History of Thoracic Surgery

Dr. Mustafa Yüksel, Pektus, chest wall repair and the Yüksel bar

Talking with Dr. Mustafa Yuksel of Marmara University Hospital (Faculty of Medicine) about chest wall repairs, pectus defomities, the Yuksel bars and the future of 3D printing.

Istanbul, Turkey

Istanbul is famous as one of the world’s truly great cities; with its exotic Eurasian mix; filled with architecture (palaces, mosques, the grand bazaar), with extensive arrays of artifacts and objects d’ art attesting to a vibrant and rich history as a former capitol (and empire in its own right), center of international trade, learning and education.

From the earliest years of the city (Constantinople), it has been a center of technology, cultural and societal advancement. While many people know about and visit (the cisterns) of the Valens aqueducts, a fourth century AD water delivery system which provided the city with fresh water, few people know that Istanbul along with places like Iran (Persia) provided us with the foundations of medicine.

Serefeddin Sabuncuoglu, 15th century Turkish physician and surgeon (Wiki commons)

Since ancient times, learned scholars and physicians in this part of the world advanced our understanding of human anatomy, physiology, disease and medicine. Much of this knowledge was lost/ banned in other parts of the western world due to ignorance or religious-based beliefs which resulted in countless suffering in Europe and the Americas.

*(If you aren’t much of a historical scholar, just watch any of several excellently researched movies, and even some more ‘so-so’ series such as London Hospital or the new American series, “The Knick” to see how medicine fared without the basic knowledge gained by Serefeddin Sabuncuoglu and other middle eastern physicians over the centuries.)

Tombs for Sultan II Mahmud, Sultan II Abdulhamid, Sultan Abdoulaziz and valued members of their courts.. now look closer.

With such strong ties to the history (and advancement) of medicine and nursing in Istanbul, it is no surprise that my work has brought me to the doorstep of modern civilization, to Dr. Mustafa Yüksel, pectus repair and 3-D printing.

Dr. Mustafa Yüksel

Dr. Mustafa Yuksel, cardiothoracic surgeon

Dr. Yüksel is a cardiothoracic surgeon and the Chief of Thoracic Surgery and faculty professor for the school of Medicine. He is the former president (for three consecutive years) of the Chest Wall International Group and spearheads Pektus (the pectus project) which is a program aimed at training surgeons, educating people and performing pectus repair.

He attended medical school at Ankara University and completed both his surgical residency and thoracic surgery fellowship in Ankara at the Ankara Ataturk Education and Research Hospital. He briefly worked as a thoracic surgeon at the Camlica Military Hospital before becoming the Chief of Thoracic Surgery at Heybeliada Education and Research Hospital.

Dr. Yüksel spent a year as a visiting fellow at the Royal Brompton Hospital with Dr. Peter Goldstraw in London, England before returning to join the faculty at Marmara University Hospital. In 2004, he studied with Dr. Donald Nuss, of Norfolk, Virginia. Dr. Nuss is the inventor of the minimally invasive pectus repair, the “Nuss procedure“.

In 2005, Dr. Yuksel performed his first Nuss procedure for repair of a pectus defect. Since then, he has performed this procedure over 600 times. He estimates that in the last several years, he has performed 150 pectus repair procedures annually. Dr. Yüksel and Marmara University have become the major center for chest wall surgery in Turkey. The program also attracts surgeons internationally, to learn more about the center. In the last month alone, Dr. Yüksel hosted surgeons from the United Kingdom, the Ukraine, Poland, Holland and other parts of Europe. The majority of these surgeons have come to see Dr. Yüksel’s titanium carinatum bars.

Dr. Yüksel has also written several textbooks and chapters on thoracic surgery.

Prof. Mustafa Yüksel, MD

General thoracic and cardiovascular surgery

Ministery of Health of the Republic of Turkey

Marmara University Pendik Training and Research Hospital

Thoracic Surgery Department

7^th Floor, F wing

Fevzi Cakmak Mah, Mimar – Sinan Cad. No 41

34899 Ust Kaynarca/ Pendik

Istanbul, Turkey

(+90) 216-625-4545 ext. 3580

Marmara University Hospital

Marmara University is the second largest university in Turkey and was founded in 1883. The university serves over 60,000 students. The main campus is located in the central Istanbul neighborhood of Fatih but the School of Medicine and University Hospital are located across the Bosphorus river in Kadikoy. (A newer, larger 600 bed facility is being built in nearby Maltepe but is still under construction).

As a public hospital, Marmara University sees patients from all over Turkey and from every social class.

The university hospital has a large thoracic surgery program, with five thoracic surgeons on staff, which allows the thoracic surgeons to sub-specialize. Dr. Yüksel sub-specializes in chest wall repair and tracheal surgery.

During my visit, I also met with Dr. Dr. Bedrettin Yıldızeli, a thoracic surgeon who is currently involved in developing a pulmonary arthrectomy program for patients with chronic pulmonary emboli. (These patients will develop pulmonary hypertension and right-heart failure if untreated.) The current prognosis for this growing patient population is quite grim, so an advancements in this area will certainly be welcomed. Dr. Yildizeli is also interested in thoracic surgery applications using the Davinci robot.

Pectus excavatum versus Pectus carinatum

The easiest way to remember and differentiate between these two conditions is to remember: In or out? Pectus excavatum or “funnel chest” is a chest wall defect that causes an inward deviation of the sternum. Think ‘excavate’ as removing from the ground or bringing something upwards/ outwards.

Thus, pectus carinatum or “pigeon breast” is an outward bowing of the sternum. I don’t have any cute little sayings to remember this one.

In extreme cases, these defects can compromise the function of the heart, lungs and mediastinal organs.

The Nuss Procedure

Historically, pectus repair was performed using open surgery, but in 1987, Dr. Nuss invented a procedure using steel bars inserted via small (2 to 3 cm) incisions into the chest. The bars are placed into position and affixed with sternal wires. The bars force the sternum and chest wall to the appropriate shape.

When used for pectus excavatum, the bars force the sternum outward from inside the chest. When used to correct pectus carinatum, the bars are placed more superficially – beneath skin and muscle but outside (and over, not under) the sternum. These bars are usually visible as a thin line in most patients. (Most patients with this condition are very thin.)

These bars usually remain in place for around two years. (They may be removed earlier if complications develop).

image provided by Stepshep (who underwent a Nuss procedure). This condition is often associated with scolosis or curvature of the spine which gives the bars a crooked appearance.

However, there are several problems related to this condition and the Nuss procedure. Much of Dr. Yüksel’s work has been aimed at corrected problems related to the hardware used for this procedure.

Metal Allergies

The usual Nuss bars are made of stainless steel and require sternal wires or similar fixation to remain in place. The stainless steel material can be problematic due to the incidence of nickel and steel allergies in some patients. While Dr. Yüksel performs pre-operative allergy testing in all patients prior to surgery, and takes a complete history to determine a pre-existing allergy, up to three (3%) of patients without pre-operative metal allergies will develop one from continuous contact with the stainless steel bars. While these patients are given steroids and other medications to treat this allergy, it often persists, requiring bar removal.

a collection of Yuksel and standard bars used for the Nuss procedure — a collection of Yüksel and standard bars used for the Nuss procedure

Dr. Yüksel developed titanium bars to combat the problem of metal allergies. (The majority of patients are allergic to alloys or components in the stainless steel, particularly if nickel is used). These patients readily tolerate titanium.

One of the other technical problems encountered during this procedure is the inability to affix the bars to the chest wall securely. This happens more commonly in older patients who have less flexible bones. (As patients mature, bones become more rigid). The majority of patients undergoing this procedure are children, adolescents and teens but older patients often present after becoming symptomatic due to organ compression.

Using titanium bars can actually compound this problem, since titanium is a much stronger, less flexible material than stainless steel. So, Dr. Yüksel created a new way of securing the bars into position using either clips or screws – similar to the techniques used by orthopedic surgeons to stabilize a fracture.

The Yüksel Bars

Dr. Yüksel currently has three designs, two patented, with the third patent pending. He developed the first design in 2008, and several hospitals (6 or 7) are using his design for their repairs. These designs are also being used by other surgeons across Europe.

The different designs are used for different problems and allow the bars to be more readily customized for each patient. The bars are designed to be able to be used on very small children, pectus carinatum as well as older adults. (The average age of his patients is 17. The youngest patient was 6 years old – and he recently operated on a brother and sister in their late fifties. (The is a 20% familial risk.)

Each bar has adjustable plates for clip placement.

A Yuksel titanium bar — A Yüksel titanium bar

3-D Printing?

But Dr. Yüksel isn’t content to rest on his laurels. He is always thinking, creating and innovating. His newest project involves 3-D printing.

Dr. Yuksel experiments with a 3-D printer for chest wall repairs — Dr. Yüksel experiments with a 3-D printer for chest wall repairs

Dr. Yüksel is currently experimenting in creating customized implants for patients using a 3 D printer. The printing itself takes one to three hours, but the entire process takes considerably longer as patients undergo CT Scan reconstructions to allow Dr. Yüksel and his team to recreate a sternum, a thoracic vertebra or a tracheal implant.

His work is currently hampered by his materials – the plastic used for 3-D printing is too toxic for long-term human use, but he reports that new, safer materials are being developed in the United States. These non-toxic materials will allow surgeons to repair and replace damaged organs in a way that is not currently possible.

One final thought

One of thousands of hydatid cysts removed by Dr. Yuksel — One of thousands of hydatid cysts removed by Dr. Yüksel

During my visit, we talked about some of the specific thoracic conditions endemic to particular geographic areas. I mention hydatid cysts as an example from a previous interview. Dr. Yüksel laughs and reaches for a gallon-sized jar on a high shelf.

While Istanbul is a European city (with low rates of empyema and similar type infections), Dr. Yüksel talks about his thoracic surgery training in Ankara and many of the patients from rural areas. “I think, during my training, I removed about a thousand of these.” We talked about the epidemiology – and how it is often easily spread from seemingly innocuous sources, like cute little stray puppies.

So readers, when you see that cute stray dog during one of your travels? Don’t pet it. Or you might end up with one of these growing in your lung.

Selected bibliography for Dr. Yüksel

Bostanci K, Evman S, Yüksel M. (2012). Simultaneous minimally invasive surgery for pectus excavatum and recurrent pneumothorax. Interact Cardiovasc Thorac Surg. 2012 Oct;15(4):781-2. Epub 2012 Jul 6.

Yüksel M¹, Özalper MH, Bostanci K, Ermerak NO, Cimşit Ç, Tasali N, Yildizeli B, Fevzi Batirel H. (2013). Do Nuss bars compromise the blood flow of the internal mammary arteries? Interact Cardiovasc Thorac Surg. 2013 Sep;17(3):571-5. doi: 10.1093/icvts/ivt255. Epub 2013 Jun 19.

Yüksel M, Bostanci K, Evman S. (2011). Minimally invasive repair after inefficient open surgery for pectus excavatum. Eur J Cardiothorac Surg. 2011 Sep;40(3):625-9. doi: 10.1016/j.ejcts.2010.12.048. Epub 2011 Feb 20.

Yüksel M, Bostanci K, Evman S. (2011). Minimally invasive repair of pectus carinatum using a newly designed bar and stabilizer: a single-institution experience. Eur J Cardiothorac Surg. 2011 Aug;40(2):339-42. doi: 10.1016/j.ejcts.2010.11.047. Epub 2011 Jan 11.

Bostanci K, Ozalper MH, Eldem B, Ozyurtkan MO, Issaka A, Ermerak NO, Yüksel M. (2013). Quality of life of patients who have undergone the minimally invasive repair of pectus carinatum. Eur J Cardiothorac Surg. 2013 Jan;43(1):122-6. doi: 10.1093/ejcts/ezs146. Epub 2012 Apr 6.

Umuroglu T, Bostancı K, Thomas DT, Yüksel M, Gogus FY. (2013). Perioperative anesthetic and surgical complications of the Nuss procedure. J Cardiothorac Vasc Anesth. 2013 Jun;27(3):436-40. doi: 10.1053/j.jvca.2012.10.016. Epub 2013 Mar 30.

Ozyurtkan MO, Yildizeli B, Kuşçu K, Bekiroğlu N, Bostanci K, Batirel HF, Yüksel M. (2010). Postoperative psychiatric disorders in general thoracic surgery: incidence, risk factors and outcomes. Eur J Cardiothorac Surg. 2010 May;37(5):1152-7. doi: 10.1016/j.ejcts.2009.11.047. Epub 2010 Feb 8.

Yüksel M, Bostanci K, Eldem B. (2011). Stabilizing the sternum using an absorbable copolymer plate after open surgery for pectus deformities: New techniques to stabilize the anterior chest wall after open surgery for pectus excavatum. Multimed Man Cardiothorac Surg. 2011 Jan 1;2011(623):mmcts.2010.004879. doi: 10.1510/mmcts.2010.004879.

Additional readings

About Pectus Repair

Medscape article with color photographs – article by Andre Hebra, may require subscription.

Jo WM, Choi YH, Sohn YS, Kim HJ, Hwang JJ, Cho SJ. (2003). Surgical treatment for pectus excavatum. J Korean Med Sci. 2003 Jun;18(3):360-4. pdf version: Nuss

Johnson WR, Fedor D, Singhal S. (2004). Systematic review of surgical treatment techniques for adult and pediatric patients with pectus excavatum. J Cardiothorac Surg. 2014 Feb 7;9(1):25. doi: 10.1186/1749-8090-9-25. While this article is dated (back to the early days of minimally invasive pectus excavatum repair aka Nuss procedure) it gives some good general information. The biggest limitations are in the comparisons of Nuss and the Ravitch procedure.

History of Thoracic Surgery and medicine in Turkey

I have provided a very limited list of citations (free full text only).

Batirel HF¹, Yüksel M. (1997). Thoracic surgery techniques of Serefeddin Sabuncuoğlu in the fifteenth century. Ann Thorac Surg. 1997 Feb;63(2):575-7. pdf provided by Dr. Yüksel

Kaya SO, Karatepe M, Tok T, Onem G, Dursunoglu N, Goksin I (2009). Were pneumothorax and its management known in 15th-century anatolia? Tex Heart Inst J. 2009;36(2):152-3. Did Turkish physicians recognize and treat this condition a full 350 years before its first mention in western writings?

Heybeli N. (2009). Sultan Bayezid II Külliyesi: one of the earliest medical schools–founded in 1488. Clin Orthop Relat Res. 2009 Sep;467(9):2457-63. doi: 10.1007/s11999-008-0645-1. Epub 2008 Dec 9.

Zuhal Ozaydim (2004). Some landmarks in the history of medicine in Istanbul. JISHIM. Several of these landmarks including some of the medical museums are open to the public. The Medical History Museum of Istanbul is located on Koca Mustafa Pasa in the Fatih neighborhood of Istanbul (Asia side) and is open o weekdays 8 am to 5pm, free.

*Undoubtably, some readers will take issue with these statements, but the abandonment of the teachings of many of the Moor physicians (brought to European courts), as well as the prohibition against human dissections and other religious prohibitions (from various Crusades, Inquisitions and other religious actions/ proclamations) retarded the development of modern medicine by several centuries. In reading historical medical literature, it is evident and (not infrequent) to see that important discoveries, diagnoses and treatments were made, possibly published and used in a limited circle and then forgotten, only to be “re-discovered” decades (or centuries) later.

Thank you to Dr. Cristian Anuz, cardiothoracic surgeon, of Santa Cruz de la Sierra for providing me with an introduction to Dr. Yüksel.

Dr. Joseph Skoda

Dr. Joseph Skoda, Nihilist, Skeptic, Dermatologist.

Why we auscultate and percuss: Dr. Joseph Skoda (1805 – 1881)

Not all of thoracic surgery’s founding fathers were surgeons. In fact, one of the most important contributors to thoracic medicine, anatomy and physical examination, Dr. Joseph Skoda, was actually a dermatologist.

Walked to Vienna

The Czech born physician was also determined. Stricken with tuberculosis (consumption) as a child, yet determined to follow in the footsteps of his older brother, Franz, he defied his parents’ wishes that he enter the priesthood. While he initially studied theology, his affinity for mathematics, physics and natural sciences led him to pursue medicine. Of limited means, his education was financed by the beneficence of Madame Bischoff, the wife of a wealthy local industrialist.

Thus, instead of entering the church, in 1925, he spent six days traveling by foot; walking from his native Pilsen (Bohemia) to Vienna to attend medical school.

After obtaining his doctorate in medicine from the University of Vienna in 1831, Dr. Skoda spent a year in his native Bohemia studying Cholera before returning to the famed General Hospital of Vienna as an unpaid assistant physician. Over the next few years he worked in several different wards, including the Tuberculosis ward.

Multiple publications during the 1830’s*

During the early portion of his career, Dr. Skoda was a prolific author of medical publications such as “About percussion,” “About the Percussion of the Heart and the Sounds Originated by Heart Movements, and Its Application to the Investigation of Organs of the Abdomen”, “About the Diagnosis of Defects of Heart Valves” but it was his original research publication, “A treatise on auscultation and percussion” for which he is best known. He revived previously published but little known (or used) techniques of percussion and auscultation. He promoted the use of the stethoscope for physical examination and developed much of the terminology used for diagnosing and describing cardiopulmonary conditions.

However, these publications did little to earn the respect or admiration of his colleagues. Instead, he was demoted to ward physician for the insane ward as a punitive measure for disturbing patients with his methods of physical examination. But this animosity was not unilateral in nature.

Despite his enthusiasm for anatomy and physical examination – Dr. Skoda was not generally well-liked by his colleagues. In fact, he was appointed to several of his professional positions based on the recommendations of his close friend, Dr. Carl Freiherr von Rokitansky over the objections of his peers; including his appointment as a professor of the newly established “Modern” Medical School of Vienna. (This was a change in the traditional school of thought regarding medical education).

Some of their distaste may have stemmed from the fact that Dr. Skoda deviated from traditional dictates of the time and became the first professor to lecture in German instead of Latin. He more likely earned their enmity due to his failure to be duly impressed by their therapeutic marvels, medicinal treatments and patent medicines. Dr. Skoda was skeptical in regards to the actual therapeutic benefits to many of the medical treatments of the era, and frequently attributed the restoration of health to the fundamentals of healthy food, clean air and basic hygiene.

Therapeutic Nihilism

In an age where tinctures of mercury, laudanum and turpentine were popular remedies alongside bleeding, cupping and leeches, Dr. Skoda’s adage of “To do nothing is best in internal medicine” was probably more correct than his peers. This skepticism earned him the label of “therapeutic nihilist” who disdained modern medical interventions but this is far from the truth.

He was more like the fictional television physician, “Dr. House” of his generation.

First pericardial aspiration

Despite his mistrust of traditional medical and pharmaceutical quackery, Dr. Skoda ventured to experiment with specific medical interventions such as pleural aspiration, and pericardiocentesis as well as use of newer investigational medications such as salicylates (which later became modern-day aspirin). Dr. Skoda along with Dr. Franz Schul performed the first known pericardial aspiration in 1840.

Advancing physical examination and stethoscope use

Through the use of diagnostic tools like the stethoscope (which he promoted and refined after re-discovering and advancing the work of Viennese physician, Leopold Auenbrugger, as well as French physicians; Rene Laennec and Pierre Piorry), Dr. Skoda was instrumental in advancing physical examination as a tool for diagnosis.

Cardiac Murmurs and Adventitious Breath sounds

He first described and diagnosed the ‘drum-like’ sound of pneumonia, the Skodaic resonance of pleural effusions and supported the earlier work of Boullaud & Rouanet on cardiac sounds including the grades and distinguishing sounds of different murmurs. He gave us much of the terminology we use today, to describe rales, friction rubs, crepitus, bronchophony and voice conduction.

The next time you hear the tympanic sound during percussion [indicating a pleural effusion], remember this “Skodaic resonance” finding and Dr. Joseph Skoda.

* His major work in skin diseases and contributions to the specialty of dermatology begin in 1841. He continued to make various contributions to the field of medicine until his death at the age of 76 due to cardiac disease.

References

Davies MK, Hollman A. (1997). Joseph Skoda (1805-1881). Heart. 1997 Jun;77(6):492.

Sakula, A. (1981). Joseph Skoda 1805-81: a centenary tribute to a pioneer of thoracic medicine. Thorax. 1981 Jun;36(6):404-11

JAMA editiorial, “Joseph Skoda, Physican Diagnostician” October 19, 1964.

Additional Resources

A Practical Guide to Clinical Examination: Lungs – University of California, San Diego.

Basics of lung percussion – Loyola University Medical Education Network

A Travelers Guide to the History of Biology and Medicine: Austria

The Auscultation Assistant – UCLA site with examples of heart and lung sounds

The cowboys and rodeo stars of thoracic surgery

Discussing Dr. Joseph Coselli and ‘the cowboys of cardiac surgery’ along with some of our own heros of thoracic surgery here at Cirugia de Torax.

There’s a great article in this month’s Annals of Thoracic Surgery, by Dr. Joseph Coselli, from Texas Heart Institute and the Michael DeBakey Department of Surgery at Baylor. His article, entitled,” My heros have always been cowboys” is more than just a title torn from the song sheets of Willie Nelson. It’s a look back at both the pioneers of cardiac surgery and his own experiences as a cardiac surgeon. He also discusses the role of surgeons, and medical practitioners in American society in general and the promises we make to both society at large and our patients.

Here at Cirugia de Torax, I’d like to take a moment to look back at the surgeons that inspired and encouraged me in this and all of my endeavors. Some of these surgeons knew me, and some of them didn’t – but their encouragement and kindnesses have spurred a career and life that have brought immense personal and professional satisfaction.

Like Dr. Coselli, I too, took inspiration from the likes of Dr. Denton Cooley. But our stories diverge greatly from there. I never met Dr. Cooley and I probably never will. But it was a related story, from my former boss (and cardiothoracic surgeon), Dr. Richard Embrey that led to an email to Dr. Cooley himself. My boss had too trained under Dr. Cooley, Dr. Debakey and the Texas Heart Institute, the citadel of American heart surgery. Then, somehow, along the way – Dr. Embrey stopped to work at our little rural Virginia hospital. We were the remnants of a larger Duke cardiothoracic program but we were a country hospital all the same.

While I learned the ins and outs of surgery from Dr. Embrey (and Dr. Geoffrey Graeber at West Virginia University) on a day-to-day basis, I was also weaned on the folklore of cardiothoracic surgery – stories of the giants of history, like the ones mentioned in Dr. Coselli’s article, as well as local Duke legends who occasionally roamed the halls of our tiny ICU and our two cardiothoracic OR suites; Dr. Duane Davis, Dr. Shu S. Lin and Dr. Peter Smith. While never working side-by-side, Dr. D’Amico’s name was almost as familiar as my own. As the sole nurse practitioner in this facility, without residents or fellows, there was no buffer, and little social divide in our daily practice. Certainly, this changed me – and my perceptions. I asked the ‘stupid’ questions but received intelligent and insightful answers. I asked even more questions, and learned even more..

These opportunities fed my mind, and nurtured my ambitions. Not to be a physician or a doctor, but to learn as much as possible about my specialty; to be the best nurse possible in my field. It also nurtured a desire to share these experiences, and this knowledge with my peers, my patients and everyone else who ever had an interest.

It was that tiny little email, a gracious three-line reply from Dr. Cooley himself that made me realize that I didn’t have to rely on folklore and second-hand stories to hear more. That’s critical; because as we’ve seen (here at Cirugia de Torax) there are a quite of few of “Masters of thoracic surgery” or perhaps future giants that haven’t had their stories told. Dr. Coselli and his fellow writers haven’t written about them yet.. So I will.

Sometimes I interview famous (or semi-famous) surgeons here, but other times, I interview lesser-known but equally talented/ innovative or promising surgeons. All of them share similar traits; dedication and love for the profession, immense surgical talent and proficiency and sincere belief in the future of technology of surgery.

So, let’s hope that it won’t take forty more years for these surgeons to be recognized for their contributions to thoracic surgery in the way that Cooley, DeBakey and Crawford are heralded in cardiac surgery.

K. Eckland, ACNP-BC

Founder & Editor -in – chief

Pneumonectomy: for Tuberculosis

a discussion of Tuberculosis as a surgical disease, with a look at the historical perspectives.

Pneumonectomy, or surgical removal of one entire lung (versus removal of smaller segments of the lung) is a major surgery which is not performed without serious consideration to alternative treatments. Pneumonectomy is indicated as the treatment of choice for otherwise unresectable cancers, as well as serious lung infections such as tuberculosis.

In fact, surgery for tuberculosis (including pneumonectomy) was one of the first set of procedures that helped establish thoracic surgery as a specialty. In the era preceeding the development of antibiotics, there was no effective treatment for tuberculosis – which carried a high mortality rate. Surgical resection of the affected lung was the treatment of choice.

Once antibiotics were established as an effective treatment for this disease, surgery faded into the background – and was primarily reserved for cases complicated by hemoptysis or empyema.

However, in recent years, due to the rise of multi-drug resistance tuberculosis (MDR-TB), surgical resection for the treatment of Tuberculosis has been making a comeback. According to World Health Organization statistics; there were more than 8.8 million cases of TB in 2010. While the death rate has fallen significantly (40%) since 1990 – over 1.4 million people died of TB during that same year. In addition to multi-drug resistant Tuberculosis, there is another subtype called extensively drug resistant tubeculosis (XDR-TB) which is resistant to several drug regimens. (Most cases of non-XDR forms of TB are currently treated with a four drug regimen for several months.)

The emergence of these antibiotic resistant strains have brought us full circle in the surgical management of the disease. Failure of medical therapies leads to a mortality of fifty percent (Kir, et. al (1997). The re-emergence of surgery for tuberculosis is two-fold; surgery is used for both the treatment of active disease and the management of complications from tuberculosis (i.e. removal of dead or damaged lung tissue from previous TB infection.)

A review of the literature surrounding the surgical treatment of tuberculosis explores the modern surgical indications; potential complications and post-operative outcomes. Shiraishi et al. (2008) detail their experiences with surgical resection of several cases of XDR-TB at a Tokyo facility. As explained by Shiraishi, larger operations such as pneumonectomy are preferred over smaller resection procedures because the success of the operation hinges on the ability to remove all of the gross lesions (cavities) or destroyed tissue.

In this article (1997) from Saudi Arabia, Ashour discusses his experiences (from 1985 to 1995) using pneumonectomy to treat post-TB lung destruction.

By reviewing several historical sources, we can review the changing perspectives regarding the treatment of tuberculosis and the indications for surgical resection. While it may be surprising to many readers, the current indicators for surgical resection and pneumonectomy for tuberculosis encourage earlier surgical intervention. In comparison to the late 20th century, where surgery was reserved for cases of extensive lung destruction with gross hemoptysis after years of unsuccessful medical treatment, the development of MDR- TB and XDR-TB provides for ample incentive for surgeons to intervene earlier in the disease process.

Additional References:

Imaging References: Post-pneumonectomy

This article by Padovani et al. (2009) demonstrates examples of normal chest radiographs following pneumonectomy. (article is in French). Post-pneumonectomy films are shown sequentially, from immediately post-operatively, through recovery as the pneumonectomy space fills in. (fig. 1 – 4a.) Figures 4b – 11 show different views of CT scans after pneumonectomy, including views showing partial pleurectomies with mesh placement.

Chandrashekhara SH, Bhalla AS, Sharma R, Gupta AK, Kumar A, Arora R. Imaging in postpneumonectomy complications: A pictorial review. J Can Res Ther 2011;7:3-10 More radiographs following pneumonectomy – depicting potential complications. This is an excellent article reviewing potential early, late and chronic problems after pneumonectomy.

Tuberculosis:

Scannel, J. G. Tuberculosis as a surgical disease.

Naef, A. P. (1993). The 1900 tuberculosis epidemic: starting point of thoracic surgery.

Sakula, A. (1983). Carlos Forlanini, inventor of artificial pneumothorax for treatment of pulmonary tuberculosis. Thorax 1983; 38: 326 – 332.

Shampo, M. A., & Rosenow III, E. C. (2009). A history of tuberculosis on stamps. Chest; 2009; 136; 578 – 582.

Telzak et. al (1995) explored the phenomenon of multidrug resistant TB in New York City from it’s emergence in the late 1980’s, early 1990’s in this paper, “Multidrug-resistant tuberculosis in patients without HIV infection.” published in the New England Journal of Medicine (1995; 333: 907- 911.) In comparison to other studies, Telzak reported successful outcomes with medical management (at that point in time.)

CDC information on XDR-TB in the United States (1993 – 2006).

Surgical Management:

Adebonojo, S. A., Adebo, O. A., Osinowo, O., & Grillo, I. A. (1981). Management of tuberculosis destroyed lung in Nigeria. Journal of the National Medical Association 1981; 73 (1): 39-42. Report of the results of 20 pneumonectomies performed (1969 – 1979) in cases of moderate to massive hemoptysis. All of these patients were notably sicker than their western counterparts with active symptomology such as night sweats, weight loss, malnutrition, chest pain and varying degrees of hemoptysis. 75% had displayed symptoms for more than five years in spite of receiving several years of antibiotic therapies. Despite this, surgical mortality was low, with acceptable surgical outcomes – giving an interesting historical perspective on this treatment.

Ashour, M. (1997). Pneumonectomy for tuberculosis. Eur J Cardiothorac Surg 1997; 12: 209-213. [full pdf cited in text above.] This study is interesting since the average patient is several years younger than patients in the other studies presented here – demonstrating some of the geographic variability in disease patterns, which is discussed by the author of this article.

Harrison, E. (1967). Present views on the application of surgery in the treatment of pulmonary tuberculosis. Dis Chest 1967; 52: 305 – 309. A beautiful article reviewing the historical applications as well as current (1960’s) indications for surgical treatment of tuberculosis.

Kir, A., Tahaoglu, K., Okur, E., & Hatipoglu, T. (1997). Role of surgery in multi-drug-resistant tuberculosis: Results of 27 cases. Eur J. Cardiothorac Surg 1997; 12: 531 – 534. Turkish study.

Nuboer, J. F. (1956). Lung resection in the treatment of pulmonary tuberculosis. Journal of National Medical Association 1956; 48 (6): 407 – 414. Dutch paper on the use of surgical resection for the treatment of tuberculosis.

Pecora, D. (1965). Pneumonectomy for pulmonary tuberculosis. Dis Chest 1965; 48: 153 – 159. Historical review of pneumonectomy for tuberculosis.

Quinlan, J. J., Schaffner, V. D., Kloss, G. A., & Hiltz, J. E. (1962). Pulmonary resection for tuberculosis: a review of 1257 operations. Journal of the Canadian Medical Association, 1962; 86 (17).

Shiraishi, Y., Katsuragi, N., Kita, H., Toishi, M., & Onda, T. (2008). Experience with pulmonary resection for extensively drug resistance tuberculosis. Interact CardioVasc Thorac Surg 2008; 7:1075-1078. [full text pdf link in text].

Shiraishi, Y., Katsuragi, N., Kita, H., Tominaga, Y., & Hiramalsu, M. (2010). Different morbidity after pneumonectomy: multidrug-resistant tuberculosis versus nontuberculosis mycobacterial infection. Interact CardioVasc Thorac Surg 2010; 11:429-432.

Smith, R. A. (1982). The development of lung surgery in the United Kingdom. Thorax 1982; 37: 161 -168. [full text cited above.].

Takahashi, N., Ohsawa, H., Mawatari, T., Watanabe, A. & Abe, T. Case Report: multidisciplinary treatment by pneumonectomy, PMX and CHDF in a case of pulmonary supparation complicated with septic shock. Ann Thorac Cardiovasc Surg 2003; 9: 319-322.

Trapp, W. G., & Allan, M. L. (1963). Changing indications for resection of pulmonary tuberculosis. Dis Chest 1963; 43: 486 – 493.

UCLA case studies in surgical management of TB and complications.

Yaldiz, S., Gursoy, S., Ucvet, A., & Kaya, S. (2011). Surgery offers high cure rate for drug resistant tuberculosis. Ann Thorac Cardiovasc Surg 2011; 17:143-147. A Turkish study looking at pulmonary resection and chemotherapy for drug resistant TB in 13 patients (from Jan 2003 to Dec 2006). High operative mortality (7.6%) in this study reflects small study size (1 patient). No patients relapsed after surgery.

The University of Mississippi: Pioneers in Transplant

Reviewing the history of the first lung transplant and other medical firsts while here in Jackson, Mississippi.

The University of Mississippi Medical Center has been home to some of the greatest innovations in cardiothoracic and transplant surgery, including two of the world’s first organ transplants by Dr. James D. Hardy.

After becoming the first chair of the department of surgery in 1955, Dr. James D. Hardy, was off and running. The University of Mississippi performed the state’s first heart surgery in 1959. More remarkably, just a few years later, Dr. Hardy and his team performed the world’s first lung transplant on June 11, 1963. This was followed by the world’s first heart transplant in January of 1964. While neither of the patients survived long-term (the lung transplant patient died of renal failure 18 days after transplantation, and the heart recipient survived only 90 minutes) these were breakthroughs in the field of surgery. Both of these procedures have changed surgery immeasurably, by lifting the ceiling of our expectations and possibilities. The entire specialty of transplantation was born that hot, humid summer night, here in Jackson, Mississippi*. The cardiac transplant itself opened the door to even further research into xenotransplantation (the initial transplant was a chimpanzee heart to a person). Of course, neither of these surgeries were without considerable controversy at the time – the lung transplant recipient was an incarcerated felon (mirroring some of the current ethical dilemmas faced today by correctional health). The heart transplant sparked an international outcry similar to Baby Fae twenty years later (1984), if only much, much greater in intensity.

Today, the campus itself is large and sprawling, easily located just off I-55 and across the street from the Sonny Montgomery VA facility. St. Dominic’s hospital is visible from the parking lot.

The cardiothoracic surgery program at the University of Mississippi remains alive and well with four cardiothoracic surgeons, performing a range of procedures including a small number of heart transplants. University of Mississippi continues to be the only transplant center in the state – and according to the organ procurement and transplant network performed 9 heart transplants, but did not report any lung transplant or heart lung transplants since 1990.

(I did not have a chance to talk to the surgeons at the University of Mississippi during this brief visit. I hope to return in the future to talk about current programs, and what impact this history has made on medicine and surgery at the University of Mississippi.)

References and Additional Resources:

Dr. James D. Hardy – at the University of Mississippi website.

photo courtesy of the University of Mississippi — Dr. James D. Hardy, transplant pioneer

There is also the James Hardy library on the campus (in the James D. Hardy building) that holds copies of all of his articles, books and even films of the first transplants. (It’s really just one room but it’s crammed full of all sorts of interesting artifacts from the early days of heart / lung surgery.) They keep it locked normally, but are happy to unlock it for any interested visitors. Ms. Neill is one of the people in charge of the artifacts and she tells me that they are working on cataloging and compiling the original films for eventual posting on the internet. There’s even a plaque on the operating room door where the original surgery was performed – along with framed pictures of the surgery, and even one of the patient (lung transplant); awake and looking pretty good on day 3 after surgery.

* The first kidney transplant was in 1954.

a selection of citations and links to articles detailing the rich, and sometimes colorful history of thoracic surgery

This section is for snippets depicting the history of Thoracic Surgery.

Attached is the notes from a International Thoracic Surgery Meeting in 1950. Note the job listings on page five.

History of Thoracic Surgery (in Iran) – in honor of one of my favorite Thoracic surgeons. Quite an interesting read – and a reminder that modern medicine/ surgery originated in the middle east.

History of thoracic surgery and the Southern Thoracic Surgical Association – a paper presented on the anniversary of the organization.

The series of articles, “The mid-century revolution in thoracic and cardiovascular surgery” by A. P. Naef are an excellent and interesting overview on the history of cardiothoracic surgery. But, then again, Dr. Naef sounds like a pretty fascinating guy in his own right. Part three is my personal favorite in this series..

The mid-century revolution in thoracic and cardiovascular surgery: Part 1.

Part Two: Prelude to 20th century cardio-thoracic surgery

Part Three [esophagectomy or the story of the esophagus as told by the lives of Richard Sweet, Ivor Lewis and Marc Orringer]

Part Four: [the rise of cardiac surgery]

Part Five: [mitral surgery]

Part Six: [open heart surgery]