About Thoracic Surgery – Thoracic Surgery

Ultra-fast open tracheostomy

Dr. Chin-Hao Chen demonstrates ‘ultrafast open tracheostomy.’

“Ultrafast open tracheotomy”

Currently tracheostomy procedures are performed one of two ways; using the traditional surgical (open) method and a percutaneous method.

Both methods have benefits and drawbacks. In open tracheostomy, the primary drawback is the need to transport the patient in the operating room at most hospital facilities. Postoperative bleeding is less frequent in open method. However, postoperative wound infection and poor healing of the stoma in some cases may be troublesome.

As a bedside procedure, percutaneous tracheostomy is rapidly gaining in popularity due to the fast, and relative ease of the procedure. However, it comes with its own set of risks and potential complications such as pneumothorax. As a minimally invasive procedure, the risk of bleeding is minimized, but cases of severe hemorrhage have been reported. The cause of this massive and severe bleeding in percutaneous method is partly due to the lack of delicate dissection of pre-tracheal soft tissues, which led the injury of isthmus of thyroid gland, esophagus, and major vessels in the neck.

In summary, percutaneous method provided a faster approach and less wound infection while having the possibility of severe bleeding complication. Open method takes more time to complete the procedure and risk of wound infection is slightly higher. But open dissection method can minimize unnecessary injury and bleeding.

Several studies comparing the two methods have demonstrated fairly equivalent outcomes. However, ultra-fast open tracheostomy offers another option for patients who may need long-term mechanical ventilation.

The method designed by Dr. Chin-Hao Chen is called “ultra-fast open tracheostomy “.

The procedure usually takes around 4-6 minutes. Dr. Chen reports that he has performed the procedure in over 250 cases (253 cases to date). There have been no bleeding complications; (acute or delayed ). We did have a few minor wound infections. We did have one patient, who had a more severe infection (but the patient’s underlying diagnosis was sepsis and organ failure.)

Dr. Chen states, “I invented the procedure about ten years too late. Prior to that, it might have been very popular. But now that the percutaneous puncture method has been developed, it is not so valuable.”

Dr. Chen previously presented, “A Modified Open Method for Sutureless Tracheostomy” at a conference in Taiwan last year. At that time, he discussed his experiences and outcomes performing the procedure on 108 cases. He reported his average operating time as 5.0 minutes.

Dr. Chen has also provided video clips to demonstrate his procedure, which is simple and fast.

References and Resources

Aaron’s tracheostomy page – site about tracheostomies and tracheostomy care by a nurse, Cynthia Bissell. Good reference information for patients and their families.

Mayo Clinic site – all about surgical tracheostomies. (“Minimally-invasive” aka percutaneous)

Cho YJ. (2012). Percutaneous dilatational tracheostomy. Tuberc Respir Dis (Seoul). 2012 Mar;72(3):261-74. doi: 10.4046/trd.2012.72.3.261. Epub 2012 Mar 31

Durban, C. (2005). Types of tracheostomies. Respiratory Care, 50(4): 488 – 496. Excellent article with historical review of techeostomy techniques.

Richter T, Gottschlich B, Sutarski S, Müller R, Ragaller M. (2011). Late life-threatening hemorrhage after percutaneous tracheostomy. Int J Otolaryngol. 2011;2011:890380. doi: 10.1155/2011/890380. Epub 2011 Apr 14.

Susanto, Irawan (2002) Comparing percutaneous tracheostomy with open surgical tracheostomy. BMJ. 2002 January 5; 324(7328): 3–4.

Youssef TF, Ahmed MR, Saber A. (2011). Percutaneous dilatational versus conventional surgical tracheostomy in intensive care patients. N Am J Med Sci. 2011 Nov;3(11):508-12. doi: 10.4297/najms.2011.3508.

Long term complications of tracheostomy:

Epstein, S. (2005) Late term complications of tracheostomy. Respiratory care, 2005, ;50(4):542–549.

This article was co-authored by Dr. Chin-Hao Chen and K. Eckland

Dr. Pierre – Emmanuel Falcoz and the Thoracoscore

Dr. Pierre Emmanuel Falcoz, thoracic surgeon from Strasbourg, France and the thoracoscore for predicting in-patient mortality.

The ‘thoracoscore’ is a scoring system created to predict the risk of in-hospital death after thoracic surgery. This model was first created and tested by Dr. Pierre – Emmanuel Falcoz. Dr. Falcoz is a thoracic surgeon at the Hospital Civil in Strasbourg, France*.

The thoracoscore uses nine variables to predict patient surgical mortality and has been tested and validated in several large studies. The variables are age, gender, ASA (anesthesia classification), performance status class, dyspnea score, priority of surgery, procedure class, diagnosis group and co-morbidity score.)

Definitions of Variables:

Age of patient has been divided into three groups; under 55 years of age, 55 – 64 years old, and 65 years and older.

ASA classification – this is the scoring used and devised by the American Society of anesthesiologists in 1963. These are:

A normal healthy patient.
A patient with mild systemic disease.
A patient with severe systemic disease.
A patient with severe systemic disease that is a constant threat to life.
A moribund patient who is not expected to survive without the operation.
A declared brain-dead patient whose organs are being removed for donor purposes.

Performance Status:

World Health Organization Performance status

Grade	Explanation of activity
0	Fully active, able to carry on all pre-disease performance without restriction
1	Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2	Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours
3	Capable of only limited self-care, confined to bed or chair more than 50% of waking hours
4	Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair
5	Dead

Dyspnea Score: the dyspnea scale by the medical research council.

mMRC Breathlessness Scale
Grade	Degree of dyspnea
0	no dyspnea except with strenuous exercise
1	dyspnea when walking up an incline or hurrying on the level
2	walks slower than most on the level, or stops after 15 minutes of walking on the level
3	stops after a few minutes of walking on the level
4	with minimal activity such as getting dressed, too dyspneic to leave the house

Priority of Surgery: Urgent/emergent versus elective.

Procedure class: pneumonectomy or other lung procedure

Diagnosis group: benign versus malignant

Co-morbidity score: number of significant co-morbid conditions (smoking, history of cancer, chronic obstructive pulmonary disease, diabetes mellitus, arterial hypertension, peripheral vascular disease, obesity and alcoholism).

Scoring:

Using specific calculations assigned to each category score – each calculation is summed together to determine the patient’s risk group. Estimated mortality is assigned by risk group. (See table 5 in original article to compare predicted mortality to actual mortality in Falcoz et. al. 2007).

Several of the surgeons interviewed previously report that they use this scoring system routinely, as part of their pre-operative assessments. While several of the variables are intuitive (ie. urgency of surgery[1] increases mortality), this scoring system also validates previous surgical observations.

One of the strengths of the thoracoscore is the use of scales to measure everyday performance (ie. performance status, breathlessness) versus clinical indicators such as pulmonary function tests, pet scans and other more costly/ time-consuming diagnostic devices. (During initial data collection Falcoz et. al collected these measures [PFTs etc.] but during analysis, these criteria were not shown to be statistically significant).

References

The Thoracoscore on-line calculator: includes risk category definitions

Thoracoscore app for iTunes – in french

Chamogeorgakis TP, Connery CP, Bhora F, Nabong A, Toumpoulis IK. (2007). Thoracoscore predicts midterm mortality in patients undergoing thoracic surgery. J Thorac Cardiovasc Surg. 2007 Oct;134(4):883-7.

Chamogeorgakis TP, Connery CP, Bhora F, Nabong A, Toumpoulis IK. (2009). External validation of the modified Thoracoscore in a new thoracic surgery program: prediction of in-hospital mortality. Interact Cardiovasc Thorac Surg. 2009 Sep;9(3):463-6.

Falcoz, et. al. (2007). The thoracic surgery scoring system: Risk model for in-hospital death in 15, 183 patients requiring thoracic surgery. J. Thorac Cardiovasc Surg 2007; 133 (2) 325-32.

Falcoz PE, Dahan M; French Society of Thoracic and Cardiovascular Surgery; Epithor Group (2008). Focus on the thoracoscore. J Thorac Cardiovasc Surg. 2008 Jul;136(1):242-3.

[1] This is classified as ‘priority of surgery’ on the thoracoscore.

* Attempted to contact Dr. Falcoz while working on this article, but was unable to do so.

The Happiness of Surgeons

Today’s surgery is a far cry from the surgical practice of our fathers and grandfathers, and it shows. Surgeons today report high levels of burnout, job dissatisfaction and depression in a survey of American surgeons reported in a new article by Balch et. al.

A new study by Balch et. al. (Oct 2011) published in the Annals of Surgery, examines the levels of (un)happiness, depression and career (dis)satisfaction among the different surgical specialties. When compared, surgeons in academic practices reported greater career satisfaction than surgeons working in private practice. Cardiothoracic surgeons (thoracic surgeons not examined separately as this was an American study) reported the longest workdays, and heaviest workloads but lower rates of dissatisfaction in comparison to trauma surgeons, urologists and several other specialties. However, all specialties had high rates of disillusionment – as anywhere from fifteen percent(pediatric surgeons) to thirty-six percent of vascular surgeons surveyed indicated that they would not choose to become a surgeon again. Thirty-three percent of pediatric surgeons and fifty-four percent of vascular surgeons would not encourage their children to become physicians.

Over a quarter of cardiothoracic surgeons (27.5%*) surveyed would not choose to be surgeons – and almost half (49%**) would not recommend medicine as a career for their children.

Unfortunately, given all the changes in medicine (and surgical practice) regarding compensation and malpractice issues, these results are not surprising. Surgery has become an increasingly unprofitable business in this country, but surgeons are not prepared adequately in their training to be successful businessmen. Sometimes being a talented and skilled surgeon just isn’t enough.

* cardiothoracic surgeons ranked 7th highest in this category.

** the third highest rate behind vascular and general surgeons.

Updates:

Physician’s Money Digest (October 2012) – “Most Overrated Jobs”

Thoracic surgery and the STS database

a discussion of the Thoracic Surgery database, the Society of Thoracic Surgeons and the upcoming STS conference in Atlanta, Georgia. A call for participants in the Thoracic Surgery database.

Next week (October 13 – 15th, 2011) is the annual STS database conference, Advances in Quality and Outcomes held in Atlanta, Georgia this year. In advance of this event, we are discussing the STS Thoracic Surgery database.

The STS database is a massive undertaking by the Society of Thoracic Surgeons which compiles and reports surgical outcomes on thousands of surgeons and surgical programs. This information is published, and is used to rate surgical programs nationally. The pinnacle of these results is the three star rating.

The cardiac arm of the STS database is more well-known than the general thoracic portion of the database, which began in 2003. While this cardiac data is reported nationally, it is contributed by STS members worldwide. Participation is voluntary, and members pay to participate in the database. Now, the STS is planning on opening up the General Thoracic arm of the database to international participants (in just a few short months.) The General Thoracic database is also open to general surgeons – and currently has 217 sites reporting data – which is more than a fifty percent increase from just a year ago.

This database is important for more than just bragging rights. By collecting and publicizing surgical outcome data – the STS database also serves to drive compliance with national and international guidelines for pre-operative and peri-operative care. (After all, who wants to be ranked last?) Having outcome measures published makes surgeons and surgical programs accountable to their patients and the community. Due to the weight and importance of the data collected, the data collection procedure is a meticulous and involved process – with scheduled data ‘harvest’ dates and a specialized reporting methodology (hence the need for an annual conference.) This data on pre-operative risk factors, surgical procedures and outcomes also helps to drive and support research to determine who is best suited to perform thoracic surgery procedures such as esophagectomies, lobectomies and sympathectomies. These databases have revolutionized surgical care around the world, and represent the largest and best organized / collected and audited data in the field of surgery.

Here at Cirugia de Torax. org, we would like to encourage thoracic surgeons worldwide to participate in the general thoracic database as part of efforts to improve overall quality and surgical outcomes.

Additional Information about the STS database:

These maps compare the number of participating programs for cardiac and thoracic surgery.

The Thoracic Surgery database collection form – this is the form surgeons and members of the surgical team use to collect and document care and outcomes.

I will continue to publish helpful information and guides to participation in the STS database over the next few weeks.

Don’t like the existing database? Or not eligible to participate?

If you are a thoracic surgeon operating in Latin America, we would like to invite you to participate in our own thoracic surgery database. It’s a completely computerized data submission process that works on smartphones – to simplify to data collection process. Patient data is kept private but surgical results are available for all participating surgeons. Best of all – we don’t charge for the ‘privilege’ of participating. Email us at k.eckland@gmail.com for more information and password.

Who is performing your thoracic surgery, part II

Promoting the thoracic surgery specialty during an interview with Ilene Little, founder and writer for Traveling4Health.com

I was recently interviewed by a long-time journalist, Ilene Little. Ms. Little, a former reporter for the Seattle Times, who founded and maintains the Traveling 4 Health website, an on-line site created to provide savvy senior citizens with more information about overseas retirement and health care options.

Ilene Little and I discussed the role of nurse practitioners in surgical specialities, as well as the need to educate the public for continued patient safety. As part of this, I discussed the role and mission of Cirugia de Torax.org in providing patient education on surgical topics, and promoting the international thoracic surgery specialty among lay people. We also talked about the necessity of providing a worldview versus a country-specific (or United States dominated) discourse in this era of increased globalization.

Ms. Little’s recently published an article based in part of the interview and content from our site. It is available at her site, Traveling4health.com

The Thoracic Surgeons of Bogota

After living and working in Bogota, Colombia for the last five months as part of a separate project, I have decided that the story of the thoracic surgeons of Bogota needs to be told. I have been interviewing surgeons from multiple specialities day in and day out for months, but it the personal stories and the practice patterns of these thoracic surgeons that have emerged, which speak to me as a writer. It seems only natural after spending so much time with these fine surgeons to want to write a separate book, dedicated to these surgeons.

However, this book is not a fawning promotion brochure but a detailed glimpse into the behaviors, practices and history of thoracic surgery in Bogota.
Unlike my previous books, this is not a book about surgical tourism, though it would be incomplete without that information. Rather it is a brief narrative of the story of their daily lives, professional and personal and my perspectives as a stranger in the midst of these men and women.
I hope to complete The Thoracic Surgeons of Bogota by August, but I will keep you informed on my progress.

K. Eckland

8 May 2011

Who is performing your thoracic surgery?

The majority of general thoracic surgical operations in the United States are performed by surgeons not specializing in thoracic surgery. [despite the fact that] Both general thoracic surgeons and cardiac surgeons achieve better outcomes than general surgeons.” Schipper et. al (2009).

Research has shown that speciality specific training contributes greatly to surgical outcomes, yet large numbers of surgeons persist in operating outside their area of expertise.
In fact, in the United States, the majority of thoracic surgery procedures are not performed by board-certified thoracic surgeons. Unfortunately, the majority of patients are uninformed about the different training and subspecialties among surgeons, and it appears that general surgeons are not hastening to inform them. While most patients are sophisticated enough to realize and understand that a general surgeon is not the best candidate to remove a large brain tumor, this does not apply to a lung tumor.

It is up to us, as patient advocates, and specialty practitioners to inform and protect the public. (Lest you consider this statement suspect due to self-interest – read the linked article, which reviews the body of literature comparing surgical outcomes in thoracic surgery among thoracic and nonthoracic surgeons.)

Why does this happen? As Wood & Farjah (2009) explain: (italics are mine)
“Thoracic surgeons are well aware of the apparent moral hazard that occurs in a community when a patient is referred to the local general surgeon for lung cancer resection but to the general thoracic surgeon if the patient is higher risk, is a “VIP” (health professional or relative, community or business leader), or if the patient demands specialist care. If high-risk or “important” patients benefit from operations done by thoracic surgeons, it seems likely that other patients will as well. This tacit understanding of the benefits of specialty care is obvious and is supported by research from Schipper and others, yet appears to be undermined by local factors that have yet to be confronted by hospitals, payers, patient advocacy groups, or policy makers.

Physicians referring patients requiring thoracic operations may prefer to direct a patient to a nonspecialist due to local politics and economics, potentially benefiting directly or indirectly if the patient is cared for within the same hospital or same medical group. Although many hospital credentials committees require specialty board certification to provide specialty care, this is often overlooked because of local traditions, reluctance to restrict or offend current medical staff, and concern about potential financial implications if lack of hospital “specialists” results in redirection of certain patients to a competing hospital.”

“National specialty societies representing surgeons are generally silent on the issue in an effort to avoid disenfranchising one or more of their constituencies. These well-intended but incongruous local incentives could be overcome by policy decisions by health care systems, payers, agencies evaluating quality, and government policy makers.”

Does local politics, local traditions and financial incentives to the referring physician seem like a good reason to refer a patient to an unqualified surgeon – when conclusive, and comprehensive data shows otherwise?

The Influence of Surgical Specialty on Outcomes

“STS: Lung Cancer Survival Best When Thoracic Surgeon Wields Scalpel” Dr. Farjah, “Using those figures, he estimated that “500 to 1,000 lives could be saved if all lung cancer surgeries were performed by board certified thoracic surgeons.””

Full-text article at Thoracic Surgery news – Dr. Michele Ellis on lung resection mortality by surgeon specialty.

8/24/2011 : after a telephone interview with Ilene Little, this story was highlighted at Traveling4Health, a medical site for consumers.