Interviews with Thoracic Surgeons

A closer look at HITHOC in Germany

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.

Back in 2011, Dr. Ried and his colleague, Dr. Hofmann at the University Medical Center in Regensburg, Germany, briefly discussed their HITHOC program, which was started in 2008.

Now, thoracics.org is in Germany to talk with Dr. Hofmann as well as another thoracic surgeon at a different facility in southwestern Germany.

sign — Heading south to Freiburg im Breisgau

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.

church — Freiburg is known for it’s massive cathedral, Munster Unserer Lieben Frau (Cathedral of our Lady). Construction began in 1200 and was completed over 315 years later.

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.

clinic sign

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.

the canals of Freiburg in the historic district

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.

roman ruins — Part of old Roman fortress in the historic quarter of Regensburg

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.

Fotor_156010569958864

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].

IMG_20190611_162641_resized_20190614_060212748 — Dr. Michael Reid (left) with Dr. Hans Stephen Hofmann

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.

As some of our long time readers know, thoracics.org no longer just reports on news and events in thoracic surgery. After multiple requests from our readers, we now facilitate specialty treatment too.

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 kristin@americanphysiciansnetwork.org

thoracics OR Regensburg — In the operating room, with the robot behind me (case is over).

Selected citations

Both surgeons are widely published on multiple thoracic surgery topics. This is a limited selection of citations related to HITHOC.

Ried M, Hofmann HS, Dienemann H, Eichhorn M. (2018). [Implementation of Hyperthermic Intrathoracic Chemotherapy (HITHOC) in Germany]. Zentralbl Chir. 2018 Jun;143(3):301-306. doi: 10.1055/a-0573-2419. Epub 2018 Mar 12. German. PMID: 29529693 It was an article similar to this that started thoracics.org journey to Germany.

Ried M, Marx A, Götz A, Hamer O, Schalke B, Hofmann HS. (2016). State of the art: diagnostic tools and innovative therapies for treatment of advanced thymoma and thymic carcinoma. Eur J Cardiothorac Surg. 2016 Jun;49(6):1545-52. doi: 10.1093/ejcts/ezv426. Epub 2015 Dec 15. Review. PMID:26670806

Hofmann HS, Wiebe K. (2016). [Cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion]. Chirurg. 2010 Jun;81(6):557-62. doi: 10.1007/s00104-010-1926-2. Review. German. PMID: 20454769

Ried M, Lehle K, Neu R, Diez C, Bednarski P, Sziklavari Z, Hofmann HS. (2015). Assessment of cisplatin concentration and depth of penetration in human lung tissue after hyperthermic exposure. Eur J Cardiothorac Surg. 2015 Mar;47(3):563-6. doi: 10.1093/ejcts/ezu217. Epub 2014 May 28. PMID: 24872472

Kerscher C, Ried M, Hofmann HS, Graf BM, Zausig YA. (2014). Anaesthetic management of cytoreductive surgery followed by hyperthermic intrathoracic chemotherapy perfusion. J Cardiothorac Surg. 2014 Jul 25;9:125. doi: 10.1186/1749-8090-9-125.

Ried M, Potzger T, Braune N, Neu R, Zausig Y, Schalke B, Diez C, Hofmann HS. (2013). Cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion for malignant pleural tumours: perioperative management and clinical experience. Eur J Cardiothorac 2013 Apr;43(4):801-7. doi: 10.1093/ejcts/ezs418. Epub 2012 Aug 10. Early article on their HITHOC results with 8 patients.

Ried M, Hofmann HS. (2013). [Intraoperative chemotherapy after radical pleurectomy or extrapleural pneumonectomy]. Chirurg. 2013 Jun;84(6):492-6. doi: 10.1007/s00104-012-2433-4. Review. German. PMID: 23595855

Ried M, Hofmann HS. (2013). The treatment of pleural carcinosis with malignant pleural effusion. Dtsch Arztebl Int. 2013 May;110(18):313-8. doi: 10.3238/arztebl.2013.0313. Review. PMID: 23720697 Link to article in english discussing limited utility of HITHOC for pleural carcinosis.

Ried M, Neu R, Schalke B, Sziklavari Z, Hofmann HS. (2013). [Radical pleurectomy and hyperthermic intrathoracic chemotherapy for treatment of thymoma with pleural spread]. Zentralbl Chir. 2013 Oct;138 Suppl 1:S52-7. doi: 10.1055/s-0033-1350869. Epub 2013 Oct 22. German. PMID: 24150857

Ried M, Potzger T, Braune N, Diez C, Neu R, Sziklavari Z, Schalke B, Hofmann HS. (2013). Local and systemic exposure of cisplatin during hyperthermic intrathoracic chemotherapy perfusion after pleurectomy and decortication for treatment of pleural malignancies. J Surg Oncol. 2013 Jun;107(7):735-40. doi: 10.1002/jso.23321. Epub 2013 Feb 5. PMID: 23386426. Discussed the effects of cisplatin on tissue.

Ried M, Speth U, Potzger T, Neu R, Diez C, Klinkhammer-Schalke M, Hofmann HS. (2013). [Regional treatment of malignant pleural mesothelioma: results from the tumor centre Regensburg]. Chirurg. 2013 Nov;84(11):987-93. doi: 10.1007/s00104-013-2518-8. German. PMID: 23743993

Interview with the master: Dr. Benny Weksler

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.

reflection — Memphis is more than just the home of Elvis Presley

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.

MUH-UT-Exterior2015-340 — University of Tennessee affiliated – Methodist Hospital (official UT photo)

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.

Dr. Benny Weksler, MD , Thoracic Surgeon

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.
PMID: 23052816

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.
PMID: 27406439

Why you should have attended VATS Peru 2016

Why you should have attended VATS Peru 2016

There were plenty of reasons for surgeons from all over Latin America to converge on Cuscu, Peru for the 2^nd 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.

img_1281_fotor — A surgeon in the master course receives instruction from Dr. Diego Gonzalez Rivas

2. Lectures from the master surgeon himself; Dr. Diego Gonzalez Rivas: That’s where the second critical component comes in, in the form of the candid, direct and straight-forward lecture by Dr. Diego Gonzalez Rivas on Control of Inter-operative Bleeding. If you weren’t paying attention during this lecture, it’s obvious in the lab. This isn’t a computer course where you can dial in your answers, fast-forward thru lectures and print off a shiny new certificate. This isn’t a computer app, or a simulation that you can reset and re-start as soon as the surgery heads off course, to try again.. It’s real surgery.

3. Dr. Carlos Fernandez Crisosto

Lastly, if you didn’t attend VATS Peru, then you missed an opportunity to know and to talk to Dr. Carlos Fernandez Crisosto. VATS Peru is his brainchild, and the organization was created specifically to advance minimally invasive surgery in Peru. VATS Peru is separate from ALAT (the Latin American Society of Thoracic Surgeons), of which Dr. Fernandez is the current president. VATS Peru is also separate from the Peruvian Society of Thoracic Surgeons which has its own focus in the thoracic surgery specialty.

Dr. Carlos Fernandez Crisost0, Cardiothoracic and Vascular surgeon

Dr. Fernandez, a Tacna native, works at Daniel Alcides Carrion Essalud facility in the southernmost region of Peru. He is the sole cardiovascular and thoracic surgeon for the city of Tacna, and performs cardiac, vascular, and endovascular surgeries in addition to general thoracic surgery. While he is a trained cardiovascular surgeon, (in addition to general thoracic) thoracic surgery is what he enjoys most.

He trained in Argentina, and practiced in Cordoba, Argentina for 23 years before returning to Tacna in the last few years.

His average case volume is around 380 surgeries a year, and he reports that all of his thoracic surgeries are generally performed using the uniportal thoracoscopic approach. He also does transplant, which requires him to travel to Lima specifically to perform the procedure. The transplant program is small and performs 4 to 5 transplants per year.

In his practice he sees the usual oncology cases, and empyemas but he also sees a large number of patients with tuberculosis, as well as an assortment of hydatid cysts, and pectus cases. Trauma from accidents, as well as injuries from guns, and knives also comprises a large part of his practice.

Dr. Fernandez is pleased with the success of his course, since this is only the second time the course has been available here in Peru. It was a complex logistical arrangement to hold the course in Cusco this year, but with the help of his wife, a professional events planner, they were able to pull of the event with very few hiccups. Next year, they plan to hold the event in Lima, the capitol of Peru and a city famed for its gastronomic offerings.

If you missed this year’s VATS Peru, look for VATS Peru 2017 here at Thoracics.org next fall.

Dr. William Guido and the state of thoracic surgery in Costa Rica

Cusco, Peru

One of the guest lecturers at the 2^nd 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.

Best of luck to Dr. Guido and his colleagues.

Single port surgery conference in Berlin

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.

The February conference takes place in Berlin, Germany on the 19th thru 21st. While Dr. Gonzalez Rivas, Dr. Delgado and Dr. Prado are headlining the event, other prominent thoracic surgeons such as Gaetano Rocco (Italy) and Alan Sihoe (Hong Kong) will also be lecturing at this event.

The conference includes live surgery demonstrations as well as a wet-lab for hands-on practice.

Deadline for registration is February 6th. Interested surgeons should contact:

R. Mette, M. Schmitt
Charité – Universitätsmedizin Berlin
Tel. +49 30 450 622 132 | Fax +49 30 450 522 929
E-mail: thoraxchiurgie@charite.de

To download the event brochure, click: VATS_Course_2015 brochure

In other news – the newest trailer for the documentary about Dr. Gonzalez Rivas and his work was recently released. I encourage all thoracic surgery personnel to see (and promote) this movie, which highlights the work of one of our own.

“This is Life” a new movie about Dr. Diego Gonzalez Rivas

a new film showing the life-changing efforts of one thoracic surgeon.. It’s about time!

I am excited beyond words to hear that my long-time hero and champion of modern-day thoracic surgery, Dr. Diego Gonzalez Rivas, is featured in a new documentary film, “This is Life”. The film follows the life of a patient undergoing a single incision thoracoscopic lobectomy. The film is being released this December.

I eagerly await the film – and am happy to see thoracic surgery (and Dr. Diego Gonzalez Rivas) get their due. For too long, our humble specialty has been overlooked for the more ‘glamorous’ cardiac surgery. This oversight has led to a dire shortage of thoracic surgeons in many parts of the world.

Hopefully, this is only part of an ongoing effort to have thoracic surgery recognized as an independent and complex surgical specialty requiring extensive knowledge, advanced skills and training. It is not an ‘add-on’ for cardiac surgeons with insufficient cardiac consultations.

Dr. Gonzalez Rivas and single-port surgery in Shanghai, China

For those of you hoping to see – and learn from the best, Dr. Gonzalez Rivas will be spending much of the month of October in Shanghai, China at the “National Uniportal VATS Training Course & Continuing Medical Education Forum on General Thoracic Surgery” which runs from October 8th to November 8th, 2014 at Tongi University.

Alas! To my eternal regret, Cirugia de Torax will not be in attendance. However, I will have sources on the ground – and hope to post more information during the conference,

Dr. Ahmet F. Işık talks about pleural mesothelioma, HITHOC, and thoracic surgery in Gaziantep, Turkey

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 kristin@americanphysiciansnetwork.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.

modern Gaziatep is featureless at first glance — modern Gaziantep is featureless at first glance

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.

Gaziantep is famed for their copper work

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 closer you look, the more you see. photo courtesy of wiki-commons — The closer you look, the more you see.
photo courtesy of wiki-commons

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 of Gaziantep Hospital

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.

Dr. Levent Elbeyli (in loupes) in the operating room

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.

Dr. Levent Elbeyli operates as Dr. Isik observes.

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).

What’s not to love about that?

Article updates:

Since our original visit to Dr. Isik, he has continued his work on HITHOC for malignant pleural mesothelioma and other cancers. You can read his latest paper, “Can hyperthermic intrathoracic perfusion chemotherapy added to lung sparing surgery be the solution for malignant pleural mesothelioma?”

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 hyperthermic perfusion 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.

Isik AF, Ozturk G, Ugras S, Karaayvaz M. (2005). Enzymatic dissection for palliative treatment of esophageal carcinoma: an experimental study. Interact Cardiovasc Thorac Surg. 2005 Apr;4(2):140-2. Epub 2005 Feb 16.

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.

Maruf Şanlı, MD, Ahmet Feridun Isik, MD, Sabri Zincirkeser, MD, Osman Elbek, MD, Ahmet Mete, MD, Bulent Tuncozgur, MD and Levent Elbeyli, MD (2008). Reliability of positron emission tomography–computed tomography in identification of mediastinal lymph node status in patients with non–small cell lung cancer. The Journal of Thoracic and Cardiovascular Surgery, Volume 138, Issue 5, Pages 1200–1205, November 2009.

Sanlı M, Isik AF, Tuncozgur B, Elbeyli L. (2009). A new method in thoracoscopic inferior mediastinal lymph node biopsy: a case report. J Med Case Rep. 2009 Nov 3;3:96. doi: 10.1186/1752-1947-3-96.

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.

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.

CTSnet recognizes Dr. Diego Gonzalez Rivas

Dr. Diego Gonzalez Rivas receives recognition from the global network of cardiothoracic surgeons, CTSnet.

CTSnet.org, the largest global network of cardiothoracic surgery professionals has recently recognized Dr. Diego Gonzalez Rivas for his pioneering efforts in thoracic surgery.

a TEDtalk favorite

This comes on the heels of a recent TEDtalk on Dr. Gonzalez and the process of innovation in surgery. During this 18 minute talk, Dr. Gonzalez talks about his own experiences in surgery.

Dr. Diego Gonzalez Rivas, a “fan” favorite here at Cirugia de Torax, is at the forefront of the field due to his contributions to minimally invasive surgery in the area of single-port thoracoscopy.

The dynamic young Spaniard has been making headlines over the last decade as he introduced and then refined the single port surgical technique. He and his colleagues, Dr. Maria Mercedes
de la Torre Bravos and Dr. Ricardo Fernandez Prado at the Minimally Invasive Thoracic Surgery Unit (UCTMI) in Coruna, Spain have successfully used this technique on thousands of patients, for a wide variety of procedures including sleeve lobectomies, pneumonectomies, bilobectomies and other complex procedures.

Dr. Gonzalez-Rivas demonstrates single port thoracoscopy at the National Cancer Institute in Bogota, Colombia — Dr. Gonzalez-Rivas demonstrates single port thoracoscopy at the National Cancer Institute in Bogotá, Colombia

Despite this widespread fame, Dr. Gonzalez Rivas remains unaffected and approachable. He spends much of his time in operating rooms around the world, teaching his technique to his peers. Next week, he heads to Guangzhou, China.

Living legends and Cirugia de Torax

writing about Dr. Diego Gonzalez Rivas and the other living legends in thoracic surgery and connecting people to the world of thoracic surgery

Readers at Cirugia de Torax have certainly noticed that there are numerous articles regarding the work of Dr. Diego Gonzalez Rivas. This week in particular, after a recent thoracic surgery conference and an afternoon in the operating room – there is a lot to say about the Spanish surgeon.

It’s also hard to escape that fact that I regard him in considerable awe and esteem for his numerous contributions to thoracic surgery and prolific publications. I imagine that this is similar to how many people felt about Drs. Cooley, Pearson or Debakey during their prime.

Making thoracic surgery accessible

But the difference is Dr. Diego Gonzalez Rivas himself. Despite the international fame and critical surgical acclaim, he remains friendly and approachable. He has also been extremely supportive of my work, at a time when not many people in thoracic surgery see the necessity or utility of a nurse-run website.

After all, the internet is filled with other options for readers; CTSnet.org, multiple societies like the Society of Thoracic Surgeons (STS), and massive compilations like journal-based sites (Annals of Thoracic Surgery, Journal of Thoracic Disease, Interactive Journal of Cardiothoracic Surgery).

But the difference between Cirugia de Torax and those sites is like the difference between Dr. Gonzalez Rivas and many of the original masters of surgery: Approach-ability and accessibility.

This site is specifically designed for a wider range of appeal, for both professionals in thoracic surgery, and for our consumers – the patients and their families. Research, innovation, news and development matters to all of us, not just the professionals in the hallowed halls of academia. But sometimes it doesn’t feel that way.

Serving practicing surgeons

For practice-based clinicians, and international surgeons publication in an academia-based journal requires a significant effort. These surgeons usually don’t have research assistants, residents and government grants to support their efforts, collect their data and clean up their grammar. Often English is a second or third language. But that doesn’t mean that they don’t make valuable contributions to their patients and the practice of thoracic surgery. This is their platform, to bring their efforts to their peers and the world.

Heady aspirations

That may sound like a lofty goal, but we have readers from over a 110 countries, with hundreds of subscribers along with over 6,000 people with Cirugia de Torax directly on their smart phone. Each month, we attract more hits and more readers.

Patient-focused information

That’s important for the other half of our mission – connecting our patients with the world of thoracic surgery. Discussing research findings, describing procedures and presenting information to the people who are actually undergoing the procedures we are writing about. Letting them know what’s new, what’s changed – and what to expect.

Every day, at least 200 people read “Blebs, Bullae and Spontanous Pneumothorax”. Why? Because it’s a concise article that explains what blebs are, how a pneumothorax occurs and how it’s treated. Another hundred people usually go on to read the accompanying case report about blebectomy, for similar reasons. There are links for more information, CT scans and intra-operative photos included, so that people can find exactly what they need with a minimum of effort.

Avoiding ‘Google overload’

With the massive volume of information available on the internet, high-quality, easily understood, applicable information has actually become even more difficult for patients to find than ever before. Patients spend hours upon hours browsing through academic jargon, commercial websites and biased materials while attempting to sift through the reams of information for pertinent and easily understandable information. There is also a lot of great material out there – so we provide links to reputable sites, recommend well-written articles and discuss related research.

Connecting patients to surgeons

We also provide patients with more information about the people they are entrusting their bodies, their hopes and their lives to. It’s important that they know about the Dr. Benny Wekslers, the Dr. Hanao Chens, and the Dr. Diego Gonzalez Rivas out there.

Update: June 2019

After multiple reader requests from this site, we have launched a service to assist readers in pursuiting minimally invasive thoracic surgery, uniportal surgery, HITHOC and other state-of-the-art thoracic surgery procedures with the modern masters of thoracic surgery. We won’t talk a lot about this on the site, but we do want readers to know that we are here to help you. If you are wondering what surgery costs like with one of the world’s experts – it’s often surprisingly affordable.

If you are interested in knowing more, please head to our sister site, www.americanphysiciansnetwork.org or send an email to kristin@americanphysiciansnetwork.org.

Keeping it ‘real’

Looking over the shoulder of Dr. Gonzalez Rivas in the operating room

As much as I may admire the work and the accomplishments of Dr. Gonzalez-Rivas – it’s important not to place him on a pedestal. He and his colleagues are real, practicing surgeons who operating on regular people, not just heads of state and celebrities. So when we interview these surgeons and head to the OR, it’s time to forget about the accolades, the published papers and the fancy titles. It’s time to focus on the operations, the techniques, the patients and the outcomes because ‘master of thoracic surgery’ or rural surgeon – the operation and patient are all that really matters.

K. Eckland

TedTalks about the New Masters of Thoracic Surgery

TedTalks sits up and takes notice of one of the New Masters and Superstars of modern thoracic surgery, Dr. Diego Gonzalez Rivas.

It looks like even the illustrious and élite Ted Talks have taken notice of the New Masters of Thoracic Surgery – these visionary, game-changing surgeons who are revolutionizing the thoracic surgery specialty.

The Spanish-language lecture entitled, “El viaje de los pioneros: Dr. Diego Gonzalez Rivas” should be just as inspiring to readers/ and viewers as it is to Cirugia de Torax.

If you don’t speak Spanish – don’t despair! Dr. Gonzalez’ TED talk is now available with captions in multiple languages. (Click on the closed captioning icon for translation options.)

Sometimes, it’s lonely out front – and being innovative is difficult. It’s one thing to be Ivor Lewis, Pearson or McKeown but it’s another to be the first or sole surgeon to challenge edicts and procedures laid down by the giants of the specialty. But without the modern-day Dylewskis, Gonzalez Rivas, Chen, (and others) – technology within the specialty would remain static.

These surgeons take big risks with their careers and reputations by attempting to deviate from long-standing surgical traditions. But sometimes, it pays off – and when it does, it is wonderful to see these daring and forward thinkers receive the admiration and appreciation they deserve for their contributions to the field and to their patients.

Dr. Santolaya, Dr. Sales dos Santos, Dr.Berrios and Dr. Diego Gonzalez Rivas

Congratulations, Dr. Diego Gonzalez Rivas! Here’s to your continued success..

Cirugia de Torax by K. Eckland is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License. Based on a work at cirugiadetorax.org. Permissions beyond the scope of this license may be available at cirugiadetorax.org.

This article is one of several articles and content from Cirugia de Torax that has been used commercially without consent, permission or attribution/ proper citation.

In the operating room with Dr. Mauricio Velaquez: Single port thoracoscopy

a day in the operating room with one of Colombia’s New Masters of Thoracic Surgery

Cali, Colombia

Dr. Mauricio Velasquez is probably one of the most famous thoracic surgeons that you’ve never heard of. His thoracic surgery program at the internationally ranked Fundacion Valle del Lili in Cali, Colombia is one of just a handful of programs in the world to offer single port thoracic surgery. Dr. Velasquez has also single-handedly created a surgical registry for thoracic surgeons all over Colombia and recently gave a presentation on the registry at a national conference. This registry allows surgeons to track their surgical data and outcomes, in order to create specifically targeted programs for continued innovation and improvement in surgery (similar to the STS database for American surgeons).

Mauricio Velasquez, thoracic surgeon — Dr. Mauricio Velasquez after another successful case

Dr. Velasquez is also part of a team at Fundacion Valle del Lili which aims to add lung transplant to the repertoire of services available to the citizens of Cali and surrounding communities.

He is friendly, and enthusiastic about his work but humble and apparently unaware of his growing reputation as one of Colombia’s finest surgeons.

Education and training

After completing medical school at Universidad Pontificia Bolivariana in Medellin in 1997, he completed his general surgery residency at the Universidad del Valle in 2006, followed by his thoracic surgery fellowship at El Bosque in Bogotá.

The Colombia native has also trained with thoracic surgery greats such as Dr. Thomas D’Amico at Duke University in Durham, North Carolina, and single port surgery pioneer, Dr. Diego Gonzalez Rivas in Coruna, Spain. He is also planning to receive additional training in lung transplantation at the Cleveland Clinic, in Cleveland, Ohio this summer.

Single port surgery

Presently, Dr. Velasquez is just one of a very small handful of surgeons performing single port surgery. This surgery is an adaptation of a type of minimally invasive surgery called video-assisted thoracoscopy. This technique allows Dr. Velasquez to perform complex thoracic surgery techniques such as lobectomies and lung resections for lung cancer through a small 2 – 3 cm incision. Previously, surgeons performed these operations using either three small incisions or one large (10 to 20cm) incision called a thoracotomy.

By using a tiny single incision, much of the trauma, pain and lengthy hospitalization of a major lung surgery are avoided. Patients are able to recovery and return to their lives much sooner. The small incision size, and lack of rib spreading means less pain, less dependence on narcotics and a reduced incidence of post-operative pneumonia and other complications caused by prolonged immobilization and poor inspiratory effort.

However, this procedure is not just limited to the treatment of lung cancer, but can also be used to treat lung infections such as empyema, and large mediastinal masses or tumors like thymomas and thyroid cancers.

Team approach

Part of his success in due in no small part to Dr. Velasquez’s surgical skill, another important asset to his surgical practice is his wife, Dr. Indira Cujiño, an anesthesiologist specializing in thoracic anesthesia. She trained for an additional year in Spain, in order to be able to provide specialized anesthesia for her husband’s patients, including in special circumstances, conscious sedation. This allows her husband to operate on critically ill patients who cannot tolerate general anesthesia. While Dr. Cujiño does not perform anesthesia for all of Dr. Velasquez’s cases, she is always available for the more complex cases or more critically ill patients.

In the operating room with Dr. Velasquez

I spent the day in the operating room with Dr. Velasquez for several cases and was immediate struck by the ease and adeptness of the single port approach. (While I’ve written quite a bit about the literature and surgeons using this technique, prior to this, I’ve had only limited exposure to the technique intra-operatively.) Visibility and maneuverability of surgical instruments was vastly superior to multi-port approaches. The technique also had the advantage that it added no time, or complexity to the procedure (unlike robotic surgery).

OLYMPUS DIGITAL CAMERA — Dr. Velasquez performing single port thoracoscopy

Cases proceeded rapidly; with no complications.

Note to readers – some of the content, and information obtained during interviews, conversations etc. with Dr. Velasquez may be used on additional websites aimed at Colombia-based readers.

Recent Publications

Zarama V, Velásquez M. (2012). Mainstem Bronchus Transection after Blunt Chest Trauma. J Emerg Med. 2012 Feb 3.

Talking with Dr. Diego Gonzalez Rivas about single port surgery

an Interview with Dr. Diego Gonzalez Rivas – and coverage of ‘Videotoracoscopia y cirugia robotica en torax: Avances y perspectivas’ in Santiago, Chile

Santiago, Chile

I was a little intimidated to actually interview Dr. Diego Gonzalez Rivas after reading his articles and pestering him with emails for the last few years. But he was just as nice and patient with my questions as he’s always been.

Dr. Gonzalez is here in Santiago for the single port thoracic surgery / robotic surgery conference at Clinica Alemana, hosted by Dr. Raimundo Santolaya.

Since publishing the last few articles on his single port technique, Dr. Gonzalez has been in high demand from thoracic surgeons wanting to learn more, and to train in single port techniques. In addition to traveling the world to teach – he continues to offer training at the Minimally Invasive Thoracic Surgery Unit at the Complexo Hospitalario Universitario de A Coruna, in Coruna, Spain.

Dr. Gonzalez reports that single port thoracoscopy doesn’t just provide patients with the least invasive surgery possible, but that single port thoracoscopy is superior to traditional VATS in the vast majority of cases. Single port thoracoscopy is defined by the creation of one 2cm to 4cm incision – with no rib spreading and utilization of video-assisted thoracoscopy.

“Forward Motion”

He states that using a single port approach gives much better visibility than traditional VATS. This visibility is equal to that of open surgery – versus the 3 or 4 port approach, which is constrained by the 30 degree movement / rotation of the thoracoscope. This visibility concept; called ‘Forward Motion,’ along with the ease of using instrumentation through the same port makes single port surgery amendable to most thoracic surgery procedures.

Learning curve? What learning curve?

He reports that members of the “Playstation Generation” as he terms the newest young surgeons, adapt more readily to the use of both traditional and single port thoracoscopy. In fact, he reports that the residents (in his program) are able to learn and use this approach with minimal assistance.

With the exception of lung transplantation (requiring the traditional clamshell incision), Dr. Gonzalez reports that he is able to successfully perform a wide range of surgeries from wedge resections and lobectomies to more complicated procedures such as pneumonectomies and sleeve resections.

In today’s lecture he debunks some of the myths regarding the ‘classic contraindications’ to video-assisted thoracoscopy (VATS) such as broncheoplasty, the presence of dense adhesions or the need for complete lymph node dissection. While he reports that dense adhesions may make the procedure more painstaking and difficult – it is still possible.

Lymph Node Dissection

In cases of lymph node dissection – he reports that lymphadenectomy is actually superior by single port and other VATS methods, with the average surgeon actually harvesting more nodes, more easily.

While he initially believed that right upper lobe resections would be impossible with this method – his recent experiences (included in an upcoming paper on 102 cases) show that any anatomic complexities are readily overcome by an experienced VATS surgeon. Not only that, but he has been able to successfully remove very large (8cm or greater) lung tumors using this method – by slightly enlarging the port at the time of specimen removal. He has also successfully removed Pancoast tumors and performed chest wall resections with this procedure, as well as single port thoracoscopy after previous VATS or previous thoracotomy including completion pnuemonectomies and completion sleeve lobectomies.

One of the biggest obstacles for surgeons implementing the single port method is the dreaded complication of catastrophic bleeding. This often causes inexperienced single port surgeons to hasten to convert to open surgery without attempting to control the bleeding. Dr. Gonzalez presented several cases today to demonstrate the difference between controlled bleeding that can be managed with the speedy application of surgical staples, clips or sutures versus heavy uncontrolled bleeding, which requires quick recognition and prompt conversion to open thoracotomy.

He reports that in the over 500 cases he has performed by VATS (3 port, dual port and single port), conversion to open thoracotomy remains a very rare occurence. (He presented data on his outcomes today.)

In his own practice, he reports that prior to 2007 the majority of cases were by traditional thoracotomy. He began using 3 port VATS more heavily in 2007 – 2009. After training with Dr. D’Amico at Duke University in Durham, NC – he moved to dual port thoracoscopy in 2009. Since 2010, his practice is almost exclusively single port thoracoscopy.

The future of single port thoracoscopy

Dr. Gonzalez believes the future of single port thoracoscopy will be a hybridization of current robotic thoracic surgery (which now uses three and four port techniques) to using less invasive, smaller robotic arms that will allow surgeons to enjoy the micro-precision of robotic technology through a single port.

Not just a ‘single port surgeon’

While he is famous internationally for his innovations in the field of minimally invasive surgery, he is also a transplant surgeon. In fact, along with his partners, he performed an average of 35 – 40 lung transplants a year.* This makes the transplant program in Coruna the second largest in Spain, despite the relatively small size of Coruna compared to other cities such as Barcelona or Madrid.

For patients who are interested in Dr. Gonzalez-Rivas and his program, please contact him at Info@videocirugiatoracica.com

I published an article based on this interview over at Examiner.com

* Spain is reported to have one of the highest rates of voluntary organ donation in the world. According to data provided by the Organ Registry of Spain – there were 230 lung transplants in 2011.

Additional Information

Spanish language interview with Dr. Gonzalez

Dr. Gonzalez’s YouTube channel

Publications/ References – Dr. Gonzalez Rivas

1. Single-port video-assisted thoracoscopic anatomic segmentectomy and right upper lobectomy. Gonzalez-Rivas D, Fieira E, Mendez L, Garcia J. Eur J Cardiothorac Surg. 2012 Aug 24

2 / Single-incision video-assisted thoracoscopic lobectomy: Initial results. Gonzalez-Rivas D, Paradela M, Fieira E, Velasco C.J Thorac Cardiovasc Surg. 2012;143(3):745-7

3 / Single-incision video-assisted thoracoscopic right pneumonectomy. Gonzalez Rivas D, De la Torre M, Fernandez R, Garcia J. Surgical Endoscopy. Jan 11. 2012 (Epub ahead of print)

4 / Single-port video-assisted thoracoscopic left upper lobectomy. Gonzalez-Rivas D, de la Torre M, Fernandez R, Mosquera VX. Interact Cardiovasc Thorac Surg. 2011 Nov;13(5):539-41

5 / Video-assisted thoracic surgery lobectomy: 3-year initial experience with 200 cases. Gonzalez D, De la Torre M, Paradela M, Fernandez R, Delgado M, Garcia J,Fieira E, Mendez L. Eur J Cardiothorac Surg. 2011 40(1):e21-8.

6 / Single-port Video-Assisted Thoracoscopic Anatomical Resection: Initial Experience. Diego Gonzalez , Ricardo Fernandez, Mercedes De La Torre, Maria Delgado, Marina Paradela, Lucia Mendez. Innovations.Vol 6.Number 3. May/jun 2011. Page 165.

Books/ Book Chapters

1 / Thoracoscopic lobectomy through a single incision. Diego Gonzalez-Rivas, Ricardo Fernandez, Mercedes de la Torre, and Antonio E. Martin-Ucar. Multimedia Manual of Cardio-Thoracic Surgery. MMCTS (2012) Vol. 2012 doi:10.1093/mmcts/mms007. Includes multiple videos demonstrating single port techniques.

2 / Tumores del diafragma. M. de la Torre Bravos, D. González Rivas, R. Fernández Prado, JM Borro Maté. Tratado de Cirugía Torácica. Editores L. Fernandez Fau, J. Freixinet Gilart. SEPAR Editores médicos SA. Madrid 2010. Vol 2, Sec VIII, Capitulo 87: 1269-78.

3 / Trasplante Pulmonar. C. Damas, M. De la Torre, W. Hespanhol, J.M. Borro. Atlas de Pneumología. Editores A. Segorbe Luís y R. Sotto-Mayor 2010. Vol 2, Capítulo 54 651-8.

4 / Doble utilidad hemostática y sellante de fuga aérea de tachosil en un caso de cirugía compleja por bronquiectasias. M. De la Torre, J.M. Borro, D. González, R. Fernández, M. Delgado, M. Paradela. Anuario 2009. Casos clínicos en cirugía. Accesit en la 3ª edición de los Premios Nycomed 2008.

5 / Cirugía Torácica videoasistida avanzada. D. González Rivas. Videomed 2008. Certamen internacional de cine médico y científico.

6 / Traumatismo Torácico. M. de la Torre, M. Córdoba. En « Manual de Urgencias en Neumología». Editado por Luis M Domínguez Juncal, 1999 165-78.

7 / Neumotórax. M. Córdoba, M. de la Torre. En « Manual de Urgencias en Neumología». Editado por Luis M Domínguez Juncal, 1999 139-56.

8 / Cirugía del enfisema. P. Gámez, J.J. Rivas, M . de la Torre. En « Neumología Práctica al Día». Boehringer Ingelheim 1998 77-102.

9 / Neumotórax. J.J. Rivas, J. Torres, M. de la Torre, E. Toubes. En « Manual de Neumología y Cirugía Torácica». Editores Médicos S.A. 1998 1721-37.

Single-port thoracoscopy as a first-line approach & the “Chen esophagectomy”

Dr. Chih-Hao Chen at Mackay Memorial Hospital in Taiwan talks about his experiences with single port/ single incision thoracic surgery (SITS) as well as the “Chen esophagectomy”; a new single port approach to esophagectomies.

Single-port thoracoscopic surgery (SITS) as a first-line approach
With the advent of minimally invasive surgical techniques such as VATS, surgeons now have the ability to perform multiple surgical procedures such as lobectomy, decortication and even esophagectomy through 1 – 2 cm port incisions instead of traditional open surgery. However, as mentioned during an interview with Dr. Mark Dylewski, few American* surgeons have fully embraced this technology. Even fewer surgeons internationally have embraced the emerging single port techniques that have developed from VATS. One of these surgeons is Dr. Chih-Hao Chen at Mackay Memorial Hospital in Taiwan. We previously discussed one of his studies here at Cirugia de Torax, so it was with great delight when we had an opportunity to discuss his continuing research and development in this area in a series of emails.
Dr. Chen is currently in the forefront of the movement to make SITS a first-line approach for majority of thoracic surgery procedures that can currently be approached with traditional VATS. The biggest risk to this “less is more” approach to port placement is needing to add additional ports during the case (thus converting to traditional VATS 3-4 port approach).

As Dr. Chen explains, “In contrast to creating 3 small wounds, I always try single-port first. If it is technically unavoidable, I would make the second port incision. If it is still difficult, a third port incision would be made. The conversion rate (to 2-port or three port methods not open) is very low in most conditions.
“I believe the role of SITS as a first-line endoscopic approach is possible in nearly all patients. So far, I have performed roughly, SITS in more than 150 patients with various thoracic diseases, including esophagectomy in 5 cases using 2.5 cm single incision”.
However, the contraindications for the SITS approach are mainly those with “unstable hemodynamics in trauma”, “highly complicated cancer resection(such as sleeve lobectomy, etc)” and “thick and dense peel in chronic empyema”.

Dr. Chen was kind of the provide this clip of him performing single port thoracoscopy.

Over 150 cases, so far.

“According to my experience, patients with spontaneous pneumothorax and acute stage empyema as well as solitary pulmonary nodules are the best candidates for such procedure. The time required for the same operation is much shorter in single-port approach. For simple spontaneous pneumothorax, the time may be as short as 20-25 minutes. ( from skin incision to suture )”.
As I mentioned in my report (see publications linked below), the conversion rate of such condition is pretty low and worthy to try. In my experience, SITS w/o trocar greatly decrease incisional pain and have pleasant cosmetic results, as the wound can be extremely small”.

A recent case: Wedge resection by SITS

Procedure: single-port approach for a case of lung cancer in a 77 year-old woman.

Multiple wedge resections, pleural biopsy and LN smapling were performed.

Single incision — single incision (now with chest tube) and specimen removed (photo courtesy of Dr. Chen)

The wound was 1.5 cm in length and the specimen is 7cm X 4cm ( solid part :2.5 cm ). The specimen was removed within an endo-bag. (From previous experience, I knew that a specimen of this size can be safely removed through a tiny incision w/o destruction of the specimen.

Her chest tube was removed within 24 hrs and patient reports minimal discomfort. ( I injected Marcaine in ICS to prevent neuralgia in all cases.)

Sometimes innovation is hard
As we’ve seen frequently in the history of medicine / surgery, early innovators and adopters of new technology are often face significant resistance from their colleagues despite utilizing ‘best-evidence’ to support their ideas. People, many people, including surgeons – don’t like change and are sometimes hesitant to learn and practice techniques that develop in the years following fellowship.
One of the reasons Dr. Chen contacted Cirugia de Torax is to share his experiences and this technique with other interested thoracic surgeons. ‘Unfortunately, only a small portion of thoracic surgeons would like to try such procedure in Taiwan. Actually, most of them considered the procedure not valuable. Therefore, I would like to publish more experiences in the journals, which is one way to tell them “to try”.

Wait.. Did you say single-port thoracoscopy for esophagectomy?

“Esophagectomy in my team was performed by single-port thoracoscopic approach (in the chest). However, the abdominal portion was performed with four-port or 5-port laparoscopic approach, because the abdominal part was done by another doctor who is not familiar with single-incision laparoscopy (SILS). However, I have to admit that esophagectomy through single-port approach is much more difficult than other procedures. The main reason for this is that the esophagus is located in posterior mediastinum.”

While I usually utilize a more anterior ICS as my port incision for other single-incision procedures because the anterior ICS is very easy, with low conversion ( to 2- or 3-port ) rate. However, the same port is not appropriate for esophagectomy because of poor visualization.

New Approach, the “Chen esophagectomy” but ergonomic considerations
“For the reason, I tried a more lateral port incision (usually 5 ICS along the mid-axillary line. ) This is a BIG problem for me due to ergonomic issues. Manipulation of endoscopic instruments and the endoscope through the port is uncomfortable. At times, I have to rest for a while in order to alleviate soreness in my arm”.
“The time-determining step is to loop the esophagus. Proximal and distal dissection as well as lymph node dissection would be done with a harmonic scalpel. (We resected the esophagus, the anastomosis is in the neck ). For uncomplicated case, the procedure in the chest takes aroud 1-2.5 hours”.

*American research data suggests that VATS is used for less than 30% of all thoracic surgery procedures. However, anecdotal evidence suggests that internationally, VATS is utilized with much higher frequency outside of the United States.

Articles about single-incision thoracoscopic surgery (SITS) by Dr. Chih-Hao Chen

Chih-Hao Chen, Shih-Yi Lee, Ho Chang, Hung-Chang Liu, Chao-Hung Chen (2012). The adequacy of single-incisional thoracoscopic surgery as a first-line endoscopic approach for the management of recurrent primary spontaneous pneumothorax: a retrospective study. Journal of Cardiothoracic Surgery 2012, 7:99 [abstract only, full article pending publication.]

Chih-Hao Chen, Shih-Yi Lee, Ho Chang, Hung-Chang Liu, Chao-Hung Chen (2012). Technical Aspects of Single-Port Thoracoscopic Surgery for Lobectomy. Journal of Cardiothoracic Surgery 2012, 7:50.

Chih-Hao Chen, Ho Chang, Tzu-Ti Hung, Hung-Chang Liu (2012). Single Port Thoracoscopic Surgery can be a First-line Approach for Elective Thoracoscopic Surgery. Revista Portuguesa de Pneumologia, Portuguese Journal of Pulmonology, 2012, Sept 22.

New Masters: Dr. Mark Dylewski, Robotic Surgery

Talking with Dr. Mark Dylewski, one of the new masters of thoracic surgery in the area of robotic surgery

Most of us never had the opportunity to meet or talk to some of the ‘masters’ of thoracic surgery like Dr. Hermes Grillo (1923 -2006), the ‘Father of Tracheal Surgery’ but as we have discussed before, thoracic surgery is not static. New technologies and new techniques are emerging all the time, and with these developments – new masters of thoracic surgery.

Dr. Mark Dylewski, may look too young to be the father of anything, but he is certain to be remembered in thoracic surgery history as one its new masters, and as one of the ‘fathers of robotic-assisted thoracic surgery’. While he is not the only surgeon doing robotic surgery, he is certainly one of the most prolific robotic / thoracic surgeons and has trained a large number of his peers.

cirujanos — Dr. Garrett Walsh and Dr. Mark Dylewski, thoracic surgeons

Talking to Dr. Dylewski about robotic surgery

At the recent conference, Advances in Lung Cancer and Mesothelioma, we had the opportunity to sit and talk with Dr. Dylewski about the state of robotics in thoracic surgery. Dr. Dylewski is one of the foremost experts on the topic and teaches robotic surgery techniques at the South Miami Hospital Center for Robotic Surgery. Since he started performing robotic surgery in 2006, he estimates that he has taught over 200 thoracic surgeons how to perform surgery utilizing the DaVinci robot.

In comparison to other minimally invasive techniques (specifically VATS), Dr. Dylewski believes that robotic surgery has greater potential for use in thoracic surgery, due to its easy adoptability. He reports that unlike VATS, robotic surgery techniques utilize traditional surgical skills so that surgeons are usually proficient at robotic surgery after performing 30 – 40 cases. There are no counter-intuitive movements or altered visibility/surgical perspectives which are two of the things inherent in video-assisted thoracoscopy. He attributes both of these issues with the failure of more wide-spread adoption of VATS despite the availability of this technology for over twenty years. According to Dr. Dylewski, less than 30% of all thoracic procedures in North America are currently done using VATS.

Simply put, even some of the best thoracic surgeons may have trouble adapting to VATS techniques and as many as 20% will never fully adjust to video-assisted surgical techniques.

However, in his experience, robotic-assisted thoracic surgery such as complete portal robotic lobectomy ( aka CRPL-3 or CRPL-4, depending on the number of arms used) has a greater potential for widespread use. He explains that despite the initial hefty price tag, the robotic technology easily justifies its equipment costs, in terms of subsequent savings and benefits from decreasing the length of stay, less patient discomfort and greater patient satisfaction. He reports that these benefits have led to the adoption of robotic surgery as the standard of care in other specialties such as gynaecology despite the relative newness of this technology.

Dr. Dykewski also presented data regarding surgical outcomes from 355 cases, which includes a wide variety of thoracic procedures such as lobectomies, esophagectomies and mediastinal surgeries. Surgical outcomes were comparable to VATS procedures with a markedly shorter length of stay.

Dr. Mark Dylewski, MD

Thoracic Surgeon

Director of General Thoracic & Robotic Surgery

Baptist Health of South Florida

Miami, Florida

OR live with Dr. Dylewski

Spanish news story about Dr. Dylewski on YouTube

Selected publications

Dylewski MR, Ohaeto AC, Pereira JF. (2011). Pulmonary resection using a total endoscopic robotic video-assisted approach. Semin Thorac Cardiovasc Surg. 2011 Spring;23(1):36-42.

Ninan M, Dylewski MR. (2010). Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg. 2010 Aug;38(2):231-2. Epub 2010 Mar

Additional References and Resources

Meyer M, Gharagozloo F, Tempesta B, Margolis M, Strother E, Christenson D. (2012). The learning curve of robotic lobectomy. Int J MId Robot. 2012 Sep 18. doi: 10.1002/rcs.1455. The authors of this publication report that it takes 18 – 20 complete portal robotic lobectomies to obtain competency.

The New Masters

The innovative and dynamic ‘New Masters’ of thoracic surgery

Most of us never had the opportunity to meet or talk to some of the ‘masters’ of thoracic surgery like Dr. Hermes Grillo (1923 -2006), the ‘Father of Tracheal Surgery’ or Dr. Joel Cooper, the “Father of Lung Transplant” or legends in esophageal surgery such as Dr. Griffith Pearson or Dr. Henry Heimlich.

However, as we have discussed before, thoracic surgery is not static. New technologies and new techniques are emerging all the time, and with these developments – new masters of thoracic surgery. These include innovative and dynamic young surgeons such as Dr. Diego Gonzalez, and Dr. Mark Dylewski. We hope to bring you more New Masters here at Cirugia de Torax.

Talking with Dr. K. Adam Lee, MD about minimally invasive surgery

In Jupiter, Florida talking about robots, lung cancer screening and solitary pulmonary nodules with Dr. K. Adam Lee, thoracic surgeon

Jupiter, Florida

Dr. K. Adam Lee, MD and Dawn Bitgood, FNP

All my prepared questions fly out of my mind as I greet Dr. Lee and his team. It’s been several months since I first contacted Dr. Lee to ask about his new thoracic surgery program at Jupiter Medical Center in coastal Florida, but it has taken this long for me to find a way to Florida. After nine months here, Dr. Lee is well-settled into his new position as medical director of the thoracic surgery and lung center.

Detecting and treating lung cancer

We talk about the regional differences in thoracic surgery, with Dr. Lee confirming that the majority of his practice is surgical oncology; including diagnosed lung cancer and solitary pulmonary nodules. In fact, since coming to Jupiter, Dr. Lee has started a lung cancer screening program based on the newly released CT scan guidelines for the early detection of lung cancer, as well as a lung nodule clinic for the evaluation of lung nodules.

Minimally invasive surgery

With Dr. Lee, “minimally-invasive’ is the theme. “I want patients to ask, ‘do I have to have a thoracotomy?” he states. “I want patients to know that there are minimally invasive options,” he continues as he talks about the advantages of minimally invasive techniques such as robotic-assisted thoracic surgery (RATS) and video-assisted thoracoscopic surgery (VATS). “Why should patients have all the pain [associated with large surgical incisions] if there is no reason not to do minimally invasive surgery?”

Dr. Lee should know; he’s been performing robotic surgery since 2003.

Lee Robot — Dr. Lee, performing surgery with the DaVinci robot

Teaching others

As part of his commitment to advancing technologies, he has recently paired with Ethicon Endo-surgery to be able to provide training in minimally invasive surgery to thoracic surgery colleagues all over the world. Twice a month, he travels to other facilities to demonstrate these techniques for other surgeons. The operating rooms at the hospital here have recently been outfitted for web-based broadcasting for the remainder of the time, so that surgeons, regardless of location are able to watch these demonstrations[1].

He reports that learning to perform robotic surgery is easier for surgeons to learn than video-assisted thoracoscopic surgery, explaining that while the instrumentation is different (using robotic arms to perform surgery), the tissue manipulation and techniques are closer to open surgery [compared to VATS], and thus more familiar to conventionally trained surgeons.

I didn’t get to see Dr. Lee in the operating room – but soon, everyone will be able to.

[1] Surgeons interested in learning more can contact either Ethicon Endo-surgery or Dr. Lee directly.

* I was surprised to find out that the lung cancer screening program (CT scan, radiology interpretation/ consultation and a consultation with a thoracic surgeon) is under 300.00 USD. In an age of exorbitant medical fees, this is an affordable option for early detection of lung cancer.

Block, Tuffier, Blalock & Gonzalez? Returning to single incision thoracoscopic surgery with Dr. Diego Gonzalez – Rivas

Checking in with Dr. Diego Gonzalez – Rivas and his team in Coruna, Spain – the innovators in single incision thoracic surgery, as Dr. Gonzalez publishes a new report on single incision pneumonectomy.

After speaking with Dr. Raimundo Santolaya last week – I contacted Dr. Diego Gonzalez over at UTCMI in Coruna, Spain to see what he’s been doing since our last contact, and discuss a possible interview in the future.

The single-port thoracic surgery superstar and his colleagues are certainly keeping busy – and continue to push the edges of modern thoracic surgery firmly into more and more advanced minimally invasive techniques.

Last fall, he published another case report on single incision VATS – lobectomy, and since then he has continued to operate and publish reports on his successes. Now he has an upcoming case report on a right-sided single-port pneumonectomy, which was largely held as one of the last frontiers in VATS procedures. (Pneumonectomy by standard VATS, despite being reported in the literature several years ago, remains a relatively uncommon procedure.)

While a common criticism of his work is related to the fact that removing a portion of the lung as large as a lobe, or an entire lung requires a small additional incision at the conclusion of the case – but these criticisms are weak at best – and fail to see the true clinical importance of his continued innovation and investigation in advancing video-assisted thoracoscopic surgery for the benefits of our patients. Ten years from now – single incision VATS will be a common procedure, and Drs. Gonzalez, Fernandez and De la Torre will be the ones responsible.

References: Single port pneumonectomy

Gonzalez-Rivas D, de la Torre M, Fernandez R, Garcia J. (2012). Single-incision video-assisted thoracoscopic right pneumonectomy. Surg Endosc. 2012 Jan 11. [Epub ahead of print – abstract re-posted below]

Abstract

BACKGROUND: The most common approach for Video-assisted thoracoscopic (VATS) lobectomy is undertaken with three or four incisions, including a utility incision of about 3-5 cm. However, major pulmonary resections are amenable by using only a single utility incision. This video shows the technical procedure of a right pneumonectomy by single-incision approach with no rib spreading.

METHODS: A 52-year-old woman was proposed for single-incision VATS resection of a 5-cm right lower lobe adenocarcinoma. A 4-cm incision was made in the fifth intercostal space. We placed a 30-degree, high-definition, 10-mm thoracoscope in the posterior anterior part of the incision. Digital palpation confirmed that the tumor involved the fissure and the posterior portion of the upper lobe, which indicated the need for right pneumonectomy. We inserted the instruments through the anterior part of the utility incision to start the detachment of the right upper lobe by using a harmonic scalpel. The first step was dissecting the inferior pulmonary vein. The hilar structures were exposed by using harmonic scalpel and a long dissector (Fig. 1A). The upper and middle-lobe pulmonary veins were dissected and transected, allowing visualization of truncus anterior, which was then stapled. The inferior pulmonary vein and the intermediate truncus artery were divided, allowing optimal exposure to the main bronchus, which was stapled. The lung was removed in a protective bag by adding 1 cm to the incision, and a systematic lymph node dissection was performed. A single chest tube was placed in the posterior part of the utility incision.

RESULTS: Total surgery time was 210 min. The chest tube was removed on postoperative day 2, and the patient was discharged home on day 4 with no complications.

CONCLUSIONS: Single-port VATS pneumonectomy for selected cases is a feasible procedure, especially when performed from a center with previous experience in double-port VATS approach.

DISCUSSION: Recent advances in surgical and video-assisted techniques have allowed minimally invasive pneumonectomy to be undertaken safely. VATS pneumonectomy is not a new procedure and in fact was initially reported 15 years ago and was felt to result in less postoperative pain and a faster return to normal activities [1]. Despite this, there have been only a few case reports or series published of VATS pneumonectomies [2,3].

Additional References/ Resources

Gonzalez – Rivas, D., Fernandez, R., De la Torre, M., & Martin – Ucar, A. E. (2012). Thoracoscopic lobectomy through a single incision. Multimedia manual cardio-thoracic surgery, Volume 2012. This is an excellent article which gives a detailed description, and overview of the techniques used in single incision surgery. Contains illustrations, full color photos and videos of the procedure.

Gonzalez-Rivas D, Paradela M, Fieira E, Velasco C. (2012). Single-incision video-assisted thoracoscopic lobectomy: initial results. J Thorac Cardiovasc Surg. 2012 Mar;143(3):745-7.

Gonzalez-Rivas D, de la Torre M, Fernandez R, Mosquera VX. (2011). Single-port video-assisted thoracoscopic left upper lobectomy. Interact Cardiovasc Thorac Surg. 2011 Nov;13(5):539-41.

Talking with Dr. Raimundo Santolaya, MD, thoracic and transplant surgeon at the Instituto Nacional del Torax

an interview with thoracic and tranplant surgeon, Dr. Raimundo Santolaya Cohen of Santiago, Chile

After listening to Dr. Raimundo Santolaya Cohen at the National Conference, where he discussed the diagnosis and management of Pneumothoraces, I immediately contacted him following the lecture to arrange an interview. I was delighted to be able to spend several hours in the charismatic and elegant Chilean surgeon’s company while we talked about thoracic surgery, and the state of lung transplant in Chile.

Dr. Raimundo Santolaya, is a Valparaiso native who currently practices in Santiago at the Instituto Nacional del Torax and the Clinica Alemana. He is also a professor and the Chief of the thoracic surgery fellowship program at the Universidad de Chile.

While he reports that while lung transplant programs are fairly small in Chile (in comparison to American institutions) he performs several transplants every year.

In addition to his interest in pulmonary transplant, he is also keenly interested in minimally invasive surgery, including uni-port surgery. In fact, he is currently arranging for Dr. Diego Gonzalez, the Spanish thoracic surgeon to come to Chile in October to teach uni-port lobectomy.

Like most thoracic surgeons, he performs a wide range of thoracic procedures including lung surgeries, and mediastinal masses.

We also discussed the incidence of Hidatidosis/ hydatidosis, (echinococcus granulosus) which is endemic in Chile. Hidatidosis is an infection caused by a parasite transmitted by animals (commonly dogs), and is more commonly known as a tapeworm. Infection with this organism can affect multiple organs, but frequently affects the liver and the lungs, called hepatopulmonary hydatidosis. Infection is marked by the development of hydatid cysts which are filled with tapeworm larvae. In the lungs, these cysts can become quite large.

When this occurs, the cysts must be surgically excised in addition to aggressive medical management.

About Dr. Santolaya:

Dr. Raimundo Santolaya completed his thoracic surgery fellowship at the Universidad de Chile before traveling to Madrid, Spain to study lung transplant for an additional year.

Instituto Nacional del Torax

J. M. Infante 717, 4^th floor

Santiago, Chile

Telephone (56-2) 340 3462

Clinica Alemana

Manquehue Norte 1410

Centro de Diagnostico, 11^th floor

Santiago, Chile

Telephone (56-2) 210 1114

Talking with Dr. Luis Marcelo Argote Green, National Institute of Medical Science

Talking to the interesting and entertaining Dr. Marcelo Argote Green, of Mexico City at the LXXI Congreso for Sociedad Mexicana de Neumologia y Cirugia de Torax

Mexico

A wicked streak of good luck allowed me to catch up with Dr. Luis Marcelo Argote Green at the Mexican Society of Pulmonology and Thoracic Surgery conference in Cancun for an interview.

Dr. Argote Green has been practicing in Mexico City for four years, since completing his fellowship in thoracic surgery at Brigham Women’s & Children’s Hospital in Boston, Massachusetts. He trained under the guidance of several of the most prominent American thoracic surgeons including the ever elusive* Dr. David Sugarbaker.

Dr. Argote maintains an active, and diverse practice as he is currently operating in several facilities within the supercity, including that National Institute of Medical Science. This gives him a wide range of exposure and experience to patients from all across the city, and across all demographic lines. As a surgeon at one of the countries more prominent public facilities, he also receives patients from around the country – particularly the more challenging or complex cases. He reports that this along with the high incidence of HIV and other autoimmune conditions such as scleroderma and lupus make his day-to-day practice different from the average small town physicians practice, or even the West Roxbury Veteran’s facility where he completed some of this training. “I saw maybe two or three cases with patients with this level of complex co-morbidities when I was training, but here I see it everyday.” He enjoys this aspect of his work which gives him a deeper level of experience than he might otherwise have at this stage in his career.

He has also embraced minimally invasive technologies such as VATS, and RATS, and currently performs uni-port lung biopsies, and VATS lobectomies. He also particularly enjoys treating patients with mediastinal masses, and uses a unilateral VATS approach for many of these tumor resections versus the traditional median sternotomy.

During our in-depth conversation, we also discussed some of the differences I had observed during my time in Mexico – particularly the inter-collegial relationships between pulmonologists and thoracic surgeons. He explained that this is due in part to a shared history, and that in Mexico – thoracic surgery was a outbranching of pulmonary medicine, as pulmonologists initially sought additional training in more invasive procedures, including surgery. While there is now more delineation between the specialties, there remains a sense of commonality often spoken of during this conference by the participants which is sometimes striking to outsiders like myself.

* Long-time readers know of our ongoing attempts to contact Dr. Sugarbaker for an interview.

Dr. Ross Bremner, and the state of thoracic surgery in Arizona

Talking with Dr. Ross Bremner, Chief of Thoracic Surgery and Chair of Thoracic Disease & Transplant at St. Joseph’s Hospital in Phoenix, Arizona.

St. Joseph’s Hospital

After talking to Dr. Bremner of the phone, I felt compelled to come down to Phoenix and meet him in person. I am glad I did. While St. Joseph’s is a large 607 bed hospital – it’s just one of many large healthcare facilities in the Phoenix area. The same can not be said of their robust thoracic surgery program. They have a surprising range of thoracic surgery subspecialties, and sub-specialty programs including transplant, anti-reflux surgery, minimally invasive surgery, esophageal surgery program and robotic surgery. As you can imagine, I felt a bit like a kid in a candy store – so overwhelmed by the array of services, that my mind was just bursting with questions. (I rounded with the group and got to see the full spectrum of patients – including four recent post-transplant patients.) They also have a pediatric thoracic surgery program and plan to start a pediatric transplant program soon.

The head of the program, Dr. Ross Bremner is one of five thoracic surgeons at the Heart & Lung Institute of St. Joseph’s Hospital in Phoenix, Arizona which is currently the state’s largest thoracic surgery program. A native of Johannesburg, Dr. Bremner maintains international ties to his home country by staying active in the South African Cardiothoracic Surgery Society. He began his thoracic surgery career at University of Southern California (USC) where he met and recruited both Dr. Michael Smith, MD and Sandra Ogawa, ACNP.

As Arizona has grown, so has thoracic surgery. Despite the relatively small population of Arizona overall, both the esophageal surgery program and the lung transplant program maintain volumes that are competitive with the big-name east coast institutions.

With over 45 lung transplants last year – and the University of Arizona currently out of the running, Dr. Bremner* and his team are set to boost those numbers this year. They have already done ten transplants here in the first quarter of 2012, and anticipate doing fifty to sixty this year. (If you remember from our previous posts about lung transplantation – even very large institutions are not doing huge numbers of transplants. In fact, you can check the numbers at the Organ Procurement and Transplant Network if you’re interested*.)

St. Joseph’s also has an esophageal surgery program which maintains the high volumes of esophagectomies needed for optimal outcomes. Dr. Bremner reports that they perform on average 50 – 60 esophagectomies for esophageal cancer ever year in addition to their benign esophageal surgery program. (As we discussed with Dr. Molena, ‘benign’ is a bit of a misnomer for esophageal conditions since achalasia, esophageal strictures and other non-cancerous conditions of the esophagus may have a huge negative impact on the individual’s quality of life.)

The Heart & Lung Institute also offers training courses for surgeons and residents in minimally invasive surgery – in fact, they are teaching a course the weekend of my visit.

As a practicing surgeon in Phoenix, Arizona, Dr. Bremner also sees numerous cases of Coccidoidomycosis** (or Valley Fever) which is endemic to this area of the country. In fact, Maricopa county, which encompasses the city of Phoenix sees more cases annually than the California valley the disease was originally named for.

* At the site, you can create data reports by organ, region, outcome, waiting period, etc.. For example – using this data table – we can see that there were a total 1,516 isolated lung transplants in the United States in 2011 which is actually a decrease from 2010 and 2009.

** Readers can anticipate a future article on this topic

More about Dr. Ross Bremner, MD, PhD

Dr. Bremner is a genial gentleman and a ready conversationalist. Our interview was relaxed, but informative. He welcomed my questions on a variety of topics and was generous with his time. In fact, I had ready access to multiple members of his team, and spent the entire afternoon with the department of thoracic surgery. It was an engaging afternoon, and highlighted one of the reasons I pursue interviews and opportunities to speak to my colleagues within thoracics; it was an opportunity to learn more about the specialty, and the care of thoracic surgery patients.

Dr. Bremner is a board-certified thoracic surgeon. After obtaining his baccalaureate degree and medical school training at Witwatersrand University in South Africa, he continued his education in the United States.

He completed his general surgery residency, PhD research and thoracic surgery residency at the University of Southern California. He was the Director of the Hastings Thoracic Oncology Research Laboratory on the USC campus. At this lab, surgeons along with researchers from multiple disciplines conduct research on the diagnosis and treatment of lung cancer including research in gene therapies prior to coming to Arizona.

He has several YouTube videos talking about his current research projects at St. Joseph’s.

He also has an informational series for patients about Lung Transplant over at EmpowHer.com

Dr. Ross M. Bremner, MD, PhD

Chief of Thoracic Surgery

Chair of the Center for Thoracic Disease & Transplantation

Heart & Lung Institute – St. Joseph’s Hospital and Medical Center

500 W. Thomas Road, Suite 500

Phoenix, Arizona 85013

Tele: (602) 406 4000

Fax: (602) 406 3090

Selected publications (not a full listing)

Jacobs JV, Hodges TN, Bremner RM, Walia R, Huang J, Smith MA. (2011). Hardware preservation after sternal wound infection in a lung transplant recipient. Ann Thorac Surg. 2011 Aug;92(2):718-20. [no free text available].

Felton VM, Inge LJ, Willis BC, Bremner RM, Smith MA. (2011). Immunosuppression-induced bronchial epithelial-mesenchymal transition: a potential contributor to obliterative bronchiolitis. J Thorac Cardiovasc Surg. 2011 Feb;141(2):523-30. [no free text available].

Gotway MB, Conomos PJ, Bremner RM. (2011) Pleural metastatic disease from glioblastoma multiforme. J Thorac Imaging. 2011 May;26(2):W54-8. [no free text available].

Coon KD, Inge LJ, Swetel K, Felton V, Stafford P, Bremner RM. (2010). Genomic characterization of the inflammatory response initiated by surgical intervention and the effect of perioperative cyclooxygenase 2 blockade. J Thorac Cardiovasc Surg. 2010 May;139(5):1253-60, 1260.e1-2. [no free text available].

Wu C, Hao H, Li L, Zhou X, Guo Z, Zhang L, Zhang X, Zhong W, Guo H, Bremner RM, Lin P. (2009). Preliminary investigation of the clinical significance of detecting circulating tumor cells enriched from lung cancer patients. J Thorac Oncol. 2009 Jan;4(1):30-6. [no free full-text available].

Backhus LM, Bremner RM. (2006). Images in clinical medicine. Intrathoracic splenosis after remote trauma. N Engl J Med. 2006 Oct 26;355(17):1811.

Backhus LM, Sievers E, Lin GY, Castanos R, Bart RD, Starnes VA, Bremner RM. (2006). Perioperative cyclooxygenase 2 inhibition to reduce tumor cell adhesion and metastatic potential of circulating tumor cells in non-small cell lung cancer. J Thorac Cardiovasc Surg. 2006 Aug;132(2):297-303. [no free full-text available].

Backhus LM, Sievers EM, Schenkel FA, Barr ML, Cohen RG, Smith MA, Starnes VA, Bremner RM. (2005). Pleural space problems after living lobar transplantation. J Heart Lung Transplant. 2005 Dec;24(12):2086-90. [no free text available].

Backhus LM, Petasis NA, Uddin J, Schönthal AH, Bart RD, Lin Y, Starnes VA, Bremner RM. (2005). Dimethyl celecoxib as a novel non-cyclooxygenase 2 therapy in the treatment of non-small cell lung cancer. J Thorac Cardiovasc Surg. 2005 Nov;130(5):1406-12. [no free full-text available].

Sievers EM, Bart RD, Backhus LM, Lin Y, Starnes M, Castanos R, Starnes VA, Bremner RM. (2005). Evaluation of cyclooxygenase-2 inhibition in an orthotopic murine model of lung cancer for dose-dependent effect. J Thorac Cardiovasc Surg. 2005 Jun;129(6):1242-9. [no free full-text available].

Bowdish ME, Barr ML, Schenkel FA, Woo MS, Bremner RM, Horn MV, Baker CJ, Barbers RG, Wells WJ, Starnes VA. (2004). A decade of living lobar lung transplantation: perioperative complications after 253 donor lobectomies. Am J Transplant. 2004 Aug;4(8):1283-8. [no free full-text available].

Starnes VA, Bowdish ME, Woo MS, Barbers RG, Schenkel FA, Horn MV, Pessotto R, Sievers EM, Baker CJ, Cohen RG, Bremner RM, Wells WJ, Barr ML. (2004). A decade of living lobar lung transplantation: recipient outcomes. J Thorac Cardiovasc Surg. 2004 Jan;127(1):114-22. [no free full-text available].

Haddy SM, Bremner RM, Moore-Jefferies EW, Thangathurai D, Schenkel FA, Barr ML, Starnes VA. (2002). Hyperinflation resulting in hemodynamic collapse following living donor lobar transplantation. Anesthesiology. 2002 Nov;97(5):1315-7.

DiPerna CA, Bowdish ME, Weaver FA, Bremner RM, Jabbour N, Skinner D, Menendez LR, Hood DB, Rowe VL, Katz S, Kohl R. (2002). Concomitant vascular procedures for malignancies with vascular invasion. Arch Surg. 2002 Aug;137(8):901-6; discussion 906-7.

Bremner RM, Hoeft SF, Costantini M, Crookes PF, Bremner CG, DeMeester TR. (1993). Pharyngeal swallowing. The major factor in clearance of esophageal reflux episodes. Ann Surg. 1993 Sep;218(3):364-9; discussion 369-70.

Talking with Dr. Daniela Molena

at John Hopkins, talking with Dr. Daniela Molena about minimally invasive thoracic surgery.

Baltimore, Maryland

John Hopkin’s newest recruit to the Department of Thoracic Surgery, Dr. Daniela Molena is a bright point in the future of thoracic surgery. While she has only been at Hopkins for a few short months (since September) she is already innovating and bringing positive changes to the institution. In fact, there is too much to say about this fascinating and charming surgeon in just one article.

A practicing general surgeon in her native Italy, Dr. Molena rapidly became interested and proficient in the surgical treatment of benign esophageal diseases. As a specialist in diseases of the esophagus, she has extensive training in both gastrointestinal and thoracic surgery. Pursuit of this education brought her to the United States.

Once here, Dr. Molena took advantage of the opportunities to train with some of the most renown surgeons in the country; with Dr Marco Patti in San Francisco, with Dr Peters Jeffrey in Rochester, Memorial Sloan Kettering Cancer Center in NY with Dr Rusch Valerie and Dr. James Luketich at the University of Pittsburgh Medical Center, and now here at John Hopkins with Dr. Stephen Yang. She believes this gave her a better appreciation for all the different techniques and schools of though in thoracic surgery. “I don’t just use a specific surgeon’s approach, I can use the best I have learnt from each mentor and apply it to best fit the individual patient and their needs.”

Once she arrived here, she hit the ground running; gathering research on esophageal surgery; starting a lung cancer screening program for some of Baltimore’s more poverty-stricken communities, arranging for patient outreach sessions for cancer patients, working with Dr. Avo Meneshian’s robot-assisted thoracic surgery (RATS) program at the John Hopkins Bayview facility, and quickly advancing, promoting and heading a new program for minimally invasive esophageal surgery (including minimally invasive esophagectomy (MIE) for esophageal cancer). She favors the Ivor-Lewis style procedure but performs it via thoracoscopy and laparoscopic approaches. She thinks it is important to stress that minimally invasive surgery is just the approach or the tool to gain access to the chest to complete a surgical procedure. Thus, a minimally invasive procedure does not mean a lesser or inferior resection. “It’s how we get in – once we get in [to the chest], we can do whatever surgery is needed, respecting oncologic principles.”

While the MIE program is young, Dr. Daniela Molena hopes to grow this program with time, as part of a multi-disciplinary program for esophageal cancer patients. This holistic approach which combines diagnosticians, oncologists, dietitians, nutritionists, nurses, and surgeons is also an immensely practical one. This multi-specialty clinic ensures that the patient/ and their family is able to meet with, consult with and work collaboratively with all of these specialties to determine their course of treatment on the same day during a single trip. This alleviates much of the financial and transportation hardships experienced by many of the families travelling from around the country (and around the world[1]) for treatment at John Hopkins.

Dr. Molena takes this holistic approach to thoracic disease very seriously. As she explains, “Even benign (non-cancerous) esophageal diseases are terrible for patients and their families. They have to learn to adapt and accept that even with treatment, life may never be the same”. She feels that it is essential that we speak to patients openly, and honestly and set realistic expectations, stating “People, especially our patients, are remarkably resilient if we communicate clearly with them during this process.” She also feels that as a surgeon she is here to do more for her patients that operate, that it’s not just about cutting. She is here to help patients (and their loved ones) find all the resources they need to regain optimal health and promote wellness. “It is more than just surviving the surgery. It’s about health & wellness,” she finishes.

It’s a strong, profound statement and a reminder for surgery but one that reflects the thoughts and feelings of many of the wonderful thoracic surgeons I have met, interviewed or worked with. But in Medicine, with many of it’s rigid definitions and delineations; too often the surgeons themselves, their motivations, and their desire to heal gets lost among the surgeries, and the procedures.

More about Dr. Daniela Molena

John Hopkins – Department of Thoracic Surgery, Surgeon profile

Medical School: Faculty of Medicine University of Padova (Padova Italy)
(1996)

General Surgery residencies:

University of Rochester Medical Center (Rochester NY) – General Surgery (2009)

Faculty of Medicine University of Padova (Padova Italy) – General Surgery (2001)

Faculty of Medicine University of Padova (Padova Italy) – General Surgery (1999)

Fellowships:

Memorial Sloan-Kettering Cancer Center (New York NY) – Cardiothoracic Surgery (2011)

University of Pittsburgh Medical Center (Pittsburgh PA) – Cardiothoracic Surgery (2010)

New York Presybterian Hospital (New York NY) – Cardiothoracic Surgery (2011)

Memorial Sloan-Kettering Cancer (New York NY) – Cardiothoracic Surgery (2009)

Universita Degli Studi di Padova (Padova Italy) – Minimally Invasive Surgery (2002)

[1] John Hopkins has a separate department called the International Patient Center which is devoted to detangling and simplifying the health care process for overseas patients.

Contact Information:

The Johns Hopkins Hospital

600 N. Wolfe Street

Baltimore, MD 21287

Phone: 410-614-3891

Appointment Phone: 410-933-1233

Selected publications

Dubecz A, Molena D, Peters JH. Modern surgery for esophageal cancer. Gastroenterol Clin North Am. 2008 Dec;37(4):965-87, xi. Review.

Zaninotto G, Annese V, Costantini M, Del Genio A, Costantino M, Epifani M, Gatto G, D’onofrio V, Benini L, Contini S, Molena D, Battaglia G, Tardio B, Andriulli A, Ancona E. Randomized controlled trial of botulinum toxin versus laparoscopic heller myotomy for esophageal achalasia. Ann Surg. 2004 Mar;239(3):364-70.

Zaninotto G, Costantini M, Portale G, Battaglia G, Molena D, Carta A, Costantino M, Nicoletti L, Ancona E. Etiology, diagnosis, and treatment of failures after laparoscopic Heller myotomy for achalasia. Ann Surg. 2002 Feb;235(2):186-92.

Patti MG, Molena D, Fisichella PM, Whang K, Yamada H, Perretta S, Way LW. Laparoscopic Heller myotomy and Dor fundoplication for achalasia: analysis of successes and failures. Arch Surg. 2001 Aug;136(8):870-7.

Williams VA, Watson TJ, Gellersen O, Feuerlein S, Molena D, Sillin LF, Jones C, Peters JH. Gastrectomy as a remedial operation for failed fundoplication. J Gastrointest Surg. 2007 Jan;11(1):29-35. [no free full-text available].

In the operating room with Dr. Carlos Ochoa

After my first encounter with the young, energetic thoracic surgeon in Mexicali in November of 2011, I’ve been waiting for an opportunity to return to Mexico to learn more about Dr. Ochoa and his practice. After spending an exhausting 48 hours with Dr. Ochoa, I must say that my first impressions regarding this surgeon were correct. He is tireless in his dedication to his patients, and his efforts to treat the people of Mexicali with the most modern surgical treatments available are impressive.

He carries a small black backpack with him everywhere he goes. After following him to the operating room for the first case; I know why. He brings much of his own, privately purchased sterile equipment with him – especially when he is operating at the public hospital. Out of the bag came sterile packages of double lumen endotracheal tubes*. Sterile packages of surgical instruments. His own freshly laundered surgical scrubs. (The hospital does provide its own sterile surgical gowns, gloves and patient drapes.)

Dr. Ochoa’s black bag filled with sterile supplies

He knows he could ‘do better’ and make more money in a larger city at a more affluent hospital in Mexico, but as he explains – there are only three thoracic surgeons for all of Northern Mexico[1]. He says this without pretension, or expectations. The people of Mexicali need him – even if they don’t know it. Prior to his arrival, affluent patients went to Tijuana or the United States for treatment. Poorer patients often went without.

100_2269 — Dr. Carlos Ochoa, at Hospital General de Mexicali

After two cases that morning, and another that evening, we round at several hospitals seeing patients – finishing well past midnight. He remains unflagging, unhesitating – even swinging past the emergency department at the General hospital to make sure there were no chest trauma cases arriving before finally signing out for the night[2].

We meet again, the next morning and it starts all over again – rounds, clinic visits, surgery, and more rounds. It is well past ten pm when we finish. In my brief 48 hours in Mexico during this trip – I’ve spent most of it in the company of Dr. Ochoa while he strives to build his practice and his reputation as a new surgeon. Watching him, I am frankly, fatigued but he’s ready to continue for as long as he’s needed.

It’s an impressive start to what I anticipate to be a long and rewarding career in thoracic surgery.

* This isn’t as strange as it sounds, especially since he is the only thoracic surgeon in the area (thus the only surgeon using double lumen ET tubes in the city.)

[1] Despite high rates of thoracic diseases such as empyema and XDR tuberculosis.

[2] ‘Signing out’ simply means he is no longer on/ or in the nearby vicinity. He remains on-call 24/7.

St. George’s Hospital, NHS and the state of thoracic surgery

A visit to St. George’s Hospital in South London to talk about the state of thoracic surgery in Great Britain.

St. George’s Hospital – South London, UK

St. George’s Hospital is one of the largest teaching hospitals in the United Kingdom. In fact, with over 1,000 beds, St. George’s is the largest hospital in London, and one of the largest hospitals in Great Britain. Historically, St. George’s Hospital was the home of several prominent, and important figures in medicine and surgery, including Henry Gray (author of the classic Gray’s Anatomy text, and early anatomist), noted surgeon John Hunter (often called the ‘father of modern surgery’). Edward Jenner, inventor of the smallpox vaccine, also practiced at St. Georges.

Statue of John Hunter, anatomist and surgeon — on the grounds of St. George’s Hospital

The hospital campus itself has an interesting story, after being founded in 1733. Originally located in central London, after several moves and upgrades, it was finally removed to its current location in the working class, ethnically diverse neighborhood of Tooting in South London in 1980. (Hospital services, including the University of London medical school were moved to the Tooting site in multiple stages, starting in 1954.)

All of this makes for a fascinating backdrop for my visit to talk to British surgeons about thoracic surgery in the United Kingdom. The hospital has a dedicated cardiothoracic surgery division, located within the Atkinson Morley Wing (which also houses neurosurgery and cardiology facilities.)

The cardiothoracic surgery division and the subspecialty area of thoracic surgery are well-defined here, with multiple ancillary services such as pulmonary rehabilitation programs and is collectively known as the Chest center. The Chest Center is made up of a multi-disciplinary team which includes two thoracic surgeons, two cardiothoracic surgeons, a pulmonary interventionalist (a pulmonologist specializing in interventions such as bronchoscopy), and a nurse practitioner (known as nurse specialists in the UK). It’s a busy service line, performing over 1100 surgeries per year.

And so, I found myself spending a gray, rainy afternoon discussing the state of thoracic surgery in the United Kingdom with two very fine surgeons from St. George’s Hospital. Like many of the surgeons I have interviewed, they were modest, humble even about the important work that they do for the citizens of Surrey and West Essex counties. As a stranger to socialized medicine and the National Health Service, we started a conversation discussing some of the international headlines discussing thoracic surgery in the UK.

Contrary to recent media reports suggesting a decay in services for British citizens, the surgeons I spoke to (Hunt and Tan[1]) state that thoracic surgery is undergoing a renaissance period over the last few years: the number of dedicated specialty trained[2] thoracic surgeons have actually increased dramatically, and has almost doubled, from around forty surgeons to more than 70. The recent 2011 national audit showed an increase in both percent and total cancer operations and a dramatic decrease in surgical mortality.

This new generation of thoracic surgeons heralds a new, hopeful era for thoracic surgery in Great Britain. These new (and for the most part, younger) surgeons, in turn, embrace newer procedures and technologies for treatment of thoracic diseases. As thoracic surgeons, (versus traditional cardiothoracic surgeons) these doctors have more in-depth knowledge and interest in state-of-the-art therapies for lung cancer and other thoracic conditions. This is particularly important, as here in England, similar to many of the locations I have visited, newer technologies have advanced much quicker than the slower moving bureaucracies such as medical billing and reimbursement[3]. This means that there is often little financial incentive for surgeons to learn, adopt and embrace innovative techniques or even established advancements such as video-assisted thoracoscopy (VATS)[4]. The hospitals and the divisions they work for receive greater reimbursement for the larger, more traditional ‘open’ surgeries even if the patients are best served by smaller, minimally invasive procedures.

The thoracic surgeons at St. George’s have managed to circumvent much of this mentality by using existing data from their own program to show the benefits of minimally invasive surgery. Much of this data has been collected as part of the national database called the ‘Blue Book.’ This national audit of surgical practices and outcomes is similar to the Society of Thoracic Surgeons (STS) database, and is entirely voluntary [5]. However, unlike the STS General Thoracic database which is currently poorly attended by American surgeons – the Blue Book is well-populated by British surgeons, with 100% participation [6].

The most recent data from St. George’s suggests that all of these developments are making a difference. The two thoracic surgeons, Ian Hunt, and Carol Tan are both part of that new generation of innovators, and researchers. They report that they are doing more and more VATS procedures (as part of the 8 – 12 cases they are doing every week). They are doing more and more procedures on older patients – and sicker patients with more advanced cancers – with positive outcomes. The average VATS patient length of stay is 3 days, and even patients undergoing large open traditional cases are going home in five or six days. They have replaced epidurals with PCAs and one time spinal injections to increase patient mobility, and continue to investigate ways to reduce pneumonias and other post-operative complications.

Recent changes within the national health service have sometimes made this more difficult. Patient privacy and new public health policies make investigational trials more cumbersome and time-consuming, but it doesn’t dampen their enthusiasm.

I can’t talk about St. Georges and Thoracic Surgery without further mentioning the surgeons that help make St. George’s Hospital the top #2 or #3 institution in the UK for patient care. As I’ve mentioned, Mr. (Dr.) Ian Hunt, FRCS, MD is a humble sort of gentleman. He is also an enthusiastic, friendly and fascinating interview.

In just 2010 and 2011 alone, he was involved in at least six research papers published on two continents (see below). These papers span the spectrum of thoracic surgery topics – from metastasectomy in colon cancer to cryoablation for chest wall pain, to thoracic trauma and the use of video mediastinoscopy.

I haven’t seen him operate, but he has the qualities that seem universal and essential in the make-up of outstanding modern surgeons [7]. One of these qualities is relentless pursuit of academic and surgical knowledge. This pursuit has led Mr. Hunt across three continents and several countries, as he travelled to Alberta, (Canada), New Zealand and the United States for education and training that was not available in the UK. He has a keen interest in pursuing research and answers for the conditions that plague his patients the most; surgical resections for advanced cancers, mediastinal surgery and chest wall reconstructions, thoracic trauma, mesothelioma and airway disease. He is also interested in research and predictive tools such as the ThoracoScore (used to predict post-operative mortality – similar to the Surgical Apgar [8].)

His colleague, fellow surgeon, Carol Tan joins us during the interview. She came to St. George’s Hospital several months after Ian Hunt, and together they have been instrumental in creating a ‘atmosphere of change’ at St. Georges. We spend a few minutes talking about epidemiologic patterns of lung diseases. In comparison to other geographic areas, urban London sees more seasonal empyema patterns related to parapneumonic infections, but less chronic diseases such as tuberculosis and opportunistic fungal infections. We discuss how the use of long-term antibiotic therapy regimens has complicated the identification and diagnosis of causative organisms. We also discuss her interests in the treatment of pleural disease and St. George’s surgical programs for myasthenia gravis (in conjunction with spine surgeons) and the benefits of unconventional transcervical approaches instead of median sternotomy. Both Mr. Hunt and Ms. Tan also talk about the increasing use of ‘co-surgeons’ in the operating room, the advantages of this practice and how this is changing surgery.

Together, we discuss the Davies article and how this skewed view of the roles of pulmonary medicine and thoracic surgery mirrors many of the conflicts in cardiology and cardiac surgery [9]. We also discuss how referral patterns and timing of referrals also affects surgical outcomes and the co-dependency among specialists.

Before the end of the interview, we also talk about another faucet of thoracic surgery (that is near and dear to my heart): the use and role of nurse practitioners in thoracic surgery. Unfortunately, Caroline, the nurse specialist in thoracic surgery at St. George’s is unable to join us today. But maybe another day.

[1] “Please make the article about thoracic surgery, and what we do, not about us,” Mr. Hunt requests. In response, I have done so, but will give brief mention of both Mr. (Dr.) Ian Hunt and Ms. (Dr.) Carol Tan at the conclusion of this article, to give readers a better idea of the speakers qualifications and background.

[2] This refers to surgeons specifically focusing on thoracic surgery, as opposed to traditional cardiothoracic surgeons who are dual specialized, or general surgeons (who have omitted specialty training) but may perform thoracic procedures.

[3] This seems to be a fairly common situation in medicine, around the world. Influence of conversion on cost of video-assisted thoracoscopic lobectomy, Eur J Cardiothorac Surg. 2010 Jan;37(1):249-50; author reply 250-1. Epub 2009 Dec 5.

[4] Learning these techniques often comes at considerable expense, and inconvenience for many of these surgeons – who may have to travel to North America, Hong Kong or other large centers specializing in minimally invasive surgery for fellowships or periods of extended training.

[5] While entirely voluntary, there is a stigma attached to surgeons who do not participate under the assumption as to the reasons why they do not want their hospital, thoracic surgery program and individual surgeon data disclosed to the public.

[6] The British Blue Book is not specific to thoracic surgery only. Several other specialties such as orthopaedics contribute to this database. However, the cardiothoracic specialty is overseen by the Society of Cardiothoracic Surgery.

[7]. The qualities of outstanding modern and historical surgeons differ greatly. One of the most important qualities in surgeons past was fearlessness. These surgeons often endured failure after failure (patient deaths) before developing effective surgical techniques. As you can imagine, this quality of fearlessness would now be seen as recklessness – and would not be a desirable trait in modern surgeons for many reasons.

[8] As we discussed previously, Davies work ignores much of the existing research that demonstrates conflicting results to their opinions – including their own research which failed to confirm their propositions.

[9] The Surgical Apgar scoring system by Gwande predicts post-operative mortality and complications by measuring 4 intra-operative factors.

Additional Resources:

History of the University of London Medical School

The Society for Cardiothoracic Surgery

The Blue Book reports

Selected bibliography of Mr. Ian Hunt

* denotes lead author

(2011). Cadaveric thoracic trauma management courses for emergency physicians may contribute to improved outcomes. Eur J. Emerg Medicine 2011 Nov 22.

(2011). Is video mediastinoscopy a safer and more effective procedure than conventional mediastinscopy? Interact Cardiovasc Thorac Surg 2011 Nov 17.

(2011). A method of assessing reasons for conversion during video-assisted thoracoscopic lobectomy . Interact Cardiovasc Thorac Surg 2011 Jun 12 (6).

*(2010). Managing a solitary fibrous tumour of the diaphragm from above and below. ANZ J Surg 2010 May, 80 (5) 370-1.

*(2010). A late complication of traumatic flail segment with colonic herniation. Emerg Med J. 2010 Mar, 27 (3) 193.

*(2010). Video-assisted intercostal nerve cryoablation in managing intractable chest wall pain. J Thorac Cardiovasc Surg. 2010 Mar;139(3):774-5.

(2010). Pulmonary metastasectomy in colorectal cancer: a systematic review and quantitative synthesis. J R Soc Med. 2010 Feb;103(2):60-6.

*(2009). Minimally invasive excision of a mediastinal cystic lymphangioma. Can J Surg. 2009 Oct;52(5):E201-2. case report.

(2009). Novel fixation technique for the surgical repair of lung hernias. Ann Thorac Surg. 2009 Sep;88(3):1034-5.

(2009). Massive pulmonary arteriovenous malformation presenting with tamponading haemothorax. BMJ Case Rep. 2009;2009:bcr2006071852. Epub 2009 Feb 18. case report.

Ms. Carole Tan, MD, FRCS(C) is a board-certified thoracic surgeon. She joined the Chest Center at St. George’s Hospital in 2010. She is currently the principal investigator for PulMiCC (pulmonary metastasectomy for colorectal carcinoma.)

Ms. Tan’s clinical interests include the treatment of pleural disease, specifically malignant mesothelioma, which we have talked about on previous occasions at Cirugia de Torax. In fact, she has been widely published in this area (see bibliography below.) Prior to coming to St. George’s Hospital, Ms. Tan was the surgical coordinator for the multicenter MARS trial (on the surgical treatment of malignant mesothelioma).

Ms. Tan has also been involved in several studies on the use of sealants intra-operatively for the treatment of air leaks, and chest tube suction.

Bibliography for Ms. Carole Tan

In press:

Zakkar M, Tan C, Hunt I. Is video mediastinoscopy a safer and more effective procedure than conventional mediastinoscopy? Interact Cardiovasc Thorac Surgery.

Tan C, Treasure T, Utley M. Reply to D’Andrilli and Rendina. Eur J Cardiothorac Surgery.

PUBLICATIONS

Bliss JM, Coombes G, Darlison L, Edwards J, Entwistle J, Kilburn LS, Landau D, Lang-Lazdunski L, O’Brien M, O’Byrne K, Peto J, Senan S, Snee M, Spicer J, Tan C, Thomas G, Treasure T, Waller D. The MARS feasibility trial: conclusions not supported by data – Authors’ reply. Lancet Oncol 2011;12(12):1094-5.

Treasure T, Lang-Lazdunski L, Waller D, Bliss JM, Tan C, Entwisle J, Snee M, O’Brien M, Thomas G, Senan S, O’Byrne K, Kilburn LS, Spicer J, Landau D, Edwards J, Coombes g, Darlison L, Peto J; MARS trialists. Extra-pleural pneumonectomy versus no extra-pleural pneumonectomy for patients with malignant pleural mesothelioma: clinical outcomes of the Mesothelioma and Radical Surgery (MARS) randomised feasibility study. Lancet Oncol 2011;12(8):763-73.

Tan C, Utley M, Paschalides C, Pilling J, Robb JD, Harrison-Phipps KM, Lang-Lazdunski L, Treasure T. A prospective randomised controlled study to assess the effectiveness of CoSeal to seal air leaks in lung surgery. Eur J Cardiothorac Surg 2011;40(2):304-8.

Teh E, Fiorentino F, Tan C, Treasure T. A systematic review of lung-sparing extirpative surgery for pleural mesothelioma. J R Soc Med 2011;104(2):69-80.

Tan C, Barrington S, Rankin S, Landau D, Pilling J, Spicer J, Cane P, Lang-Lazdunski L. Role of integrated 18-FDG-PET-CT in patients surveillance after multimodality therapy of malignant pleural mesothelioma. J Thorac Oncol 2010;5(3):385-8. Treasure T, Waller D,

Tan C, Entwisle J, O’Brien M, O’Byrne K, Thomas G, Snee M, Spicer J, Landau D, Lang-Lazdunski L, Bliss J, Peckitt C, Rogers S, Marriage Nee Denholm E, Coombes G, Webster-Smith M, Peto J. The Mesothelioma and Radical Surgery randomised controlled trial: The MARS feasibility study. J Thorac Oncol 2009;4(10):1254-8.

Tan C, Gleeson F, Treasure T. Malignant pleural mesothelioma. In: Hunt I, Muers MM, Treasure T, eds. ABC of Lung Cancer, pp 25-8. WileyBlackwell, April 2009.

Treasure T, Tan C, Peckitt C, Entwisle J, Waller D, O’Brien M, Bliss J, Peto J. Mesothelioma and Radical Surgery trial (MARS): the feasibility study process. Lung Cancer 2009;63(Supplement 1):S26.

Utley M, Gallivan S, Jit M, Paschalides C, Tan C, Treasure T. Can patients progress modeling inform the management of cancer patients? In: Brailsford S, Harper P, eds. Operational Research for Health Policy: Making better decisions. Proceedings of 31st Annual Conference of the European Working Group on Operational Research Applied to Health Services, pp 243-252. Oxford, UK, Peter Lang, 2008.

Tan C, Treasure T. UK surgical trials in mesothelioma. Lung Cancer in Practice 2007;3(2):8-9.

Pai V, Gangoli S, Tan C, Rankin S, Utley M, Cameron R, Lang-Lazdunski L, Treasure T. How best to manage the space after pneumonectomy? Theory and experience but no evidence. Heart Lung Circ 2007;16(2):103-6.

Tan C, Treasure T, Browne J, Utley M, Davies CW, Hemingway H. Seeking consensus by formal methods: a health warning. J R Soc of Med 2007;100(1):10-4.

Davies A, Tan C, Paschalides C Barrington SF, O’Doherty M, Utley M, Treasure T. FDG-PET maximum standardized uptake value is associated with variation in survival: Analysis of 498 lung cancer patients. Lung Cancer 2007;55:75-8.

Faith A, Peek E, McDonald J, Urry Z, Richards DF, Tan C, Santis G, Hawrylowicz C. Plasmacytoid dendritic cells from human lung cancer draining lymph nodes induce Tc1 Responses. Am J Respir Cell Mol Biol 2007;36:360-7

Tan C, Treasure T, Browne J, Utley M, Davies CWH, Hemingway H. Appropriateness of VATS and bedside thoracostomy talc pleurodesis as judged by a panel using the Rand/UCLA appropriateness method (RAM). Interact Cardiovasc Thorac Surg 2006;5:311-6.

Tan C, Sedrakyan A, Swift S, Browne J, Treasure T. The evidence on pleurodesis for malignant effusion: a systematic review. Eur J Cardiothorac Surg 2006;29:829-38.

Treasure T, Tan C. Cannabis, pneumothorax and lung bullae: author’s reply. J R Soc Med 2006;99(4):170.

Treasure T, Tan C. Miss, Mister, Doctor: How we are titled is of little consequence. J R Soc Med 2006;99(4):164-5.

Tan C, Hatam N, Treasure T. Bullous disease of the lung and cannabis smoking: insufficient evidence for a causative link. J R Soc Med 2006;99(2):77-80.

Treasure T, Tan C, Lang-Lazdunski L, Waller D. The MARS trial: mesothelioma and radical surgery. Interact Cardiovasc Thorac Surg 2006;5:58-9.

Tan C, Treasure T. Radical Surgery for mesothelioma. International Pleural Newsletter 2006;4(1):1-2.

West D, Tan C. Thoracic surgery: new training for an old specialty. BMJ Career Focus 2006;332:6-7.

Tan C, Treasure T. Mesothelioma: time to take stock. J R Soc Med 2005;98:455-8.

Lang-Lazdunski L, Tan C, Treasure T. Extrapleural pneumonectomy for malignant mesothelioma: should pericardium be resected routinely? J Thorac Cardiovasc Surg 2005;129(5):1202.

Alphonso N, Tan C, Utley M, Cameron R, Dussek J, Lang-Lazdunski L, Treasure T. A prospective randomized controlled trial of suction versus non-suction to the under-water seal drains following lung resection. Eur J Cardiothorac Surg 2005;27:391-4.

Tan C, Sedrakyan A, Treasure T. Pleurodesis for malignant effusion: time to stop using bleomycin? World J Surg 2004;28(8):253-4.

Tan C, Treasure T. Pleural adhesions: more friend than foe. Adhesions 2004;6:23-4.

Tan C. Pleurodesis for malignant effusion. In: Treasure T, Hunt I, Keogh B, Pagano D, eds. The evidence for cardiothoracic surgery, pp 119-30. tfm Publishing Limited, 2004.

Tan C. The management of (spontaneous) pneumothorax. In: Treasure T, Hunt I, Keogh B, Pagano D, eds. The evidence for cardiothoracic surgery, pp 107-18. tfm Publishing Limited, 2004.

Ang KL, Tan C, Hsin M, Goldstraw P. Intrapleural tumour dissemination after video-assisted thoracoscopic surgery metastasectomy. Ann Thorac Surg 2003;75:1643-5.

Tan C, N Alphonso, D Anderson, C Austin. Mediastinal haemangiomas in children. Eur J Cardiothorac Surg 2003;23:1065-7.

Treasure T, Swift S, Tan C. Radical surgery for mesothelioma: How can we obtain evidence? World J Surg 2003;27:891-4.

Tan C, Swift S, Gilham C, Shaefi S, Fountain W, Peto J, Treasure T. Survival in surgically diagnosed patients with malignant mesothelioma in current practice. Thorax 2002;57iii:iii36.

Jupiter Medical Center: Q & A with Dr. K. Adam Lee

More robotic surgery as we talk with Dr. K. Adam Lee, the new director of thoracic surgery at Jupiter Medical Center in Jupiter, Florida.

Dr. K. Adam Lee, a thoracic surgeon with extensive experience in robotic surgery was recently selected as the Medical Director of the new thoracic surgery center at Jupiter Medical Center in Jupiter, Florida. (Jupiter, Florida is a oceanside community close to West Palm Beach, located between Orlando and Miami.)

Prior to coming to Jupiter, Dr. Lee was most recently at the Kennedy Health System in New Jersey.

Dr. Lee is well-known for his expertise in thoracic robotic surgery and has trained surgeons in using the DaVinci robot, in live demonstrations, conferences and educational sessions. Currently, Dr. Lee is working with three other thoracic surgeons.

After reading about Dr. Lee, I contacted him (by email) to ask about his plans for the future.

Q & A with Dr. K. Adam Lee

CdeT: There is quite a bit of interest in robotic surgery right now. Would you please tell us more about some of the robotic surgery procedures you are performing, and why these procedures are becoming popular?

Dr. Lee: [In our program, we are currently performing several different robotic procedures including]:

Robotic lobectomy for lung cancer. Lobectomy, or the surgical removal of a cancerous lobe in the lung, is the standard treatment of early-stage non small-cell lung cancer. Until recently, this procedure required a large incision that could cause the patient significant pain and a long recovery period

Segmentectomy- especially for pulmonary compromised patients, Wedge resections

Robotic thymectomy for myasthenia gravis/ Thymomas. The removal of the thymus gland is often a recommended treatment for patients who have myasthenia gravis, which is a neuromuscular disorder that can cause muscle weakness. Traditional surgery involves a large, length-wise incision along the breastbone, similar to that used for open-heart surgery.

Mediastinal biopsies and resections

Robotic resection of mediastinal masses. The mediastinum is the portion of the chest cavity between the lungs. When tumors or other masses grow in the mediastinum—such as thymoma or lymphoma—surgeons can remove the masses robotically through small incisions instead of the large incisions required with traditional open surgery.

Anterior:
Lymph nodes ie-lymphoma, metastatic lesions

Posterior:
Neurogenic tumors i.e Schwannomas.

Esophagus

Esophagectomy

Esophogeal myotomy for achalasia. Achalasia is a disorder that affects the ability of the esophagus to move food toward the stomach. Left untreated, achalasia can result in the widening of the esophagus to the point at which it begins to function as a reservoir instead of a conduit. That can lead to infection, obstruction and even the development of esophageal cancer.
Surgeons can correct this condition using a procedure called myotomy, in which the esophageal muscle is cut and repositioned.

Robotic laparoscopic Belsey fundoplasty for gastroesophageal reflux disease (GERD). The most common disease in humans, GERD affects nearly 20 percent of Americans. Nearly everyone experiences GERD from time to time, but it can lead to injury of the esophagus and upper digestive track, as well as esophageal cancer, if it is experienced on an ongoing basis. Belsey fundoplasty is a minimally invasive surgical technique that can correct problems with the esophagus that lead to GERD.

Thoracic Sympathectomy: Palmar Hyperhidrosis [this is a condition for excessive sweating of the palms.]

CdeT:. Will you be performing esophagectomies?

Dr. Lee: We will be adding minimal invasive esophageal surgery via Video Assisted and Robotic assisted thoracoscopic
procedures.

CdeT: Do you currently perform any single port surgeries?

Dr. Lee: We will review which cases would benefit from the single port exposure. Most probable are the mediastinal biopsy and resection cases.

CdeT: How many years have you been operating/ performing robotic surgery?

Dr. Lee: I have been performing robotic thoracic surgery since 2003.

CdeT: What is your average annual case volume and what
percentage of procedures are you performing using the robot?

Dr. Lee: We perform greater than 90% of all our thoracic surery cases utilizing the minimal invasive approach (VATS& RATS). We plan all of our pulmonary lobectomies for early stage Non Small Cell Lung cancers to be performed utilizing the four arm robotic lobectomy, a total endoscopic approach.

CdeT: Do you have a mesothelioma or any other specialty
clinics are part of your program?

Dr. Lee: Yes, we cover the entire spectrum of the thoracic disease process as well as participating in research trials. One of our sub specialty clinics is the emphasis on minimal invasive thoracic surgery.

CdeT: Where do you think the future of thoracic surgery is
heading?

Dr. Lee: I see the future continuing to progress in minimal invasive surgery. Currently a little over 20% across the country utilize MIS. This number will increase over the next 5 years and beyond as the result of MIS continues to show as good and better results as compared to the standard thoracotomy approach. Secondly, early detection methods will improve so as to find the cancers at earlier stages and hopefully shift the survival curves.

CdeT: What do you plan for the future of your program?

Dr. Lee: To be a comprehensive program with emphasis on early detection and minimal invasive surgery, utilizing trials and protocols for the most difficult of cases.

Dr. K. Adam Lee, MD

Thoracic Surgeon/ Medical Director of Thoracic Surgery & Lung Center

Jupiter Medical Center

1240 S. Old Dixie Highway

Jupiter, Florida 33458

http://www.jupitermed.com/lung

tele: 561 – 263 – 3604

Update: Dr. Lee’s most recent face to face interview.

Talking with Dr. Carlos Cesar Ochoa Gaxiola

Cirugia de Torax in Mexicali, Baja California to interview Dr. Carlos Cesar Ochoa Gaxiola.

I spent a very pleasant and interesting morning talking to the enthusiastic and charming young surgeon, Dr. Carlos Cesar Ochoa Gaxiola in Mexicali, Mexico. Dr. Ochoa is my favorite type of surgeon to interview. He loves what he does despite the challenges it sometimes presents (due to limited local resources such as PET/CT modalities*). His enjoyment of surgery and caring for his patients is obvious – and he readily invites me to round with him, and see his daily practice. Unfortunately, on this occasion, I am unable to do so.

Just a year and a half since completing his thoracic surgery residency, and Dr. Ochoa has made Mexicali, (the capital of Baja California) his home. As the only full-time thoracic surgeon* in this city of almost one million residents – Dr. Ochoa stays busy operating and seeing patients at both the general hospital and the ISSSTecali hospital system.

Since much of his practice is working in public facilities, Dr. Ochoa spends much of his time caring for the poor, and the underserved patients of Mexicali – who have little access to preventative health and wellness therapies. He reports that he performs a large volume of decortications and other procedures to treat empyemas and similar endemic diseases of poverty. This includes surgical treatments for tuberculosis, which remains a serious health problem in Mexico.

During our interview, we discussed his work with tuberculosis patients many of whom have multi-drug resistant tuberculosis. (The emergence of MDR and XDR strains of tuberculosis has become a rapidly spreading health threat not just in the middle east and Asia but in the United States and Mexico, particularly in border towns.) In adjoining Calexico, the University of San Diego has a tuberculosis project to help identify and aggressively treat these resistant strains. While this program has been successful in encouraging compliance and adherence to complicated (and expensive) long-term drug regimens, it also highlights the importance of thoracic surgery in the treatment of this disease. Dr. Ochoa reports that he frequently treats pulmonary complications of this [TB], and other chronic lung infections. He performs many of these operatives to prevent constrictive complications and to restore patients functional status/ prevent disability.

He also performs the entire spectrum of other thoracic surgery procedures including other types of pulmonary resections for the treatment of cancer(s), traumatic injuries to the chest, thymectomies and other mediastinal procedures, esophagectomies and tracheal surgeries. He embraces the use of minimally invasive procedures including dual port thoracoscopic procedures, and performs the majority of his cases by VATS.

He prefers the transhiatal approach for the majority of esophageal cases since it limits the development of catastrophic complications such as mediastinitis from anastomosis leak. He reports that he does not get do as many esophageal cases as he would like since the majority of the cases performed locally are done by general surgeons.

This afternoon, Dr.Ochoa is giving a presentation at the Mexican Society of Pulmonologists and Thoracic Surgeons on the topic of surgery for the treatment of COPD.

Dr. Carlos Cesar Ochoa Gaxiola, MD

Thoracic Surgeon

Av. Madero 1059

Mexicali, Baja California

Tele: 686 – 552 – 5436

email: carlos_og@yahoo.com

Brief Biography of Dr. Carlos Cesar Ochoa Gaxiola

Dr. Ochoa is certified nationally as a cardiothoracic surgeon, though he explains that similar to the United States – the majority of programs are combined – and he subspecialized in Thoracic Surgery. He states that current board certifications in Mexico make no distinction between subspecialties. He has also received additional certification by the National Counsel of Thoracic Surgery, and is a member of multiple specialty organizations including: the LatinAmerican Association of Thoracics (ALAT), Sociedad Mexicana de Neumologico y Cirugia de Torax.

Dr. Ochoa attended medical school at the Universidad Autonoma de Baja California. He completed his general surgery residency (four years) at the Hospital General del Estado; in Hermosillo, Sonora. He then performed his thoracic surgery fellowship at the Instituto Nacional de Enfermedades Respiratorias (INER). This four-year program is one of the only Thoracic Surgery specialty training programs in Mexico. He had received additional training in bronchoscopy, and video assisted thoracoscopy (VATS).

He has presented multiple case reports at national conferences.

Publications: (note: I was unable to find live links for all of his publications).

Mucormicosis Pulmonar: Presentación de un caso. Neumología y Cirugía de Tórax 2009; 68: 78-81. Download pdf.

Additional references and information:

University of San Diego Tuberculosis program – podcast of this story.

The Border Health Initiative

Notes:

* The nearest PET/ CT scanner in Baja California is located in Tijuana.

** There are two cardiothoracic surgeons who divide their time between Tijuana and Mexicali, who primarily perform cardiac surgery. Dr. Ochoa sometimes partners with these surgeons on more complex, and complicated cardiac and thoracic cases.

Talking with Dr. Orazio Amabile

a brief interview with Dr. Orazio Amabile, cardiothoracic surgeon from Phoenix Cardiac Surgery as we cross paths in Flagstaff, Arizona.

Dr. Orazio Amabile, a native Arizona resident and cardiothoracic surgeon is a youthful appearing 41-year-old with a ready smile and an engaging manner. I am rounding with him today in Flagstaff, as he fills in for the local surgeon* who is on a much deserved vacation.

Dr. Amabile is one of several cardiothoracic surgeons at Phoenix Cardiac Surgery in Phoenix, Arizona, a metropolitan city of around 6 million residents. He has been a board certified CT surgeon since 2008. It’s our second meeting, and I am impressed by his relaxed yet focused approach. We start the interview when I ask him to recount the 2007 episode in Tucson that led to his police citation for bravery. He, and his colleague, cardiothoracic surgeon, Dr. M. Christina Smith were out to satisfy a late pregnancy ‘tater tot’ craving after a long day in surgery, when they witnessed a drive by shooting. After several shots were fired into a nearby car after being side-swiped by a larger vehicle, the two surgeons (Amabile & Smith) followed the injured man’s car – and finding the man gravely, and severely injured with a bullet wound to the chest, immediately arranged for transport and emergency surgery. Dr. Amabile had already alerted the operating room, and was carrying the actively dying young man to a nearby squad car when an ambulance diverted to the scene. He climbed into the ambulance and administered emergency aid during transport including CPR as the patient arrested at the entry to hospital. He and Dr. Smith then performed the emergency surgery that saved the young man’s life. (Dr. Amabile was a fellow in cardiothoracic surgery at the University of Arizona at the time.)

Since then, Dr. Amabile has worked in Phoenix, seeing patients at several institutions (St. Joseph’s, St. Luke’s and several other smaller facilities), though Banner’s Good Samaritan Hospital is his primary center of operations. As a cardiothoracic surgeon, he operates on the whole spectrum of cardiovascular and thoracic conditions, specializing in LVADs, Aortic Surgery (aortic arch/ thoracic aortic surgery) and minimally invasive thoracic surgery including single port lobectomies, wedge resections and other lung surgeries. He estimates that he does roughly 100 – 150 lung surgeries a year as part of his practice. He states that 90% of these procedures are done via minimally invasive techniques but that he doesn’t hesitate to use open techniques if that’s what is required to get the best surgical results for his patients.

Dr. Amabile also feels that large, centralized surgery programs are essential for optimal patient outcomes. For example, he states, “Arizona has 25 cardiac surgery programs which means that each surgeon, and each surgery program has much less volume [and thus experience] than if Arizona had just a few programs.” This also has an impact on the allocation of resources – which are now shunted into twenty-five directions instead of three or four major facilities.

I ask his opinion of the future of thoracic surgery and robotics – of which he is not a fan. Like many surgeons I’ve spoken to, Dr. Amabile does not feel that the use of robotics is always justified by the increased risks to the patients. “It can make a dangerous operation more dangerous.” We discuss the lack of technical advantages and the increased case durations with robotic approaches for a few minutes before the conversation turns.

Dr. Amabile sees LVADs and device therapies as the future of thoracic surgery – particularly the use of ECMO and ambulatory ECMO devices for end stage lung disease. He became more interested in the new applications of ECMO after he attended the ELSO conference in Scottsdale last year. He envisions this treatment, device therapy as a destination rather than a bridge to transplantation. To this end – he recently started a LVAD program at Good Samaritan hospital and has recently implanted his 6th device this year. He hopes to implant ten devices in the program’s first year. As part of this, he is participating in the Intermacs database to continue research into circulatory devices. (It’s his interest in this area, and the pathophysiology involved in circulatory arrest that fuels his interest and enjoyment of aortic surgery.)

Brief Biography

At 41, Dr. Amabile is just at the beginning of a long career in cardiothoracic surgery. After attending medical school at Universidad Autonoma De Guadalajara in Guadalajara, Mexico, D. Amabile returned to the United States to do an additional year at New York Medical College. He then completed two years of his general surgery residency at Creighton University in Omaha, Nebraska before returning to his home state of Arizona for the remainder of his general surgery training and his cardiothoracic surgery fellowship (at the University of Arizona in Tucson.) Along the way, he gathered several awards in addition to his police citation mentioned above, including awards as best intern teacher, a Golden Apple award nominee (2002) and an award for excellence in customer service (the ‘Target 100’).

Dr. Orazio Amabile, MD

Phoenix Cardiac Surgery

3131 East Clarendon Ave.

Suite 102

Phoenix, AZ 85016

(602) 253-9168

* Disclosure: I previously worked for the Flagstaff based surgeon, Dr. Steven Peterson at the Heart & Vascular Center of Northern Arizona.

Robotics and Thoracic surgery : Dr. Weksler

a brief snapshot of a Dr. Benny Weksler, a thoracic surgeon using robotic technology at the University of Pittsburgh in Pittsburgh, Pennslyvania. Also, UPMC as a high volume esophagectomy center.

One of the prominent thoracic surgeons performing robotic procedures is Dr. Benny Weksler, a Brazilian native who is currently the Director of Robotic Thoracic Surgery at the University of Pittsburgh Medical Center in Pittsburgh, Pennslyvania*.

Dr. Weksler does a wide range of thoracic procedures using the daVinci robot including pulmonary lobectomies for cancer, esophagectomies for cancer, thymectomies for myasthenia gravis and thymoma, Heller myotomies for achalasia, Nissen fundoplications for GERD, repair of hiatal hernias, removal of mediastinal masses, correction of esophageal diverticula. He reports an overall annual surgical volume of approximately 450 cases, (with about 180 of these procedures using robotic technology.)

He also reports that the thoracic surgery department at UPMC is the largest esophageal center in the world, and does over 120 esophagectomies a year – and that 95% of these surgeries are done with minimally invasive techniques (via laparoscopic and thoracoscopic techniques).

Dr. Benny Weksler, MD, FACS
Associate Professor of Cardiothoracic Surgery
Director, Robotic Thoracic Surgery
University of Pittsburgh Medical Center
Pittsburgh Pa.

Office Addresses:

Hillman Cancer Center
5115 Centre Avenue
Pittsburgh, PA 15232
Phone: (412) 648-6271

VA Medical Center
University Drive C
Pittsburgh, PA 15240
Phone: (412) 688-6000

Publications (an abbreviated selection of recently published works.)

Weksler B, Sharma P, Moudgill N, Chojnacki KA, Rosato EL. (2011). Robot-assisted minimally invasive esophagectomy is equivalent to thoracoscopic minimally invasive esophagectomy. Dis Esophagus. 2011 Sep 7. [no free full text available.]

Weksler B, Nason KS, Mackey D, Gallagher A, Pennathur A. (2011). Thymomas and Extrathymic Cancers. Ann Thorac Surg. 2011 Sep 30. [no free full text available].

Weksler B, Tavares J, Newhook TE, Greenleaf CE, Diehl JT (2011). Robot-assisted thymectomy is superior to transsternal thymectomy. Surg Endosc. 2011 Sep 5. [no free full text].

Berger AC, Bloomenthal A, Weksler B, Evans N, Chojnacki KA, Yeo CJ, Rosato EL. (2011). Oncologic efficacy is not compromised, and may be improved with minimally invasive esophagectomy. J Am Coll Surg. 2011 Apr;212(4):560-6; discussion 566-8. [no free full available]. Included since topic germaine to discussion.

Sivarajah M, Weksler B. (2010). Robotic-assisted resection of a thymoma after two previous sternotomies. Ann Thorac Surg. 2010 Aug;90(2):668-70. [no free full-text available].

* Dr. Weksler was kind enough to answer my questions in a series of emails. I did not have the opportunity to visit Dr. Weksler or his program on site.

Dual port thoracoscopy for diaphragmatic plication with Dr. Edgard Gutierrez Puente

Talking with the energetic and innovative Colombian surgeon, Dr. Edgard Gutierrez Puentes.

Dr. Edgard Gutierrez Puente is a Colombian thoracic surgeon that I had the pleasure of interviewing in February of 2010. He is a professor of Thoracic Surgery at the University of Cartagena. As the only board certified thoracic surgeon in that city (of over 1 million people) – he currently operates in several facilities including: Hospital Naval de Cartagena, Clinica Universitaria San Juan de Dios, Hospital universitario del Caribe, Clinica Medihelp.

As part of a previous project on surgeons in Cartagena, I spent a considerable amount of time with Dr. Gutierrez, seeing patients in all of these facilities. As a result, I have a deep and profound respect for his dedication to his patients and his work. (As a matter of fact – I saw my first true* uni-port thoracoscopic surgery in Dr. Gutierrez’s operating room at Medi-help.)

I recently contacted Dr. Gutierrez on a return visit to Cartagena, and he was happy to tell me about some of his recent cases including a Diaphragmatic plication utilizing dual port thoracoscopy. He is currently writing up the case for publication in surgery journals. (This is more impressive than it may sound to many of us – traditionally Diaphragmatic plication requires open surgery or traditional VATS (with five ports). This is a big development in thoracic surgery, and I will be bringing you more information as soon as possible. (I don’t want to jeopardize his upcoming article – but still wanted to bring it to you first, here at Cirugia de Torax.)

* Often surgeons call a procedure with a small but 3 -5cm surgery a uni-port surgery, but this is actually more akin to a mini-thoracotomy. A true uniport VATS procedure, is as the name implies – using an incision that is only large enough to accommodate a single port – and is then used with thoracoscopy equipment (not open surgery instrumentation). This distinction is important because the amount of post-operative pain depends on the size of the incision and trauma to surrounding tissues and nerves. (A small incision that is heavily stretched from the use of open surgery instrumentation may actually be more painful post-operatively that a sightly larger incision that is under less stress.)

More about Dr. Edgard Gutierrez Puente

Contact details:

Centro Medico Bocagrande
Consultorio 606
Bocagrande Calle 5 #6 -19
Telefonos: 6658300
Celular: 3114115130

Dr. Gutierrez is a specialty trained thoracic surgeon. After completing medical school at the University of Cartagena, he completed his general surgery residency at the University of Costa Rica. He returned to Colombia for his thoracic surgery fellowship at Universidad El Bosque. He has been operating as a thoracic surgeon for over twenty years.

While his English is limited, his surgical skills aren’t. In reviewing cases and spending time in the operating room with Dr. Gutierrez, I was very impressed by his extensive use of thoracoscopy for many of the cases that often remain in the realm of open surgery. Having said that – I would like to clarify that Dr. Gutierrez is no ‘showboat’ – the decision to perform VATS in each of these cases was based on his skills, the patient’s anatomy and the ability to complete the surgery under safe and appropriate conditions via thoracoscopy Had Dr. Gutierrez been unable to visualize the anatomy easily, or access structures during surgery (or encountered any other problems during the cases) he would have immediately converted to open thoracotomy (as is appropriate.)

Talking with Dr. Juan Carlos Garzon

Interview with Dr. Juan Carlos Garzon Ramirez in Bogota, Colombia

During a recent trip to Colombia, I stopped in to re-visit* renown Bogotá thoracic surgeon, Dr. Juan Carlos Garzon Ramirez. He’s tired from a long night with three back to back urgent cases – ending at 3 am but as always, he is charming, well-spoken and engaged in our discussions on thoracic surgery, and Bogotá, his home.

garzon 002 — Dr. Juan Carlos Garzon during a VATS procedure

Dr. Juan Carlos Garzon is a dynamic, innovative young surgeon and was recently named one of Bogotá’s Hottest Young Surgeons by Adriaan Alsema of Colombia Reports for his efforts (April 2011**). (This article highlights several young surgeons contributing to the advancement of the Colombian medical community.) He currently works at several facilities including Fundacion Cardioinfantil, Clinica del Country, Clinica Colombia (and other Colsanitas facilities).

After completing his thoracic surgery training at the El Bosque in Bogotá, he went to Hong Kong for additional thoracoscopy training. He now trains other surgeons in these surgical techniques

During my visit, we talked about what he sees as the future of thoracic surgery (more minimally invasive surgery) the role of thoracic surgery in the medical tourism phenomenon and the potential role of Bogotá surgeons in this growing trend.

We also discussed his reaction to The Bogotá Surgeons which examines the interplay and dynamics among the twenty practicing thoracic surgeons in Bogotá, as well as the upcoming Thoracic Surgery conference this October (which Dr. Garzon chairs.) This year’s featured speaker, is Dr. Shu S. Lin, noted lung transplant surgeon (previously interviewed here.)

garzon crop - Copy — Dr. Juan Carlos Garzon

*Dr. Juan Carlos Garzon, is thoracic surgeon practicing in Bogotá, Colombia. He specializes in minimally invasive procedures such as VATS (video-assisted thoracoscopic surgery.) He was gracious enough during a recent visit to Bogotá to agree to several interviews as part of a separate project and is featured in both Bogotá! A Hidden Gem Guide to Surgical Tourism and The Thoracic Surgeons: Bogotá.*

More information about Dr. Garzon, and his surgical practice is available at his website, www.toracoscopica.com/

He also has several YouTube films, discussing surgical procedures (in Spanish)

**this report was based in part by information provided during an interview with Adriaan Alsema in April 2011, Medellin, Colombia.

Talking about Transplant with Dr. R. Duane Davis

Interview with Dr. R. Duane Davis, the Chief of Lung Transplant at Duke University

(Part of a series on the lung transplant program at Duke University in Durham, North Carolina)

Dr. R. Duane Davis is the Chief of the Lung Transplant Program at Duke, which is the second largest lung transplant program in the United States (after Cleveland Clinic which performed 154 transplants last year to Duke’s 117*). During my visit, surgeons performed their 70 & 71st transplant this year, and will probably complete around 140 transplants before the year’s end. Much of Duke’s success at becoming a high volume transplant center lays at the feet of Dr. Davis, who took over the program in 1994, after training with the famed Dr. Joel Cooper. However, he credits many of his achievements to his training with several pulmonologists. In fact, he reports that it was his collaborative efforts with pulmonologists that led to his initial observations regarding the frequency of gastric reflux among transplant patients. (Later this was translated into the seminal work on the relationship between reflux / aspiration and graft failure**.) He cites this as one of the more important recent discoveries in the field of lung transplantation.

He estimates that during his career (thus far) he has performed around 750 – 800 lung transplants, making him one of the world’s more prolific lung transplant surgeons.

Dr. Davis is also responsible for several decisions that have distinguished Duke among transplant programs.

One of these decisions was the elimination of upper age restrictions for recipients. Unlike many facilities, Duke does not limit eligibility for transplantation solely based on age. (Many facilities limit transplantation to patients in their mid-sixties or below.) As part of this, he also rejects much of the ageism that is often implicit in transplant. “If we have two patients, otherwise equally matched but one is 18-years-old and the other is 53, then everyone always wants to give the transplant to the 18-year-old,” he explains. “It’s ageism to do that, particularly when research shows that the 18-year-old may not do as well [due to risk of noncompliance with anti-rejection meds. etc] so we need to carefully consider all of the factors before deciding,” he continues. “It makes us all feel good to give it to the 18-year-old, but that’s not always the right decision.”

One of the other decisions is something we talked about in a previous post – the use of organs that other facilities have turned down, sight unseen. He credits this decision with the short waiting periods for Duke patients compared with other patients nationwide.

Dr. Davis explains this policy along with other efforts to expand the donor pool. “There will always be a larger demand than the supply, but by expanding our eligibility criteria we increase our likelihood of finding an organ for our patients. As Dr. Davis explains, using traditional criteria, only about 10,000 donors are available every year, and in this donor pool, only about 17% of donations are lungs. He believes this number should be at least 40%, and that many useful organs that could have been transplanted are discarded. This is why Duke often sends their procuring surgeon on site to examine the lungs personally before deciding to reject organs for transplantation, if the lungs are otherwise a good match; (by size, blood type, etc.). In an attempt to meet demand and extend the lives of patients that might not otherwise receive transplants due to the shortage of donors, Duke surgeons recently implemented a program to accept donors from cardiac death patients (where the heart has stopped beating.) In traditional donor criteria, the patient’s heart is still beating at the time of organ retrieval. However, this criteria severely restricts the amount of donors available. As part of his efforts towards these ends, he reminds people of the value that organ donation has to help others, and encourages people to become organ donors.

During the interview, he also talks about breakthroughs in transplantation, such as the double transplantation of Laura Margaret, a 16-year-old with an immune deficiency disorder (bubble boy disease) who received a double lung transplant, followed by a bone marrow transplant from the same donor. In particular, he sees this particular case as a gateway to future discoveries in preventing graft (organ) rejection.

Like most Lung transplant surgeons, transplantation is only part of what Dr. Davis does, he is also an accomplished cardiothoracic surgeon, and performs cardiac surgery (such as bypass surgery/ valve replacement and surgery for atrial fibrillation) routinely. He states that he doesn’t have a favorite procedure, but he does have a favorite scenario. “I love the Christmas transplant,” he explains, when a patient receives a transplant on or around the holidays, and I get to come out to the family after the operation, and tell them Merry Christmas.” It really is a wonderful gift for the patient, he finishes.

** Surprisingly, even very large centers such as John Hopkins (24 last year), Massachusetts General (16) and Mayo Clinic (16) perform less lung transplants that we might expect. Even UCLA only performed 50 lung transplants in 2010. (Information from Organ Procurement and Transplant Network). Like many thoracic procedures, (as mentioned during discussions on esophagectomy and other lung surgeries) better surgical outcomes are linked to high-volume centers. Whether this is a result of ‘practice makes perfect’ or is due to the fact that high volume centers like Cleveland Clinic and Duke are usually large academic centers with a wealth of resources is not entirely clear. However, I would advise patients to use caution before seeking organ transplant at a center that does only a few transplants per year (less than 20- 30.) A recent study by Weiss et. al (2009) at John Hopkins places this number at 20, which as Dr. Mathew Hartwig noted during a recent lecture, is coincidentally,the three-year average [number of lung transplants] at that center.

* Future article planned for this topic.

More about Laura Margaret:

Double lung transplant saves teen’s life

Pioneer transplant surgery

Laura Margaret story

Dr. Thomas D’Amico: Duke Thoracic Surgery

A brief interview with Dr. Thomas D’Amico, Chief of Thoracic Surgery at Duke University Medical Center.

Dr. Thomas D’Amico is one of the first American thoracic surgeons I’ve had the privilege of interviewing for the website, after he was recommended to me by several other surgeons in Colombia. (Dr. D’Amico went to Medellin as an invited guest a few years ago and apparently made quite an impression.)

The irony in this scenario is unmistakable, since I worked for Duke (at another facility) for over three years – and knew of Dr. D’Amico, but had never met or spoken to him before.

Today, Dr. D’Amico took some time out of his busy schedule so we could talk about minimally invasive surgery, esophageal surgery programs and robots.

Dr. D’Amico is the Chief of Thoracic Surgery at Duke University Medical Center in Durham, North Carolina. Together with several other physicians that make up the thoracic surgery program; the surgeons at Duke perform 1600 – 1800 cases per year. This includes the entire spectrum of thoracic surgery procedures (thoracoscopic surgeries including lobectomies, wedge resections, mediastinal tumors, etc).

Last December, Duke started a minimally invasive esophageal surgery program, as well as a robotic thoracic surgery program. (Both of these concepts should be familiar to readers since we published articles on these very topics earlier this month, talking about the TIME trial in Europe, comparing outcomes between traditional and minimally invasive esophageal surgery, as well as previous post exploring the dearth of published literature on Robotic Thoracic Surgery. )

Since its inception six months ago, the program has done 80 -100 cases of minimally invasive esophageal surgery. Notably, Duke has an established esophageal cancer program – which performs about 70 – 80 esophagectomies a year. This doesn’t sound like a lot, but it actually distinguishes this program as a high volume center, which is important for reducing morbidity and mortality. Multiple studies have confirmed that esophageal surgery patients do better (less deaths, less complications) when they have surgery with thoracic surgeons at high volume centers.

The Robotics program, headed by Dr. Mark Onaitis is performing about 8 to 10 cases per month. The program is currently limited due to access to the Divinci robot. (Currently, thoracic surgery has use of the robot one day per week.) Dr. D’Amico reports that surgical case times have been increased on the robotic cases but states that much of this is robot maneuvering time as the robot is brought into position for surgery.

I’ve asked to observe a robotic case so I can bring you first hand observations (a la Bogotá Surgery style), as well as have a chance to look around the dedicated thoracic surgery unit at Duke hospital.

Pleural mesothelioma and related conditions are less well-defined within the Duke Thoracic surgery program. They only see about 20 or 25 cases per year, and don’t really have an established program for these patients. Dr. D’Amico reports they are not actively pursuing brachiotherapy or HITHOC (intrathoracic hyperthermic chemotherapy) options. The main focus of the program remains minimally invasive procedures, which is where Dr. D’Amico sees the future of thoracic surgery.

As for the surgeon himself, he is surprisingly closed lipped about his personal and professional life, and declined to answer any questions on the subject. He has a reputation around Duke as a shy, quiet and gentle man but my time with him was extremely limited, so I have no insights, or impressions to pass along to readers. Hopefully, I’ll get another chance to speak with him in the future, so I am able to give more details about these programs, and the surgeon behind it all.

Talking to Dr. Shu Lin, MD, PhD of Duke University

In and out of the operating room with Dr. Shu S. Lin, MD, PhD, cardiothoracic surgeon and member of the Duke lung transplant program.

As I noted at the beginning of this series of posts about the Duke Lung Transplant program, I have been fortunate enough to know and work with Dr. Lin during my career as a nurse practitioner. But, in all the time we spent rounding and caring for patients at a small community hospital in Virginia, I never scratched the surface of the multi-faceted, and multi-talented Dr. Shu Lin.

Like many talented surgeons (Dr. Thomas D’Amico, Dr. Rafael Beltran, Dr. Edgard Gutierrez are just a few other examples), Dr. Lin is a humble and down to earth person. He is quick to shrug off any praise or admiration of his talents. When receiving tearful thanks from a grateful family member of one of his patients after completing a multi-hour lung transplant, he gives a shy smile, and says “it’s no problem” before giving further details of the operation and the expected post-operative recovery.

At first glance, you expect this soft-spoken and gentle natured surgeon to be shy and retiring but you quickly learn to appreciate his keen wit and fine-tuned sense of humor.

The walls of his office are papered with just a sampling of the numerous awards and recognition he has garnered since childhood, as a concert master for the symphony orchestra (violin, high school), as an avid tennis player, research awards in both the fields of surgery and immunology. More awards undoubtably lay forgotten in a desk drawer somewhere, replaced by photos of his family.

Seeing all of this makes me reconsider the Shu Lin I thought I knew, and whom I call a friend. I always knew he was a gifted and talented surgeon (I always call him ‘quietly brilliant’ due to his unassuming nature) but now, even I am overwhelmed by it all. Yet, he remains unaffected; the gracious, caring surgeon I always knew. He looked surprised when I told him that his was the toughest interview I’d ever done; especially since I’d just come from interviewing one of his colleagues. But it’s true – I pride myself at trying to maintain an aura of objectivity, and to present information with a degree of clinical professionalism, but with Dr. Lin, it’s hard. Not because he isn’t a great surgeon, and a great clinician; but because he is. I worry that this previous working relationship colors my writing, but at the same time, it is these very qualities of patience, kindness and empathy coupled with surgical skill and clinical knowledge that are so important for patients to know about, and read about.

It’s a little awkward too, I think it’s difficult for Dr. Lin to see me in my new role of interviewer, and it’s the first time I’ve seen him in a year – since I left Virginia to embark as a medical writer in Bogotá, Colombia. But after a few minutes, we settle into our roles as he explains some of the issues in lung transplantation. It helps that he’s a great teacher [to the residents and fellows in cardiothoracic surgery].

“I haven’t updated my profile in a few years, I am no longer researching xenotransplantation” [using organs from other species] he says before we launch into a discussion on the effects of acid reflux on lung tissue and graft survival in patients post-transplant. This is one of the current projects at Duke (with Dr. Davis, and Dr. Mathew Hartwig, whom I hope to interview soon).

We review some of the history of lung transplantation, which is ‘still in its infancy’, and discuss the role of continued research to address the problems in transplant surgery; such as graft rejection. He also talks about the need to better delineate lung disease and effective treatment strategies. “Transplantation is always the final option for treatment, after medical therapies fail so it’s important that we know as much as we can about both the diseases and the effectiveness of current therapies.” This is one of the reasons Dr. Lin feels very strongly about the need for patients to participate in research studies – “the more we know, the more we can do to treat them.” This is also important when we discuss the future of lung transplantation.

Dr. Lin sees several evolving adjuvant treatments as essential for driving the future of lung transplant therapies:

– The development of mechanical devices similar to the newest ambulatory VAD (ventricular assist devices) used in heart failure, to allow patients to use mechanical lungs during daily living. Currently, ambulatory ECMO devices allow patients to walk (with assistance) while receiving therapy, which improves survival and prevents complications related to prolonged hospitalization. Dr. Lin foresees the development of more efficient devices (aka artificial lungs) that would resemble the newest VADs in functionality, and would allow patients to live longer, better quality of life while awaiting lung transplant.

– Better medications: the development of a new, better generation of anti-rejection drugs with less side effects than Tacromilus (FK-506), steroids, cyclosporine.

– Tissue therapies, gene therapies – to prevent rejection of transplanted tissues,and prolong graft function.

Dr. Lin believes that the continuing development of all of these competing and adjuvant therapies will promote future research into lung transplantation, for better quality of life for patients, longevity and better post-transplant outcomes.

Dr. Lin still maintains an active cardiac surgery practice since by its nature, lung transplant surgery is sporadic. As a busy cardiac surgeon, Dr. Lin performs a full range of cardiac surgery procedures; most commonly coronary artery bypass surgery and valve repair/ replacement. So during my visit, after rounding on his transplant patients, and post-cardiac surgery patients, I observe him performing two bypass surgeries (coronary artery bypass grafting or CABG). This is familiar territory for me – but later, I see him in his role of transplant surgeon during a double lung transplant with Dr. Hartwig.

Lung Transplant - Dr. Shu S. Lin — Lung Transplant Surgery with Dr. Shu S. Lin

In the operating room, Dr. Lin is deliberate and methodical in his actions, but surprisingly, appears more relaxed*. He tells jokes (clean ones) and stories while working, and appears more comfortable, and unguarded than I am used to seeing. It’s like he left all of the mundane problems of the world outside the operating room door. He works well, in tandem with Dr. Hartwig, who is the newest member of the thoracic surgery department and remains focused but completely aware of his surroundings. This time, I am able to witness the surgery entirely from the recipient’s angle – from the initial clamshell incision, and preparations for the removal of the first lung – to Dr. Reddy’s arrival and lung delivery, and the placement of both lungs to closure of the incisions.

This time, when the lungs are first inflated together, after completing the final anastomosis – there is no struggle, the lungs work perfectly. There were concerns when the donor network first called – that maybe one of the lungs had sustained injury, but as per department policy***, in these cases, Dr. Reddy investigates on site, and make the determination whether the lungs are useable after inspection (in telephone consultation with Dr. Lin).

The entire surgery takes less time than I expected, and by one am – we are in the waiting room, talking to the family.

*He’s not normally tense or uptight, but tends to be very serious during rounds, as part of his role of professor. [Dr. Lin is a professor of both surgery and immunology.]

*** This is one of the reasons Duke has the shortest waiting list time period of any transplant facility in the US. While many facilities reject offered ‘marginal’ appearing organs based on lab values, and the chest x-ray, the surgeons at Duke will often go to inspect the organs before rejecting them outright. As Dr. Davis explained during a separate interview, “sometimes they only give you information about the right or left lung, not both. Maybe the information they give you suggests the lung isn’t perfect, but not terrible either. In these cases, instead of turning the organs down, we would rather take a closer look – so a potentially useable organ doesn’t get wasted. A lot of times, when we actually examine the organs – at least one lung is actually in good condition [suitable for transplant]”.

By doing this – Duke does run the risk of having more ‘dry runs’ than other facilities, meaning that when they get to the donor, the organs aren’t useable, and the procurement team returns empty-handed, but they also get good, functional organs for their patients – that would have been lost. “We get more organs that other facilities,” Dr. Davis explains, “because UNOS/CDS (organ network/ carolina donor services) often call us after everyone else has turned them down.”

Additional information:

History of Lung Transplantation – paper by George Patterson (pdf)

Just one of many of his of grateful patients tells her story.

More information about Ventricular Assist Devices

Medline

VAD information from the manufacturer – with photos