Category: Interviews

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).

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.

Dr. Velasquez in the operating room with Lina Caicedo Quintero (nurse)

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).

Dr. Velasquez performing single port thoracoscopy

Cases proceeded rapidly; with no complications.

close up view

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.

Sandy Ogawa, ACNP and anti-reflux surgery at St. Joseph’s Hospital

Talking with Sandra Ogawa, ACNP about ‘What to do when the purple pill fails?”

Phoenix, Arizona

During my visit with Dr. Bremner at St. Joseph’s Hospital, I had the pleasure of meeting several members of the thoracic surgery team, including Sandy Ogawa.

Ms. Ogawa is an acute care nurse practitioner specializing in Thoracic Surgery.  She initially began working with Dr. Bremner at USC as a nurse coordinator, and has been working with Dr. Bremner since he was a thoracic surgery fellow.  After returning to school for her master’s degree – Ms. Ogawa became a nurse practitioner in thoracic surgery.

Since then she has taken on a wide range of duties and responsibilities caring for thoracic surgery patients, with a keen interest in anti-reflux procedures such as the Nissen fundaplication and the Toupet procedure.

One of the things we talked about was her upcoming presentation on proper patient selection and patient referral, or as Ms. Ogawa states, “What to do when the purple pill fails?” 

Who should consider surgery for reflux?

The best patients for surgical treatment of reflux are patients who have failed first-line medical treatments such as Nexium (or other proton pump inhibitors.)  Patients should explore these options as well as standard medical recommendations such as weight loss, and dietary modification prior to seeking the advice of a surgeon.

Symptoms & Complications of Reflux

Symptoms of GERD are varied and can range from simple heartburn to dysphagia (difficulty swallowing), chest pain, respiratory infections and dental erosion.  Uncontrolled gastric reflux has been shown to negatively impact the patient’s quality of life; through interrupted sleep, impaired eating and other activities of daily living.

Uncontrolled or untreated GERD can lead to serious complications including esophageal ulceration, development of esophageal strictures, pneumonias and scarring of lung tissue (from aspiration of acid contents) and increase the risk of developing esophageal cancer.

At St. Joseph’s, Dr Bremner and his colleagues specialize in both of these procedures  (Nissen fundaplication and Toupet procedure) as well as re-do procedures for patients with re-current symptoms or re-current hernias after surgery.

Pre-surgical Evaluation: Diagnosis & Testing

Having ‘heartburn’ alone isn’t the only factor to consider prior to undergoing an anti-reflux procedure.  The are multiple physiological factors that also help surgeons determine whether surgery is an appropriate treatment, and which surgical procedure is the best surgical option.

As part of their anti-reflux program, all pre-operative evaluation procedures (endoscopy with four quadrant biopsies, barium esophagrams, and manometry are performed in-house.  In fact, the department has their own manometry lab, where they read all of their studies (versus sending patients to multiple departments).  These tests help determine whether reflux is related to different conditions such as the presence of a hiatal hernia, or a malfunctioning esophageal sphincter.  It is also important to rule out other causes of symptoms such as dysphagia such as an esophageal stricture since this condition is treated differently.  If there is acid damaged tissue (tissue changes in the esophagus and stomach due to acid erosion), biopsies of the tissue will be taken to rule out Barrett’s esophagus or esophageal cancer.

Guess we’ll have to wait for the rest of Ms. Ogawa’s presentation to hear more.

Additional Resources: Anti-reflux procedures, GERD and treatment strategies

Overview of GERD, and treatment options from New York Times – health section.

Bansal A, Kahrilas PJ. (2010).  Treatment of GERD complications (Barrett’s, peptic stricture) and extra-oesophageal syndromes.  Best Pract Res Clin Gastroenterol. 2010 Dec;24(6):961-8. Review.  Does surgery prevent long-term complications from reflux disease?  A review of the literature reveals inconsistant results: bad data, or bad research design?

Davis CS, Baldea A, Johns JR, Joehl RJ, Fisichella PM.  (2010).  The evolution and long-term results of laparoscopic antireflux surgery for the treatment of gastroesophageal reflux disease.  JSLS. 2010 Jul-Sep;14(3):332-41. Review.  Comparison of surgical techniques.

Epstein D, Bojke L, Sculpher MJ; REFLUX trial group. (2009).  Laparoscopic fundoplication compared with medical management for gastro-oesophageal reflux disease: cost effectiveness study.  BMJ. 2009 Jul 14;339:b2576.  Surgery emerges as the cheaper option.

Ip S, Chung M, Moorthy D, Yu WW, Lee J, Chan JA, Bonis PA, Lau J.  (2011).  Comparative Effectiveness of Management Strategies for Gastroesophageal Reflux Disease: Update [Internet].  Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Sep.  Report showing similar efficacy in therapies.

Kripke C. (2010). Medical management vs. surgery for gastroesophageal reflux disease.  Am Fam Physician. 2010 Aug 1;82(3):244.  Kind of a skimpy statement, which doesn’t really answer the clinical question.

Lippmann QK, Crockett SD, Dellon ES, Shaheen NJ (2009).  Quality of life in GERD and Barrett’s esophagus is related to gender and manifestation of disease.  Am J Gastroenterol. 2009 Nov;104(11):2695-703. Epub 2009 Sep 15

Moraes-Filho JP, Navarro-Rodriguez T, Barbuti R, Eisig J, Chinzon D, Bernardo W; Brazilian Gerd Consensus Group. (2010). Guidelines for the diagnosis and management of gastroesophageal reflux disease: an evidence-based consensus.  Arq Gastroenterol. 2010 Jan-Mar;47(1):99-115

Shan CX, Zhang W, Zheng XM, Jiang DZ, Liu S, Qiu M.  (2010).  Evidence-based appraisal in laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease.  World J Gastroenterol. 2010 Jun 28;16(24):3063-71.  Review of literature comparing surgical techniques.

Tessier DJ.  (2009).  Medical, surgical, and endoscopic management of gastroesophageal reflux disease.  Perm J. 2009 Winter;13(1):30-6.  Review article aimed at Primary care physicians.  Excellent overview article of GERD and treatment options.