need to include social workers, psychologists and other counseling services in both the preoperative and postoperative care of our patients, when necessary for their long-term health and wellness. Unfortunately, due to social stigma, health care/ insurance or financial restrictions as well as provider hesitation**, not enough of our patients receive consultations or referrals to appropriate resources. We can’t change insurance regulations, but by becoming more familiar with our local resources and providers, we can overcome many of the other barriers to supporting our patients emotional health.
 I was unable to find literature that specifically cites BPF as a contributing factor to psychosocial complications such as divorce, depression or suicide but the impact of chronic wounds on emotional health, family life and other quality of life indicators are well documented. However, Okonta et. al (2015) and Lois & Noppen (2005) both cite QoL issues in patients with BPF.
** Provider hesitation is a nice term for all the reasons providers sometimes fail to seek mental health referrals for patients; such as fear of embarrassing our patients, believing that counseling is only needed for psychiatric emergencies, failure to understand local resources available, or our own discomfort with mental health “issues”.
References and Additional Readings
Arnold, P. G. & Pairolero, P. C. (1990). Intrathoracic muscle flaps: an account of their use in the management of 100 consecutive patients. Annals of Surgery, 1990; 211(6): 656-660. Study looking at one hundred cases from May 1977 and February 1988. In this potent reminder of the morbidity and mortality that is associated with patients requiring muscle flaps, as well as the advances in medicine over the last two decades, there were 16 operative deaths and 43 additional all-cause deaths in the operative survivors. Interestingly, one of these late-term deaths was due to suicide.
Levine, L. A. (2013). The clinical and psychosocial impact of Peyronie’s disease. Am J Manag Care. 2013 Mar;19(4 Suppl):S55-61. While unrelated to thoracic surgery, patients with Peyronie’s disease have many of the same emotional and psychological stressors as patients with other chronic wound conditions such as BPF.
As Dr. Gonzalez Rivas demonstrates, minimally invasive surgery isn’t just for “easy” cases. Case study with brief discussion and literature review
Uniportal VATS with chest wall resection at Shanghai Pulmonary Hospital
Authors: Gonzalez – Rivas, D. & Eckland, K.
Surgeons: Dr. Diego Gonzalez Rivas with Dr. Boxiong Xie assisting.
Case: 66-year-old patient with large left upper lobe mass extending into chest wall, biopsy proven carcinoma.
Pulmonary function tests – within acceptable margins
CT scan – showing a large left-sided lung upper lobe mass with chest wall invasion and rib involvement at the level just beneath the scapula.
Procedure: Uniportal (single incision) VATS with rib resection
Description: at a glance
Due to tumor location, port placement had to be carefully considered and adjusted.
Vital signs at initiation of operation: HR 78, NSR B/P 95/56 Oxygen saturations: 100% (intubated with double lumen ETT)
First incision: 14:17
The tumor was adherent to the chest wall, requiring chest wall resection with rib resection.
The tumor was palpated thru the 2 cm incision allowing the surgeon the benefit of open surgery despite using a minimally invasive technique.
Ribs were resected using a guillotine designed for minimally invasive use.
Lung resection complete at 17:42. The tumor was removed enblock using a bag system to prevent tumor spillage.
Lymph node dissection completed at 17:56
There was a brief run of PVCs lasting about 30 seconds (B/P 83/54) with no desaturations. Patient was otherwise hemodynamically stable for the duration of the case.
Frozen section: clear pleural margins
As noted by Pischik and others, many of the traditional contraindications for VATS procedures are no longer applicable, particularly for surgeons well versed in minimally invasive techniques like uniportal thoracoscopic surgery. In the case above, several of these contraindications were successfully addressed, including multiple adhesions, an incomplete interlobar fissure and a tumor with chest wall involvement.
That being said, this case was technically challenging from start to finish, due to the position of the chest wall tumor that required adjustment of port placement, a lengthy dissection of dense adhesions in addition to a sizeable chest wall mass. Hilar dissection was complicated by anatomical position, and the bronchus was difficult to access. This in addition to an incomplete fissure significantly lengthened the procedure.
VATS resection using a single port approach can be challenging even for experienced surgeons. However, it is a viable alternative for more complicated cases including those requiring a degree of chest wall resection.
This case was just one of numerous cases performed by Dr. Diego Gonzalez Rivas as part of the Uniportal VATS training course at Shanghai Pulmonary Hospital. Dr. Diego Gonzalez Rivas is the inventor of the uniportal technique and Director of Uniportal VATS training program at Shanghai Pulmonary Hospital. He has partnered with the Chinese facility to offer training courses for interested surgeons three times a year, in addition to his ‘wet-lab’ surgical training offerings in his home facility at La Coruna, Spain.
An Ordinary Afternoon at Shanghai Pulmonary Hospital
The Uniportal VATS course continues for much of the rest of the week (March 9 – 20th).
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
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
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.
on location with Dr. Diego Gonzalez Rivas as he embarks on his latest project: teaching uniportal VATS to surgeons in China
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.
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.
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!
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.
As the Florida legislature and medical community considers the impending physician shortage, many of the critical concerns regarding the on-going shortage of surgeons remain unaddressed
Now that Florida is the third most populated state (behind first ranking California and # 2 Texas) in the United States with a census of almost 20 million residents, the ongoing shortage of surgeons is predicted to become more dire over the next ten years.
The problem is multi-factorial: Training, debt, compensation (financial and otherwise)
In a recent article by Donna Gehrke – White at the Sun Sentinel, the need for over 7,000 additional physicians (in a variety of specialties) highlights some of the difficulties in training and retaining specialty physicians in American medicine. Lengthy training regimens coupled with high student loan debt as well as feelings of frustration and ‘burnout‘ plague a medical landscape that is already burdened with concerns over the fragile state of American health care, escalating healthcare costs and the impact of Obamacare and other recent federally mandated changes to the health care system.
“More schools” are not the answer
While Florida is responding to the impending crisis by opening new residency programs, this doesn’t address some of the more crucial concerns – high vacancy rates in existing programs, the exorbitant costs of a surgical education, and a growing dissatisfaction with current working conditions.
How about better loan repayment programs/ debt forgiveness? Or greater access to patients (and less time dealing with paperwork/ EMR and reimbursement issues)? Instead of lengthening/ shortening training programs and relying on computerized models, maybe consider improving the quality of American surgical training by separating the specialty into two separate tracks (like most countries)?
Seaman, A. M. (2012). Surgeon’s pressures may worsen shortage. Reuters. As we’ve noted previously, this is not a new concern, and the latest studies and reports only confirm this data. In fact, this report from the Robert Wood Johnson Foundation from 2011, highlights the fact that surgeon shortages are impacting emergency departments ability to provide emergency life-saving treatment.
Aliwadi, G. & Kron, Irving (2008). The challenges facing thoracic surgeons. Vascular disease management. This 2008 article highlights some of the difficulties in attracting and retaining medical students and surgical residents to the cardiothoracic surgery specialty. While mainly geared at cardiac surgery – and the issues raised by interventionalists and catheter based interventions, it also touches on some of the educational issues that affect both cardiac and general thoracic surgeons.
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.