Shortage of thoracic surgeons in Canada offers potential opportunities to new surgeons


New Brunswick, one of Canada’s eastern maritime provinces is struggling to maintain their thoracic surgery service line within the small province of an estimated 800, 000 inhabitants.  While a local hospital is interviewing candidates in Moncton, New Brunswick, there is currently only one thoracic surgeon for the entire province, after two other surgeons were forced to go on emergency medical leave.  While the current surgeon is a board certified thoracic surgeon, general surgeons have previously served in this position. In an article published in Canadian Broadcast News (CBC), administrators within the province reached out to potential applicants while attempting to reassure local citizens.

This comes after a local outcry over the lack of access to care for New Brunswick patients needing thoracic surgery.  Lead by a local nurse, the shortage of thoracic surgeons in the region has received extensive press. Even more so, when it was revealed that neighboring Nova Scotia will not be accepting patients from New Brunswick. (As we’ve written here before, Canada has been particularly hard hit by the thoracic surgeon shortage.

However, with this shortage, comes opportunity; for new thoracic surgeons, foreign medical graduates and other surgeons from outside the Maritime region.


To apply for the position at The Moncton Hospital:  click here.

Developments in chest tube management

from the Journal of Thoracic Disease and Dr. Chin Hao Chen (one of our favorites here at, advances in chest tube management

While chest tube placement (tube thoracostomy) is one of the more simple and straight-forward procedures in thoracic surgery, chest tube management can be fraught with frustration for both patients and providers.  While the system itself is relatively uncomplicated, it is area that often brings stress to nurses and other axillary providers who do not work with chest tubes on a daily basis.

Ideally chest tubes would be well marked and not taped to floor, but the realiy often differs (from
Ideally, chest tubes would be well marked and not taped to floor, but the reality often differs (from “Chest tube mishaps” lecture)

Ambulating with chest tubes is an exercise in logistics

Chest tubes can be knocked over, dislodged or accidentally removed from suction before the lung is completely healed.  Chest tubes also make any sort of ambulation just a little bit more complex.  The logistics of ambulating patients with one (or more pleurovacs) in addition to IV pumps, poles, foley catheters and other devices, particularly if the patient is weak or unsteady more of a chore than many can image.  A ten minute walk make take upwards of fifteen minutes in preparation, as supplies are gathered and additional personnel are summoned for assistance.

Is there an air leak?

But this is only one of the frustrations of chest tube management. The main point of contention and frustration for providers and patients alike is monitoring chest tubes for the presence / absence of an air leak, and calculating drainage.  While neither of these tasks is particularly arduous, accuracy is critically important.  Both the miscalculation of drainage as well as the report of a newly developed air leak (or an previously undetected but continued air leak) can cause significant delays in chest tube removal.  Or, if the chest tube is removed too early, it can cause a pneumothorax or re-accumulation of a pleural effusion.

choose a nonstandard color sharpie for marking chest tubes (phone by steakpinball)
choose a nonstandard color sharpie for marking chest tubes (photo by steakpinball)

The first problem can be readily addressed with use of an orange (or other non-standard color) sharpie marker.  The second problem can require a bit of ingenuity, especially since the development or detection of an air leak can occur during the course of the day -after the thoracic surgery team has been in to evaluate the patient (for example).  In fact, it’s one of the frequent calls we field on a daily basis.

Nurse:  Ummm.. did this patient have an air leak this morning?  (Or with more experienced nurses): “Mr. X developed a small air leak about an hour ago after walking in the hall.”

Then the question becomes one of whether or not the chest tube (which may have been previously scheduled for removal) can be removed.  Often, it delays chest tube removal by another day to ensure that the lung is adequately healed.

Portable suction unit used at Danville Regional Medical Center, Danville, Virginia. Photo by Brian Compton
Portable suction unit used for ambulating patients with chest tubes at Danville Regional Medical Center, Danville, Virginia. (Photo by Brian Compton)

Why can’t I just cross my fingers and pull it anyway? 

Or we can proceed at our own peril – and risk taking out the chest tube.  Sometimes the lung stays up, but often – the patients develop a pneumothorax, requiring another chest tube to be placed.   Replacing the chest tube is not just an otherwise unnecessary procedure (and all the risks entailed), it’s painful for the patients, as well as being very demoralizing for the patient.

Several thoracic surgeons have attempted to solve this problem using a myriad of devices – from portable suction machines to more novel ideas like computerized chest tube systems such as the device developed by Dr. Gaetano Rocco.  Dr. Rocco’s device was a computer that allowed patients with prolonged air leaks to be discharged home with real-time monitoring.  (It was essentially a laptop computer, and requires use of a specialized chest tube system).  It’s still a great development, but fairly expensive for use in hospitalized patients.

Additionally and unfortunately, most of these devices have failed to gain mainstream attention, or use – which means that despite all of the new technologies and techniques, many of our patients are still chained to their rooms (to the suction module) while waiting for their lung to heal.  This puts the patients at risk for additional complications in addition to prolonging their hospital stay.

Now Dr. Chin-Hao Chen et al. have designed a new device that can be used with the existing pleurovac systems to perform real-time pressure monitoring.  The paper, published in a recent issue of the Journal of Thoracic Disease demonstrates how surgeons can add this device to existing closed systems to detect air leaks and chest tube tidaling. This type of device allows surgeons to adopt state-of-the-art technologies using the standard equipment already available in their hospitals with minimal modifications.  It eliminates the question of when the is lung healed, and when can the chest tube be removed.

References and additional reading

Article cited above:

Chin-Hao Chen, Tsang-Pai Liu3,4, Ho Chang5, Tung-Sung Huang3,4, Hung-Chang Liu1,2,3, Chao-Hung Chen (2015).  A chest drainage system with a real-time pressure monitoring device. Journal of Thoracic Disease, (July 2015) 7:7.

Chest Tube Management (2007) Powerpoint from a presentation at DRMC in Danville, Virginia.

Kwiatt M1, Tarbox A2, Seamon MJ3, Swaroop M4, Cipolla J5, Allen C6, Hallenbeck S6, Davido HT7, Lindsey DE8, Doraiswamy VA9, Galwankar S10, Tulman D11, Latchana N11, Papadimos TJ8, Cook CH8, Stawicki SP8. (2014). Thoracostomy tubes: A comprehensive review of complications and related topics. Int J Crit Illn Inj Sci. 2014 Apr;4(2):143-55. doi: 10.4103/2229-5151.134182.

Thoracic surgery goes wireless

Dr. Chin Hao “Roy” Chen – inventor of the Chen esophagectomy, now presents his latest creation, the wireless thoracoscope. More about our recent article at

Our readers get the first glimpse of Dr. Chen’s newest device.  The wireless endoscope is currently undergoing animal trials at MacKay Memorial Hospital in Taipei, Taiwan.

wireless thoracoscope with disposable front portion. (Battery and microchips are re-usable
wireless thoracoscope with disposable front portion. (Battery and microchips are re-usable)

The battery operated devices are more flexible and portable for ease of use, in and out of the operating room.  Disposable shafts attach to reusable battery units, eliminating tangled cords, and concerns about the sterility of the thoracoscopic set up.

wireless thoracoscope (photos courtesy of Dr. Chen)
wireless thoracoscope (photos courtesy of Dr. Chen)

Dr. Chih Hao “Roy” Chen

Dr. Roy Chen has been a previous contributor to, and developed the Chen esophagectomy.  He currently practices at MacKay Memorial Hospital in Taipei, Taiwan.

Changing the future of thoracic surgery - Minimally invasive surgery conference in Asia with Dr. Chin Hao Chen (seond from left) and Dr Diego Gonzalez Rivas (thrid from left)
Changing the future of thoracic surgery – Minimally invasive surgery conference in Asia with Dr. Chih Hao Chen (second from left) and Dr Diego Gonzalez Rivas (third from left)

Source articles:

Thoracic Surgery goes wireless., May 31, 2015.

Chih-Hao Chen, Ho Chang, Tsang-Pai Liu, Tun-Sung Huang, Chao-Hung Chen (2015). Application of wireless electrical non-fiberoptic endoscope: Potential benefit and limitation in endoscopic surgery.   International Journal of Surgery, vol. 19 (July 2015).

Credentialing versus certification for minimally invasive thoracic surgery?

The STS Task force takes on credentiallng in minimally invasive surgery but shouldn’t they be looking at advanced specialty certification instead?

Dr. Jiang Gening (Shanghai Pulmonary Hospital) performs dual port thoracoscopy using a 3D monitor
Dr. Jiang Gening (Shanghai Pulmonary Hospital) performs dual port thoracoscopy using a 3D monitor

The term “minimally invasive surgery” gets tossed around a lot these days; it’s on advertisements for surgery clinics, hospital billboards and countless CVs. But what does that term really mean? And who has earned the right to claim this skill set?  It’s an issue that is becoming more relevant in thoracic surgery as many surgeons become trained in increasingly complex procedures.  It’s also part of a shift in referral patterns, as patients increasingly seek and even self-refer to surgeons who advertise expertise in less invasive procedures.  But right now, there is no way to designate or delineate between surgeons trained in these procedures and other general thoracic (and general surgeons).  So I was excited to see that the STS was finally going to address this area.  Or at least, I thought they were, when I saw the recent draft, entitled, “STS Expert Consensus Statement: A tool-kit to assist thoracic surgeons seeking credentialing for new technology and advanced procedures in general thoracic surgeon.

Sharp eyed readers probably already see some of the problems with this draft.  But first, a little background.


Currently, the primary certification in the United States for the thoracic surgery specialty is the American Board of Thoracic Surgery examination (ABTS) which is the entry-level requirement for thoracic surgeons after completing their surgical fellowship in thoracic surgery.  While, the ABTS certification requires a biannual re-certification to maintain credentials, this certification only covers the minimum requirements for thoracic surgery.  It doesn’t address the newest technological advances in this specialty.  This is problematic for consumers seeking surgeons specially trained and experienced in performing techniques such an uniportal surgery.  It also creates difficulties for surgeons seeking this skill set since there is no clearly defined coursework required to obtain these skills.

uniportal surgery
uniportal surgery

Certification versus credentialing

But, certification and credentialing are not the same thing.  Certification is generally a national or internationally recognized achievement, whereas credentialing is a more local process, from hospital to hospital or organization to organization.  Credentialing is done not to recognize surgical skills or achievement but to protect the healthcare facility from the kind of liability that arises when imposters impersonate medical personnel, physicians with suspended licenses continue to practice, and similar such circumstances.  Being credentialed within a healthcare network, or hospital facility isn’t an achievement per se, it’s a requirement for most of us to receive a paycheck.  It’s also extremely variable, as this draft details, and subject to the whims of the Joint Commission.

STS focuses on credentialing – not certification..

STS focuses on credentialing:  “The purpose of this consensus statement is to serve as a reference and resource for surgeons and hospitals as they plan for the safe introduction and implementation of new technologies and advanced procedures in general thoracic surgery.”

But this is – so we don’t have to.  We have the luxury of considering the bigger picture.

But whether institutional credentialing or national certification – It’s a good excuse to examine the issues more closely. So instead of looking at credentialing, we’ll use the principles advanced by STS as part of consideration for a system of certification; by a national /international organization like STS or by the American Board of Thoracic Surgery itself.  (While STS is focusing on facilities, they need to think bigger and be bigger.  This draft has the potential to serve as guideline for an advanced specialty certification, but it would need some drastic changes.)

But regardless of whether we talk about certification or credentialing, we need to first define what we are referring to when we use this terminology.

What is minimally invasive surgery?

Does traditional (3 or more port) video assisted thoracoscopy qualify? What about robotic assisted surgery?  A new document by the Society of Thoracic Surgeons Task force on General Thoracic Surgery Credentialing attempts to define minimally invasive thoracic surgery.  In the document, the authors propose set definitions to replace this vague terminology to better clarify these distinctions.  In this, they partially succeed.

How does a surgeon become a minimally invasive surgeon?

What are the qualifications for performing minimally invasive surgery? Does a weekend conference with lecture-only content qualify?  What about more extensive wet-lab courses?  Is there a case minimum for surgeons claiming competency in this surgical technique?

In their pursuit of credentialing guidelines, Blackmon et. al outlines a complicated set of checklists, proficiency levels and other suggestions for hospitals seeking to credential and privilege surgeons to perform these procedures.

Not a mandate, just suggestions

The authors claim that the purpose of this document is not to mandate the training requirements for a proposed credentialing process.  In contrast, any proposal for a certification process in minimally invasive thoracic surgery techniques, by definition, would require mandates and strict requirements.

Not only that, but I disagree with their premise regarding credentialing.  Credentialing should be equally arduous and less ‘historically’ defined.

These mandates would be a useful and valuable tool to guide and aid both consumers and surgeons.  Surgeons and residents in thoracic surgery would have a clear cut curriculum to use as a road map for obtaining training and surgical proficiency.  Consumers would have a guarantee that surgeons with these certifications had completed the minimum standards for training.

The authors propose a complicated set of proficiency levels to account for differences in regional and facility specific criteria.  The task force does such to prevent an undue burden on each surgeon to conform to a rigid set of minimum criteria, thus ‘grandfathering’ in surgeons who may have obtained their training outside of traditional frameworks. While I understand this consideration, in this aspect, I disagree.

Five levels of proficiency

While the authors intentions are sincere, a less complicated, but more strict set of qualifications would better serve the specialty.  Instead of having multiple levels of qualifications, a uniform approach would be less self-serving and more easily understood by consumers.  In this case, greater transparency is needed to protect the public, and maintain public trust.  Surgery, like every other service industry, is becoming more and more consumer-driven every day.  Using levels of proficiency that read as, “Has taken VATS training, lecture-format only” or  as cited by Blackmon et al. “the clinician has learned VATS lobectomy at our course, completing an animal skills model assessment and achieving level 3 skills verification” places too great of a burden on the consumer.  It is also serves as a disservice to thoracic surgeons and the thoracic surgery specialty in general.  By trying to be “all-inclusive,” the task force has weakened the value of this ‘credential’.  If a hospital wants to privilege a surgeon to perform a procedure after the surgeon has watched it on Youtube, that’s something for their risk management department to take on – but an advanced specialty certification would eliminate a lot of these shenanigans, (but maybe that’s what STS is hesitant to take on).  It certainly won’t be popular politically among many of the more traditional surgeons that serve as much of the general body of STS.

Traditional VATS as advanced technology?

Lastly, I find it discouraging that as a specialty, thoracic surgery is still talking about traditional VATS as an advanced surgical technology.  It initially emerged in the early 1990’s and by now, should be standard fare for all thoracic surgery fellows of the past decade.  The most recent guidelines consensus statements (of 2013) recommend VATS as first line treatment for a multitude of conditions.  Three-port VATS is no longer something out of science fiction, for today’s surgeons, it should be bread and butter.  By that criteria alone, standard VATS shouldn’t even be in consideration for inclusion as minimally invasive surgery.  That title and definition should be reserved for the more advanced, and more specialized techniques, whether robotic or uniportal.

Source document:

Blackmon et al. (2015). STS Expert Consensus Statement: a tool-kit to assist thoracic surgeons seeking credentialing for new technology and advanced procedures in general thoracic surgery. Read draft here.  You have until 5/27/2015 to send STS your opinion.

Thoracic surgeon shortage in Australia

When you need surgery, How long will you wait? (and will there be anyone to perform the operation?) The on-going surgeon shortage now affecting South Australia.

There is more evidence of the changing demographics of healthcare and an aging population and its effects world-wide on cardiothoracic surgery as the Australian newspaper, Herald Sun published reports of lengthy patient waiting lists for surgical procedures including procedures categorized as “urgent.”

waiting list

Long lines and waiting lists

More concerning, is the report of the number of patients who have died waiting for surgery*.

The report, which focuses on the Southern region of Australia highlights the shortage of specialty surgeons and the growing numbers of patients affected by these shortages.

Critics of the Australian government have also voiced concerns over the Surgeon Workforce project which aims to partially alleviate these shortages by using foreign-trained surgeons and imported labor.  This comes at a time when Australia actually has an oversupply of general practice or internal medicine physicians.

The shortage of well-trained surgeons is affecting all surgical specialties but the cardiac and thoracic surgery specialties are particularly hard hit due to the lengthy, rigorous (and often costly) training regimen  in many countries.

In the United States, this process is also exacerbated by an antiquated, sometimes arbitrary or impractical practice for residency placement that discourages international medical students.  This, along with other concerns (legitimate as well as political) that govern the regulations that permit overseas graduates to practice in the United States restricts the possibility of reducing the growing shortage in a similar manner.

The lengthy educational process is not the only factor.  Many medical students cite the strenuous work schedules, diminished job satisfaction and physically challenging surgical lifestyles as reasons medical students are choosing other specialties which are seen as being equally or more lucrative but allowing more work-life balance.

Similar shortages have been reported in Canada, the United States and the United Kingdom.

* Many international readers have asked if this is what is affecting the Americans Veteran’s Administration hospital system.  Not really, (or if so, only partially).  Th VA Scandal is a tragic example of the bureaucratic red tape that is becoming far too frequent for Americans seeking medical services.

Another home run: Dr. Gonzalez Rivas does it again!

the Babe Ruth of thoracic surgery continues his winning streak; and Dr. Benny Weksler heads south to the University of Tennessee. Kudos to both of these fine surgeons!

I am beginning to feel like a bit of a sports reporter when it comes to Dr. Gonzalez Rivas and innovations in thoracic surgery..

The Babe Ruth of modern thoracic surgery

It’s another home run for Dr. Gonzalez Rivas as he and his team perform a single port (uni-port) thoracoscopic lobectomy with under local anesthesia, as reported by a recent story, “Operan un tumor e pulmón con una sola incisión y anestesia local” by Raul Romar in La Voz de Galicia.  

Dr. Gonzalez Rivas demonstrates uniportal VATS
Dr. Gonzalez Rivas demonstrates uniportal VATS

The answer is International collaboration and sharing of ideas

Dr. Gonzalez Rivas is used to sharing his ideas.  After all, he spends a considerable amount of time traveling the world doing just that; sharing information about and teaching surgeons how to perform the single port thoracoscopic technique.  But that doesn’t mean that he does find time to learn from his peers during his travels.

The article above highlights the importance of this international collaboration as it details how Dr. Gonzalez Rivas began to consider applying a local anesthesia approach to the single port surgical technique after talking (and visiting) surgeons in Taiwan and China.

Once he found the perfect candidate, he was ready to implement local anesthesia into his single port approach.. The rest, as they say – is now headed for the Annals of Thoracic Surgery.

Click here for English translation (note translation is not exact).

Related: Dr. Diego Gonzalez Rivas: Changing the future of thoracic surgery*.

In other news:

Welcome to Tennessee!

Dr. Benny Weksler, our own American (via Brazil) superstar surgeon recently made the move to the University of Tennessee.  Dr. Weksler made the move in November of 2013 and is now settling in to his new position as Chief of Thoracic Surgery for the University of Tennessee (UT) Health Science Center and UT – Methodist.

Dr. Weksler, one of the United States most prominent thoracic surgeons, particularly in the area of esophageal surgery reports that he has big plans for the UT health system and the thoracic surgery department.

Big Plans for UT and the city of Memphis

These plans include a lung cancer screening program targeting vulnerable populations in Memphis including the uninsured/ underinsured, African-Americans (who are disproportionately affected) and smokers.

Related: Dr. Weksler talks about smoking cessation

Minimally invasive techniques for esophageal surgery

He has also started a new minimally invasive esophageal surgery program for esophageal cancer and reports “that there is almost an epidemics of squamous cell carcinoma of the esophagus” which is something tha was more rare in his previous practice in Pittsburgh, Pennsylvania.

Dr. Weksler and his colleagues are putting together a multi-disciplinary treatment plan to try to get these patients to a complete evaluation with a surgeon, an oncologist, and a radiation oncologist to provide patients with comprehensive, multi-faceted and coördinated care.

The Surgeon Speaks” – Dr. Weksler talks about robotic surgery in this 2009 Jefferson University publication.

As a former Memphis resident, I want to say, “Welcome to the mid-south.. Hope you find time in your busy schedule to enjoy Beale Street, visit the Pink Palace and tour Graceland..  On behalf of all current Memphians, we are glad you are here.”

*This article was written by the author of this post.

Dr. David Sugarbaker comes to Texas, and too much of a good thing!

Big reputations and legendary surgeons require big opportunities – and as everyone knows; every thing is bigger in Texas.

Dr. David Sugarbaker, one of the legendary American thoracic surgeons has left his position at Brigham and Women’s Hospital in Boston to join Baylor St. Luke’s Medical Center in Houston, Texas.

Dr. Sugarbaker comes to Texas to lead the new Lung Institute at the College of Medicine (Baylor University).

I’m keeping my fingers crossed that this means I have another chance to cross paths with Dr. Sugarbaker when I return to Texas in May.  I would love to talk to him about mesothelioma, HITHOC and the new Lung Institute.

In other news – It’s been too much of a good thing for our Thoracic Surgery app.  So many people have downloaded and used the application – that the hosting service will no longer support and host the application for free.  (Unfortunately, due to financial constraints – I am unable to pay for continued support and hosting services).  So thanks to everyone who made this application a success – and my apologies that I am no longer able to maintain it.

Chung et. al. Optimal timing of thoracoscopic drainage and decortication for empyema

A new Korean study looks at the best time to perform surgical interventions on patients with empyema thoracis.

In a recent issue of the Annals of Thoracic Surgery, Chung et al. attempt to answer the long-standing question over the optimal timing of surgical intervention for empyema.  This has been a long-standing debate among surgeons and other medical specialists.  Despite advances in thoracic surgery (such as video-assisted thoracoscopy) as well as wealth of surgical commentary suggesting earlier intervention, surgery is usually considered a last resort; often after weeks or months of antibiotics, tube thoracoscopy or fibrinolytic therapy.

Chung et. al raise the stakes for this discussion with their research into this issue.  In “Optimal timing of thoracoscopic drainage and decortication for empyema,” over the course of 8 years, the authors compared outcomes such as chest tube duration, number of persistent air leaks and overall length of stay by the time interval of symptomology and surgical treatment.

Why this is important

As discussed in previous posts, empyema is a serious infection with a mortality rate of approximately 1 in 5 patients.  Empyema is frequently found in the chronically ill, debilitated or malnourished.  Delays in definitive treatment (surgical decortication) plays a role in the high rate of mortality with this condition; with increased hospital stays, and increased patient debility as the patient continues to sicken, and consume their health reserves while less effective treatments are initiated.

What is early?  What is optimal?

Early surgical intervention has been theorized since the turn of the 20th century to lessen morbidity and mortality, however there have been very few actual studies to address the question of timing.  This study, while small, directly compares outcomes in patients receiving VATS at different points in the infectious process/ illness spectrum.

Using a retrospective study design, patients from April 2004 to March 2012 were subdivided into three different time intervals; symptoms for less than 2 weeks, 2 to 4 weeks and patients with symptoms persisting longer than 4 weeks prior to surgery.  Of the 128 empyema patients, the vast majority (93.7%) were treated with VATS, with only 8 patients undergoing open procedures like thoracotomy.


Patients included in the study met criteria set forth in 2000 by the American College of Chest Physicians for diagnoses of Empyema and Loculated pleural effusions with thickened parietal pleura.  Patient symptomology including symptoms such as dyspnea, persistent fever and sepsis were also taken into account when determining eligibility for surgical management.

Patients by intervals:

Less than 2 weeks (group 1) : 73 patients

2 to 4 weeks (group 2) : 43 patients

More than 4 weeks (group 3) : 14 patients

The vast majority of patients were male, with only 14 female patients in this study – spread throughout the groups.  Additional variables such as age and pre-existing and co-morbid conditions (diabetes, liver disease, TB or other lung disease, etc.) were also collected*.   The percentage of patients in each group who had undergone additional treatments for empyema pre-operatively (thoracentesis, antibiotics, etc.) was similar in all groups for antibiotics (ranging from 93% in group 1 to 100% of group 3) with around a quarter of both group 1 (24.6%) and group 3 (28.6%) requiring immediate surgery due to deteriorating status.

The 8 thoracotomy patients were used as a comparison group to evaluate the effectiveness of VATS for chronic empyema.  All eight open surgical had pre-operative empyemas of 4 weeks duration or more.

What was compared/ measured?

While patient pre-operative characteristics were collected and analyzed as part of the evaluation of the empyema groups, the main surgical outcome measures were:

–          Duration of procedure: Shorter in group 1 (average 100 minutes) versus group 2 (125 minutes) and group 3 (138 minutes).

–          Chest tube duration – shorter in groups 1 (6.92 days) and 2 (7.45 days) than group 3 (10 days).

–          Length of overall post-operative hospitalization: shorter in group 1 (9.49 days) and 2 (9.73 days) compared to group 3 (13.5 days).

–          Length of post-operative ICU stay: no significant difference

Other surgical outcomes

Overall post-operative mortality was zero.  There was no incidence of post-operative respiratory failure.

Re-operations/ Additional procedures:

Group 1 (73 patients) 2 patients with treatment failure/ empyema reoccurrence requiring re-operation with VATS (2.7%).

1 patient without complete resolution with VATS, required conversion to open decortication.

1 patient that developed a contralateral pleural effusion that required chest tube placement.

Total re-operations: 3 (4.0%)

Group 2: No re-operations.

Group 3 (14 patients)

1 patient required re-operation with VATS for treatment failure.

Prolonged air leak

Group 1: 2 patients (2.7%)

Group 2: 1 patient (3%)

Group 3: 4 patients (28.6%)

 Study Weaknesses

The biggest weaknesses in this study are the small number of participants in group 3, and the lack of a control group.

Small numbers = reduced strength of findings

How much more powerful would similar results be, had the numbers of participants in all the groups been equivalent?  For example, if Chung et al. presented data showing that air leaks occurred in over 28% of patients with older empyemas (group 3) in comparison with groups 1 (2.7% and group 2: (3%) if these groups had been equally populated, would be a much stronger argument for earlier intervention.

As it is, with just 14 participants in group 3, 28.6% is less of a dramatic finding than false precision from small numbers.  However, it serves as a credit to Dr. Chung and his medicine colleagues, as clinicians, that the majority of these patients received definitive treatment at earlier stages.

Lack of control group

Had researchers included patients who were treated only by non-surgical methods (up to 2 weeks duration) and compared the overall length of stay, incidence of respiratory failure, ICU days and mortality in these patients, the data would have had an increased impact.  However, questions remain regarding the use of VATS versus the current standards of treatment in this ‘early’ group.  While we can partially speculate that treatment failures of patients in this group represent later patients (i.e. Patient fails treatment and is referred for surgery and becomes part of group 1, 2 or 3), the missing information may have represented a crucial factor to drive the decision-making process.

For example, how many patients in that same time period, presented with early empyemas and:

–          Received antibiotics and recovered?

–          Were admitted to the hospital and died of respiratory failure/ sepsis etc. without ever making it to surgery?

But, presumably, the difficulties of collecting this data retrospectively were prohibitive.  However, does the high rate of immediate surgery in group 1 due to patient deterioration serve as a partial stand-in for this data?


 While further study is warranted to determine the optimal time for surgical intervention in empyema thoracis, this study does an adequate job at demonstrating the benefits of earlier surgical intervention.  While there was no mortality in any of the groups, patients who were operated on 4 weeks or more after being diagnosed/ demonstrating symptoms of empyema, required longer operations, developed more persistent air leaks post-operatively, with longer chest tube duration and longer overall hospital stays.

Further research in this area could include the use of experimental algorithms and protocols to ‘fast-track’ patients with loculated effusions/ empyemas to surgical decortication in an attempt to replicate or further demonstrate improved patient outcomes with earlier surgical intervention.  These algorithms would explore the use of surgery as a first-line treatment with adjuvant antibiotics independent of thoracentesis, tube thoracostomy.

*Full information is provided within several tables in the original article.

Chung, Jae Ho et al. (2013).  Optimal timing of thoracoscopic drainage and decortication for empyema.  Annals of Thoracic Surgery, 2013.

Early ambulation after lung surgery: How early?

Dr. Khandhar of Inova Fairfax Hospital in Falls Church, Virginia and early ambulation after lung surgery

One of the critical benchmarks of recovery from thoracic surgery is early ambulation (walking) after surgery – but “How early?” is a frequently encountered question.

Now, Dr. Sandeep Khandhar, thoracic surgeon of Inova Fairfax Hospital in Falls Church, Virginia aims to answer this question.

The answer, Dr. Khandhar reports is : Within 1 hour of extubation.

In a recent article by Zosia Chustecka for Medscape, she summarizes Dr. Khandhar’s recent study on post-operative ambulation in thoracic patients.  Dr. Khandhar presented these findings at the 2013 World Conference on Lung Cancer this month.

In this study, involving 750 patients who were given a goal of walking 250 feet within an hour after extubation.  In this 3 year project, only 10% of patients were unable to  walk within one hour after extubation.  60% of patients were able to walk the full distance of 250 feet within an hour of extubation.

In these patients, early mobilization was associated with a significant reduction in length of stay: from 3 to 5 days down to just 1.6 days, as well as a decreased need for intravenous narcotics post-operatively.

We have contacted Dr. Khandhar for additional information about this study.

Chustecka, Z. (2013). Lung Cancer Patients Up and Walking Within Hour of Surgery.  Medscape, 28 October 2013.    [Medscape requires a free subscription to review articles and news].

Rocco et al. “Ten year experience on 644 patients undergoing single-port (uniportal) video-assisted surgery

Reviewing “Ten years experience on 644 patients undergoing single-port (uniportal) video-assisted” by Gaetano Rocco et al. at the National Cancer Institute in Naples, Italy

In this month’s issue of the Annals of Thoracic Surgery, Dr. Gaetano Rocco and his colleagues at the National Cancer Institute, Pascale Foundation in Naples, Italy reported their findings on ten year’s worth of single-port surgery in their institution.

Who:  644 patients; (334 males, 310 females)


Annals of thoracic surgery - Rocco et. al (2013)
Annals of thoracic surgery – Rocco et. al (2013)


What:  Outcomes and experiences in single port thoracic surgery over a ten-year period.  All procedures performed by a single surgeon at this institution, and single-port VATS accounted for 27.7% of all surgeries performed during this time period.

When: data collected on thoracic surgery patients from January 2000 – December 2010.

Technical Notes:

Pre-operative CT scan was used for incision placement planning.  Incision was up to 2.5 cm (1 inch) in length depending on indications for surgery.

Since manual palpation of non-visible nodules is not possible using this technique, an ultrasound probe was used to identify these lesions.

Mean operating time was 18 minutes (diagnostic VATS) and 22 minutes for wedge resections.


30 day Mortality: 0.6% (4 patients – all who presented with malignant effusions).

Major Morbidity: 2.8%

Persistent drainage requiring re-do talc pleurodesis: 13 patients

Prolonged airleak (more than 5 days): 13 patients

Atrial fibrillation: 4 patients

Pancreatitis: 1 patient

Conversion rate:  3.7% (overall)

Conversion rate to 2 or 3 port VATS: 2.2% (14 patients)

Conversion to mini-thoracotomy: 1.5% (10 patients)

Patients underwent conversion due to incomplete lung collapse (22 patients) and bleeding (2 patients).

There were no re-operations or “take backs”.  The four patients with malignant effusions who died within the 30 day post-op period were re-admitted to the ICU.


Otherwise, all patients were admitted to either the floor or the step-down unit following surgery.

Pain management: post-operative pain was managed with a non-narcotic regimen consisting of a 24 hour IV infusion pump of ketorolac (20mg) and tramadol (100mg*).  After the first 24 hours, patients were managed with oral analgesics such as paracetamol (acetaminophen).

Limitations:  in this study, uni-port VATS was not used for major resections, as seen in the work of Dr. Diego Gonzalez and others.  This may be due to the fact that uni-port VATS was an emerging technique at the initiation of this study.

Strengths:  This is one of the largest studies examining the use of single-port thoracic surgery – and showed low morbidity and mortality.  (Arguably, the 30 day mortality in this study was related to the patients’ underlying cancers, rather than the surgical procedure itself.)

*Intravenous tramadol is not available in the United States.

Reference article

Rocco, G., Martucci, N., La Manna, C., Jones, D. R., De Luca, G., La Rocca, A., Cuomo, A. & Accardo, R. (2013).  Ten years experience on 644 patients undergoing single-port (uniportal) video-assisted surgery.  Annals of Thoracic Surgery, 2013, Aug, 96(2): 434-438.

Additional work by these authors on uni-port VATS: (many of these articles require subscription).

Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg. 2004;77:726–728.

Rocco G. Single port video-assisted thoracic surgery (uniportal) in the routine general thoracic surgical practiceOp Tech (Society of Thoracic and Cardiovascular Surgeons). 2009;14:326–335.

Rocco G, Khalil M, Jutley R. Uniportal video-assisted thoracoscopic surgery wedge lung biopsy in the diagnosis of interstitial lung diseasesJ Thorac Cardiovasc Surg. 2005;129:947–948.

Rocco G, Brunelli A, Jutley R, et al. Uniportal VATS for mediastinal nodal diagnosis and stagingInteract Cardiovasc Thorac Surg. 2006;5:430–432

Rocco G, La Rocca A, La Manna C, et al. Uniportal video-assisted thoracoscopic surgery pericardial window. J Thorac Cardiovasc Surg. 2006;131:921–922.

Jutley RS, Khalil MW, Rocco G Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesiaEur J Cardiothorac Surg 2005;28:43-46.

Salati M, Brunelli A, Rocco G. Uniportal video-assisted thoracic surgery for diagnosis and treatment of intrathoracic conditions. Thorac Surg Clin. 2008;18:305–310.

Rocco G, Cicalese M, La Manna C, La Rocca A, Martucci N, Salvi R. Ultrasonographic identification of peripheral pulmonary nodules through uniportal video-assisted thoracic surgeryAnn Thorac Surg. 2011;92:1099–1101.

Rocco G, La Rocca A, Martucci N, Accardo R. Awake single-access (uniportal) video-assisted thoracoscopic surgery for spontaneous pneumothorax. J Thorac Cardiovasc Surg. 2011;142:944–945.

Rocco G, Romano V, Accardo R, et al. Awake single-access (uniportal) video-assisted thoracoscopic surgery for peripheral pulmonary nodules in a complete ambulatory setting. Ann Thorac Surg. 2010;89:1625–1627.

Recommended reading: Rocco G. (2012). One-port (uniportal) video assisted thoracic surgical resections – a clear advance. J Thorac Cardiovasc Surg.2012;144:S27–S31.

Additional articles on single-port surgery can be found in the new single-port surgery section, under “Surgical Procedures

Courses / Classes and meetings on Uni-port thoracoscopic techniques with Dr. Diego Gonzalez Rivas

For thoracic surgeons interested in becoming more familiar with uniport surgery, this is your chance to learn from the pioneers of the technique.

Several new dates for Uni-port thoracoscopy with Dr. Diego Gonzalez Rivas.  These events span across the Americas and Europe, so if you are interested in uni-port thoracoscopic surgery, then there is something nearby.

The first date is coming up soon – in August 2013, in Bogotá, Colombia.

Dr. Diego Gonzalez Rivas in Bogotá, Colombia

I am excited about this one, and hope to be able to cover the event for readers of CdeT.  While I am currently in Medellin, I became familiar with, (and have a great deal of respect for) many of Bogotá’s finest thoracic surgeons in the past so it’s a great opportunity not just to hear more about Dr. Diego Gonzalez Rivas and uni-port thoracoscopy but to check in local surgeons and hear about some of their more interesting cases.

Dr. Gonzalez will be joined by Dr. Paula Ugalde, a well-known thoracic surgeon from Brazil (now practicing in Quebec, Canada).

As soon as I get some more details on the Bogotá event – I’ll post them here..

Split, Crotia – September 12th – 15th – 23rd Congress of the World Society of Cardio-Thoracic Surgeons.  

This conference is being jointly sponsered by the Society of Cardio-Thoracic Surgeons of South Africa (SCTSSA).  Dr. Diego Gonzalez will be talking about “Uni-port VATS major pulmonary resections in advanced lung cancer” in an afternoon session on September 13, 2013. (Obviously they don’t know much about him – since it’s only a 20 minute session – but as a CTS conference, only about 10% is thoracic topics (he is one of just a handful of thoracic speakers.)

Information about this event is available here.

Orlando, Florida – September 19th – 21st 2013

Then in mid -September 2013, he will part of a roster of the greats of thoracic surgery (Dr. Robert Cefolio, Dr. James Luketich and Dr. Thomas D’Amico) at the Duke Center for Surgical Innovation for a  course entitled, “Masters of Minimally Invasive Thoracic Surgery”.  

Complete details for this course are available here..  Sign up before 7/19 for a small discount in registration fees.

Live Thoracic  – February 2014

The second event, is a meeting/ conference/ training course in Dr. Gonzalez’s home hospital in Coruna, Spain.  The event, “Live Thoracic” will feature ‘live-surgery’ demonstrations and will be streamed for real-time viewing from around the world.

In a side note – I want to thank the nearly 6,000 students, interns, nurses, residents and thoracic surgeons who have downloaded one of my thoracic surgery apps for Android devices.

Surgical Removal of Lung Metastases in Breast Cancer

A discussion of Meimarakis’ recently published article, “Prolonged overall survival after pulmonary metastatectomy in patients with breast cancer.”

As reported in the Society of Thoracic Surgeons, and multiple other outlets, a newly published study by several surgeons in Germany shows that surgical removal of metastatic breast cancer that has spread to the lungs may improve overall patient survival. The study, by Meimarakis et al. was published in the April 2013 issue of the Annals of Thoracic Surgery.

pulmonary metastatectomy in metastatic breast cancer
pulmonary metastatectomy in metastatic breast cancer

The Meimarakis study included 81 patients over a twenty-five year period.  The study looked at the overall survival time in breast cancer patients with a pulmonary metastasis.  The study began in 1992, and data was collected retrospectively to 1982.

Poor median survival despite advances in chemotherapy

Current survival time in these patients ranges from 12 to 24 months.  However, the authors note that in up to 23% of these patients, the sole metastatic lesion is in the lung or pleural space.  In these patients with pulmonary metastasis alone, the majority survived less than 22 months after diagnosis, despite chemotherapy.  The 10 year survival has been previously reported as a dismal 9% in this population in prior studies conducted as M. D. Anderson (Meimarakis, et. al, 2013).

Role of pulmonary metastatectomy in advanced breast cancer

Unlike  pulmonary metastatectomy for colon cancer, metastatectomy has been used sparingly in this population and with no clear-cut criteria to distinguish which breast cancer patients would benefit from surgery, surgery in addition to chemotherapy, versus chemotherapy alone.  

Aim of study

The authors, at Ludwig-Maximilian University in Munich, Germany attempt to address this deficiency by investigating surgical, pathological and demographic factors that impact survival in this patient population to help determine which candidates would benefit the most from surgical intervention.

The authors looked at a multitude of factors such as presence and type of hormone receptor, histological type, size of both primary and metastatic lesions, the number of metastatic lesions, surgical grade/ resectability and the laterality of these lesions.  They also collected and compared additional markers such as CEA, LDH and CA 15-3.

These factors and their impact on survival were analyzed using statistical analysis, Kaplan-Meier estimators, log-rank tests as well as matched pair analysis of 2 year survival (metastectomy vs. standard therapy only).  These factors included data from pathological specimens and tumor typing (Meimarakis, 2013).

What makes this study particularly interesting and noteworthy, is the operative inclusions.  While patients with local residual disease, additional (non-lung) metastases or recurrent primary breast tumors were excluded, patients with contralateral lung lesions were not.

Selected patient demographics

Total number of patients: 81

Median age: 58.2 (range 28.2 to 76.3)

Breast cancers: Histological types

64.1% invasive ductal carcinoma, 17.2 % with ductal carcinoma in situ? and 18.7% other breast cancer.

Number and size of metastatic lesions:

61 (75.3%) lesions were less than 3 cm in size.

20 (24.7%) of lesions were 3 cm or greater.

The majority (51 (63%) of patients presented with a solitary lung lesion, whereas 30 (37. %) presented with two or more lesions.

Operative procedures

Meimarakis et al. performed a total of 92 operations.  These included 71 patients who underwent one procedure, 9 patients for two procedures and 1 patient with three procedures.

All of the patients undergoing more than one procedure had contralateral surgery for newly occurring metastases.  (The authors re-operated on patients within 4 to 6 weeks for synchronous metastatic lung lesions.)  This is important to remember when reviewing the primary article since the terminology ‘re-do’ operations and repeat operations can be confusing.  However, after clarifying with the primary author, there were no completion procedures (i.e. wedge converted to lobectomy based on final pathology) and no returns to the operating room for surgery due to complications.  There was no return to the operating room  for any procedures on the same side as the original procedure.  Thus for clarification, no “re-do” procedures.

All patients underwent resection via anterolateral thoracotomy.  However, patients with peripheral, previously unbiopsied nodules were initially approached via VATS with conversion to anterolateral thoracotomy for positive intraoperative pathology.

67 operations were wedge resection, with an additional 10 segmental resections.  The remainder of procedures included 7 lobectomies, 7 pneumonectomies and 1 bilobectomy.

Median operating room time was 83 minutes, with a fairly lengthy hospitalization stay (median 9 days, with a range of 3 – 63 days.)  Complication rate was 7.6% (3 patients with pneumonia, 4 patients with atelectasis).

Limitations of Study

The median follow-up was only 27.2 months.  At the end of this period, 27 of the 81 patients (33.3%) had died.  While the published study was lengthy and detailed (10 pages with multiple charts and graphs) much of this was related to discussion regarding receptor status, and existing literature.  A clearer, more streamlined algorithmic approach or scoring system utilize to their findings would be more helpful to readers in determining the likelihood of successful outcomes with surgical resection, and for encouraging replication of their research.


Despite the limited number of patients with multiple metastatic lung lesions in this study, the underlying rules of surgical resection remain consistent.  Patients who did the best, with the longest overall survival time were patients with complete surgical resection (R0).  While patients with a completely resection of a single metastasis lived longer than patients with complete resection of multiple metastases, the R0 patients with multiple metastases had greater median survival than all patients with incomplete resection, regardless of the degree of residual (R1, R2) disease (microscopic or gross disease).

Receptor positive patients with better outcomes

As seen in multiple studies, tumor types were a crucial factor in long-term outcomes; whether estrogen receptor positive (ER+), human growth factor receptor 2 positive (HER2+), progesterone receptor+ (PR+).

Median survival of all patients after metastatectomy was 82.4 months with the greatest median survival time in the 31 patients with + hormone receptor tumors (HR+) at 127.4 months (range 33.2 to 221.6 months).  In comparison, the 8 patients with HER+  had a mean survival of 66 months and only 27 months median survival for the 14 triple negative patients)*.

These findings regarding longevity and tumor receptors are similar to those reported by Welter et. al (2008) and others, but the patients from this larger study demonstrated greater longevity, which gives weight to continued study in this area.

In Meimarakis’ work, the presence of pleural infiltration or lymphangiosis carcinomatosis denoted a reduced longevity (32.1 and 34.5 months).  This may serve as a better marker of systemic disease for future classification and treatment of advanced breast cancer. 

Implications:  For breast cancer patients, the discovery of a metastatic lung lesion advances the stage of the disease, drastically changing current treatment options.  Most breast cancer patients diagnosed with metastatic disease are not considered surgical candidates even if complete surgical resection is technically feasible.  

Meimarakis’s study is one of the larger studies to date, using a large number of prospective patients versus retrospective chart review.  This gives a more comprehensive look at a multitude of factors and patient demographics.  It serves as an excellent framework for future study in this area.

But, more interesting to our readers is the low incidence of post-operative complications (7 operations; 3 patients with pneumonia, 4 patients with atelectasis).

None of the patients died post-operatively.  There were no ‘take backs’ for post-operative complications such as bleeding, prolonged air leak or post-operative infections despite the fact that almost 10% (8 patients) underwent significantly larger procedures such as pneumonectomy or bilobectomy and that all patients underwent thoracotomies versus the smaller VATS procedures.    There was no difference in outcomes in this set of patients by procedure (wedge versus pneumonectomy) though Meimarakis notes that “there is a trend to worse survival in case of pneumonectomy during R1/ R2 resection (considering the whole database [Munich Cancer Registry] i.e not only in this group of patients with breast cancer.”

As outcomes appeared independent of the surgical procedure itself; based solely on resectability and tumor type, even larger scale resections such as pneumonectomy may be worthy of consideration during preoperative surgical evaluation, particularly in patients with favorable tumor types with good potential for complete resection.

Future considerations

Using the work of Meimarakis and similar researchers, development of an algorithmic approach may be beneficial to thoracic surgeons and others who encounter pulmonary metastases from breast cancer outside of larger research facilities.

Related case reports: We previously reported a case of metastatic breast cancer that was discovered at the time of surgery, despite the use of multiple imaging and diagnostic modalities.  However, in that case, the patient also had local metastases to bone (ribs), which were also resected.

*Please see original article for further detail on patient characteristics and outcomes.

While the data (statistics, patient outcomes) is from the original research of Meimarakis et al., the commentary has been written by writers at Cirugia de Torax and may not reflect the thoughts, considerations and experiences of the primary researchers.

Reference Article

Meimarakis, G., Ruttinger, D., Stemmler, J., Crispin, A., Weidenhagen, R., Angele, M., Fertman, J., Hatz, R. A. & Winter, H. (2013). Prolonged overall survival after pulmonary metastatectomy in patients with breast cancer.  Annals of thoracic surgery, April 2013, 1170-1180.  [Free full text not available.]

Additional Information

TNM Classification Help: Manual for Cancer Staging

Kycler, W. & Laski, P. (2012). Surgical approach to pulmonary metastases from breast cancer.  Breast J. 2012 Jan-Feb;18(1):52-7. doi: 10.1111/j.1524-4741.2011.01176.x. Epub 2011 Nov 20.  [no free full text available]. Retrospective data review of 33 patients who underwent pulmonary metastatectomy (1997 – 2002) at the Great Poland Cancer Center, in Poznan, Poland.

Welter S, Jacobs J, Krbek T, Tötsch M, Stamatis G. (2008).  Pulmonary metastases of breast cancer. When is resection indicated?  Eur J Cardiothorac Surg. 2008 Dec;34(6):1228-34. doi: 10.1016/j.ejcts.2008.07.063. Epub 2008 Sep 27  [free text available].  A review of 47 cases of metastatic breast cancer with pulmonary metastatectomy, Essen, Germany.

Two years and counting

celebrating our two-year anniversary here at Cirugia de Torax

Thank You!

April 2013 marks two years since the first post at Cirugia de Torax, so it’s time to take a moment to thank the many people who have supported our efforts. This includes not just the surgeons, but our readers.

Over 66,000 visits

Since that first post, we have logged over 66,000 hits, with readers clocking in hundreds of times a day from all over the world to find out more information about conditions, procedures, the latest in thoracic research and the surgeons themselves.

We’ve traveled to the UK, Mexico, Chile, Colombia, Bolivia and the USA, to meet and interview surgeons from around the world & to bring the latest news and technology from specialty conferences. Surgeons from these, (and other) countries have shared their ground-breaking research and illustrative case stories with us.

But you don’t have to be a writer, or a surgeon to contribute to Cirugia de Torax. Numerous medical students, doctors, nurses and consumers have reached out to us – to ask questions, and share their stories. Thank you. We read each comment and every email that comes to the site. We appreciate your questions and content suggestions, and welcome your submissions.

But one of our biggest supporters has been the Association of Physicians Assistants in Cardiovascular Surgery*. Their support has been essential in bringing together other professionals in thoracic surgery and in sharing information.

with thoracic surgeons from La Paz, Bolivia
with thoracic surgeons from La Paz, Bolivia

Hits and Misses

Since our inception, we’ve had successes and failures here at Cirugia de Torax.. Successes included interviews with some of the most innovative surgeons of our age.

Less successful have been our ongoing efforts to recruit thoracic surgeons to participate in our (free) on-line registry program to compile a greater cross-section of data that includes a better understanding of patient demographics and co-morbid conditions while examining post-operative outcomes internationally.

The future of Cirugia de Torax

Here at Cirugia de Torax, we are hoping that this anniversary is just one of many.  As we continue to write, travel and explore issues within thoracic surgery, we hope to expand to provide greater coverage of global events, conferences and surgeons.  Over the next 24 months, we hope to be able to provide a wider window into thoracic surgery in areas that have not been well represented here in the past; including geographic locations such as vast swaths of Asia.  We also hope to provide additional  coverage of procedures, and treatments of conditions of the mediastinum, esophagus and chest wall.

The registry efforts will continue – as part of our ongoing efforts to make research fast, easy, internationally inclusive and surgeon friendly.

*Note: Cirugia de Torax is a volunteer project, and receives no monetary gifts or other financial support from outside organizations. Support from APACVS, and other organizations comes from recognition and referrals to our website.

Dual port VATS for recurrent spontaneous pneumothorax: Foroulis et. al

A newly published study comparing dual port thoracoscopy with mini-thoracotomy for the treatment of recurrent spontaneous pneumothorax

Here at cirugia de torax, we take a keen interest in the development of increasingly minimally invasive technologies from dual (and single-port) thoracoscopy for a variety of conditions to RATS (robot- assisted thoracic surgery).  It is our belief that by embracing these emerging technologies, we help to advance the thoracic surgery specialty.

This spring, we have had the pleasure of publishing case reports on dual port thoracoscopy for decortication of parapneumonic effusions and empyema and catching up with one of the leaders in single incision thoracic surgery, Dr. Diego Gonzalez Rivas.

This month, another entry, “A modified two-port thoracoscopic technique versus axillary minithoracotomy for the treatment of recurrent spontaneous pneumothorax: a prospective randomized study,”  by Dr. Christophoros N. Foroulis at the Aristotle Medical School in Thessaloniki, Greece was published in Surgical Endoscopy.  As noted in a previous post, there have been few (if any) published papers on dual port thoracoscopy, and no comparison studies of these two techniques.

This study, which was conducted during 2006 to 2009 followed 66 patients who were randomly assigned to receive either mini-thoracotomy or dual-port VATS for surgical pleurodesis/ bullectomy / blebectomy.

In this study, despite random assignment, each group of 33 patients were well matched in all characteristics such as age, operative side and BMI.   After surgical treatment, patients were followed for a median of 30 months (range 3 – 53 months) for development of late complications or recurrent pneumothorax.

Each treatment group – VATS versus open surgical was overseen by one surgeon with Dr. Foroulis performing all of the dual port surgeries, and Dr. Papakonstantinou performing all of the open procedures.  Outcomes were independently reviewed / evaluated by the remaining authors.

Study Findings

–  No conversions to open thoracotomy from the VATS group.

– Similar rate of recurrence between open (2.7%) and VATS (3%) group (but timing of recurrence differed.)  Both recurrent pneumothoraces in the VATS group occurred early post-operatively (POD#5) compared to the open surgical group – 13 months post-op.

– Rate of complications the same between groups but the type of complications differed. 2 patients in each group required reoperation:

VATS – reoperation for prolonged airleak

Minithoracotomy group – hematomas/ evacuation of clots

Length of stay (LOS) and post-operative pain

Surprisingly, length of stay and post-operative pain – two of the outcomes that are usually cited in favor of minimally invasive procedures – were not significantly different between the groups.


Patient satisfaction

However, patient satisfaction was significantly higher in the dual port group.  This was related to an earlier return to normal activities, and earlier full mobilization of the affected arm.

Longer procedures

VATS procedures were longer than open procedures – by a mean of 21 minutes (87.1 minutes for VATS versus 66.7 minutes for minithoracotomy) with associated increases in uni-lung ventilation time.

Discussion/ Conclusions

While previous studies had reported a recurrence rate that was significantly higher in the VATS group – that was not seen here.  The ability to detect blebs/ bullae (and thus treat) with VATS remains limited in comparison to a mini-thoracotomy, but does not appear to change outcomes after a successful pleurodesis procedure.  Dual port thoracoscopy does take more time but both procedures appear equally effective.


Foroulis, C. N., Anastasiadis, K., Charokopos, N., Antonitisis, P., Halvatzoulis, H. V., Karapanagiotidis, G. T., Grosomanidis, V. & Papakonstantinou, C. (2012).  A modified two-port thoracoscopic technique versus axillary minithoracotomy for the treatment of recurrent spontaneous pneumothorax: a prospective randomized study.  Surg Endosc 2012 May 12.  Includes color photographs of procedures.

Thank you to Dr. Foroulis for your assistance.

For more on related topics:

Case study: spontaneous pneumothorax

About spontaneous pneumothorax

Minimally invasive surgery: SITS

Endo GIA staple recall

Covidien announces a product recall of surgical staples cartridges and cautions against use in thoracic surgery patients.

Covidien, a ten billion dollar medical materials manufacturer, issued a recall notice for The Duet TRS single-use cartridges.  These cartridges which are used with the Endo-GIA stapler have been definitively linked to three deaths in thoracic surgery patients, and several serious injuries.  The mechanism of injury (according to the company) appears to be related to some ancillary material within the staple cartridges.  Unfortunately,  while amending their initial statement to state that the device “has the potential to injury tissue”, further information about the problem has not been forthcoming from the manufacturer, leading many surgeons to question to true estimates of injury, particularly given the gravity of the warnings the company has issued.  The revised warning also now lists thoracic surgery as a contraindication to use of this device.

Surgical staplers such as the Endo-GIA have revolutionized the field of surgery, and are particularly helpful in thoracic surgery by simplifying surgical resections.  Instead of suturing and oversewing incisions after a wedge resection of a lung lesion, for example – the stapler allows the surgeon to cut and close the incision in one manuever.  This is particularly helpful in thoracoscopy (and laparoscopy in general surgery) where surgeons are working through a limited space.  (Compared to the abdominal cavity – the chest cavity is a relatively inflexible space due to the rib cage – which limits maneuverability, particularly when working thru small ports instead of open incisions*). 

A list of the recalled staple cartridges can viewed here.   This information is more important for surgeons overseas, as recalled items are often re-sold to secondary markets.

* There are specialized thoracoscopy tools – long narrow tools to allow surgeons to suture, cut, grasp tissue within the chest thru small (1 to 1.5 cm_ incisions (ports).

Additional references to this story:

Coviden recalls device after 3 deaths, multiple injuries in thoracic patients.

Coviden staples contraindicated in thoracic surgery.

Update: 1/17/2012 – 1630:  Looks like we scooped Medscape on this story!

Lung resection in high risk patients

a look at the results of Dr. Wolf’s recent study of high risk patients undergoing lung resections.

From Thoracic surgery :

in a recent article by Dr. Andrea S. Wolf, she examined outcomes in two groups of patients diagnosed with stage 1A nonsmall cell lung cancer (NSCLC) – 66 patients deemed high risk due to elderly age, poor lung function (or both) matched with 158 patients considered to be low risk surgically.

Results were surprising, for several reasons, – with no surgical mortality in either group.  The long-term survival rate of the high risk group was also surprisingly good (but less than the matched group) – 58% were alive five years after surgery.

Dr. Wolf and her associates from Brigham & Women’s also presented these results at the 37th annual meeting of the Western Thoracic Surgical Association this summer.


Thoracic Surgeons and smoking cessation

The use of social media by health care professionals to connect with our patients has increased at a phenomenal rate in this age of enhanced technology, social networking and smartphones.

Thoracic surgeons, preventative medicine and other pulmonary specialists at the University of Tennessee – Health Science Center in Memphis have created a new Apple application for help smokers finally put down those cigarettes for good.  The application which is called “Quit Forever App” is free and is an important tool in an increasing arsenal of health-related applications.

Pulmonology throws down the gauntlet..

Evaluation and discussion of a new article by Davies et. al. (2011) which calls many of the current practices in thoracic surgery into question. Is this a legitimate assessment of evolving treatment strategies or another attempt for pulmonology to encroach on the thoracic surgery specialty? In this multi-part series, we will address the major points debated in this article.

In a recent article by several pulmonologists in Australia (Helen E. Davies, Andrew Rosenstengel and Y.C. Gary Lee) the authors contend the recent developments in pulmonology have largely made the thoracic surgery specialty obsolete – particularly in the treatment of pleural disease. Are there merits to their claims?  or is this just another example of an expanding turf war, reminiscent of recent battles between cardiology and cardiac surgery?

We will re-post the article here, and discuss their findings at length in a multi-part series.

From Current Opinion in Pulmonary Medicine, “The Diminishing Role of Surgery in Pleural Disease”

Helen E. Davies; Andrew Rosenstengel; Y.C. Gary Lee

 Curr Opin Pulm Med. 2011;17(4):247-254.

Abstract and Introduction


Purpose of review Pleural disease is common. Traditionally, many patients were subjected to surgery for diagnosis and treatment. Most pleural surgical procedures have not been subjected to high-quality clinical appraisal and their use is based on anecdotal series with selection bias. The evidence (or the lack) of benefits of surgery in common pleural conditions is reviewed.
Recent findings Recent studies do not support the routine therapeutic use of surgery in patients with malignant pleural effusions, empyema or mesothelioma. Four randomized studies have failed to show significant benefits of thoracoscopic poudrage over bedside pleurodesis. Surgery as first-line therapy for empyema was studied in four randomized studies with mixed results and no consistent benefits. Cumulative evidence suggests that radical surgery in mesothelioma, especially extrapleural pneumonectomy, is not justified. Advances in imaging modalities and histopathological tools have minimized the need for surgery in the workup of pleural effusions. Complications associated with surgery are increasingly recognized.
Summary Surgery has associated perioperative risks and costs, and residual pain is not uncommon. Many conventional pleural surgeries have not been assessed in randomized studies. Pulmonologists should be aware of the evidence that supports surgical interventions, or the lack of it, in order to make informed clinical decisions and optimize patient care.


Pleural diseases are common; over 1 500 000 patients develop a new pleural effusion annually in the USA alone.[1] Pleural effusion can arise from more than 60 causes, and establishing the cause and effective treatment can be challenging.

Thoracic surgery traditionally plays a major role in the workup and management of pleural effusions, from pleural biopsies to pleurodesis and from empyema to pneumothorax. Various aggressive pleural surgeries have been developed over the years: from the description of Clagett procedure in 1963[2] – a three-stage radical procedure with chest wall resection to create a permanent open window for pleural empyema – to modern day extrapleural pneumonectomy (EPP) for mesothelioma, which involves resection of lung, chest wall, hemidiaphragm, pericardium and regional lymph nodes. Most pleural surgical procedures have not been subjected to high-quality clinical appraisal (let alone randomized studies) and their use is based largely on anecdotal series often flawed with selection bias.

The aim of management of pleural diseases is to deliver the diagnosis and best management with the least invasive procedure(s), shortest hospitalization period and lowest procedural morbidity and cost. Realization of the lack of evidence for many pleural surgeries, and the growing documentation of their procedure-related complications, has prompted the pleural community to examine ‘conventionally accepted’ pleural surgical approaches using randomized trials. Not surprisingly, many (e.g. thoracoscopic poudrage) have failed to demonstrate any significant benefits. Advances in imaging techniques, histopathology methods and therapeutic protocols further contribute to a reduction in need for invasive surgeries. Worldwide, in recent decades, the role of surgical intervention for the diagnosis and management of pleural disease has diminished significantly.

Clinicians must be critically aware of the evidence (or lack of evidence) supporting a specific surgical intervention before subjecting their patient to an operation. Progress can only be made if clinicians continue to challenge the truthfulness of ‘conventional wisdom’ and work toward less invasive means to achieve better patient care.

In this review, we discuss the role of surgery in commonly encountered pleural diseases and highlight the deficit in evidence that supports many ‘accepted’ surgical interventions, and the advances in pleural research which suggest parity or superiority of noninvasive approaches.

Surgery for Diagnosis of Pleural Effusions

A significant shift in the choice of diagnostic procedure for undiagnosed pleural effusion has been seen in recent years. Open thoracotomy, once the gold standard, has given way to less invasive video-assisted thoracoscopic surgery (VATS). In turn, VATS is giving way to the less invasive pleuroscopy (or medical thoracoscopy). VATS requires general anesthesia and is performed usually through two to four portals of entry. Pleuroscopy is performed usually by pulmonologists under conscious sedation with a single or double port of entry, often as a day case.

In the UK, the number of centers offering pleuroscopy has jumped from 11 to 37 in the past decade, significantly reducing the need for VATS or open pleural biopsies.[3] Flexi-rigid pleuroscopy further increases the ease of the procedure over traditional rigid thoracoscopy and is gaining popularity.

This march toward less invasive procedures is in part driven by the realization that surgery carries a risk of chronic complications. Furrer et al.[4] reported that chronic intercostal neuralgia (persistent pain) occurred in up to 44% of patients at 6 months postthoracotomy. In another series (n = 56), 9% of patients suffered from chronic postthoracotomy pain severe enough to require daily analgesia, nerve blocks, acupuncture or specialist pain clinic visits.[5] It is not surprising that a systematic review favored VATS over thoracotomy, reporting lower analgesia requirements and a shorter length of hospital stay. However, VATS is still associated with persistent pain or discomfort at the operation site in over a third of patients after 3–18 months.[4]

No studies directly compare VATS with pleuroscopy, but several large case series have suggested similar diagnostic efficacy for malignancy. Pooled results from case series evaluating pleuroscopy show a diagnostic sensitivity for malignant pleural disease of 92.6% (95% confidence interval 91.0%–93.9%),[6–25] comparable to those achieved following VATS pleural biopsy.[26,27] Pleuroscopy is a well-tolerated, cost-effective procedure. Mortality rates are low (<0.01%) and, in a series of over 6000 cases, surgical intervention was never required for hemostasis.[28] Pleuroscopy is preferable over VATS if initial fluid analyses were uninformative, especially in suspected cases of malignant or tuberculous pleural effusions.

Furthermore, technological improvements in diagnostic imaging modalities have reduced the need for thoracoscopic biopsies. Computed tomography with pleural phase enhancement provides closer definition of the pleural surfaces and circumferential, nodular or mediastinal thickening, and a parietal pleural thickness of more than 1 cm provides diagnostic specificities of 100%, 94%, 88% and 94%, respectively, for malignant disease.[29] Similar results were recently demonstrated by Qureshi et al.[30] using pleural ultrasound.

In patients with radiological evidence of pleural thickening, the diagnostic sensitivity of imaging-guided and thoracoscopically obtained pleural biopsy samples is comparable (approaching 90%).[3]

Advances in laboratory tests and biomarkers for pleural diseases also significantly reduce the need for pleural tissue biopsies. In many endemic countries, adenosine deaminase is used in the diagnosis of tuberculous effusion especially in patients with a compatible clinical picture and a lymphocyte-predominant effusion, negating thoracoscopic biopsies.[27,31] Other examples include flow cytometry for diagnosing lymphoma from pleural fluids, amylase for pancreatic effusions or ruptured esophagus and beta-2 transferrin for duropleural fistulae.

In patients with suspected mesothelioma, the use of a rapidly growing number of biomarkers has been proposed to aid the diagnosis through serum or pleural fluid analyses (reviewed elsewhere[32,33]). Although none can substitute a histocytological diagnosis, a high mesothelin level in cases with suspicious cytology of mesothelioma can add confidence to diagnostic certainty and may obviate the need for surgery.[34] In a study of 167 prospective patients presenting with undiagnosed pleural effusion, a negative mesothelin level together with negative pleural fluid cytology for malignancy yield a negative predictive value of 94%[34] – highly comparable to the false negative rate for pleuroscopy in three large series.[13,35,36] It is anticipated that within the next decade, these biomarkers will have an established place in the diagnostic algorithms for common pleural conditions, further minimizing the need for thoracoscopy.

Surgery for Pleural Infection

Pleural infection is a centuries’ old problem, but its incidence continues to rise despite better medical care and antimicrobials. The principle of therapy is control of sepsis (antibiotics) and drainage of the infected pleural fluid collection by thoracentesis, and if this fails, surgical evacuation.

Empyema is still considered in many centers as a ‘surgical’ disease, where surgeons will insert large bore chest tubes and have a low threshold of performing thoracoscopy for fluid evacuation if there are residual radiographic opacities. The conventional belief of the benefits of surgery stemmed from many anecdotal series, flawed by selection bias. The magnitude of that bias has recently been quantified in a retrospective series of 4424 empyema patients in the USA over 20 years.[37] Empyema patients selected for surgery were significantly younger by almost 10 years (52.9 vs. 61.5 years, P < 0.001) and had a significantly lower comorbidity index (0.8 vs. 1.4, P < 0.001).[37] VATS procedures often (up to 17%[38]) require conversion to open thoracotomy, thus increasing postoperative morbidity (see above). Many aspects of these ‘conventional practices’ are now shown to be overaggressive and unnecessary. There are several factors to consider.

First, the majority of patients with pleural infection can be adequately treated with antibiotics and chest tube drainage, without needing surgery. In the Multicentre Intrapleural Sepsis Trial (MIST) (n = 454), only 18% (n = 74) failed the above approach and required surgical treatment.[39•] [This is akin to pneumothorax management, where a 20% recurrence risk after the first episode does not warrant automatic surgery.[40] Routinely, subjecting all empyema patients to surgery is, therefore, unnecessary.

Four randomized clinical trials (RCTs) have now compared first-line VATS with conservative treatment (antibiotics and chest tube drainage with/without fibrinolytics). No major advantage (e.g. on mortality) has been documented with early surgical approach in all the trials. Two RCTs of pediatric empyema, comparing primary VATS intervention with chest drain and intrapleural fibrinolytic, both showed no advantages of early surgery. On the contrary, Sonnappa et al.[41] showed that surgery was more expensive ($11 379 vs. $9127) but did not alter outcome over conservative management in 60 children with pleural infection. Higher hospital charges were observed in the study by St Peter et al.[42] and similarly no significant differences in length of stay, oxygen requirement, days until afebrile or analgesia needed (n = 36). The two trials on adult empyema were small (n = 19 and 70, respectively) and difficult to interpret. Clear criteria to guide the need for surgical decortication, following the initial treatment administered postrandomization, are lacking in both studies.[43,44] Bilgin et al.[43] and Wait et al.[44] both randomized patients for immediate VATS or chest drain and antibiotics +/− intrapleural fibrinolytic. Neither study showed a major benefit other than shorter hospital stays (8.7 vs. 12.8 and 8.3 vs. 12.8 days, respectively). Hence, a recent Cochrane review concluded that further studies are needed to determine best practice.[45]

Supplementing improvements in antimicrobial therapies, imaging guidance of chest tube drainage is now increasingly used in place of surgical evacuation of pleural collections. This practice has reduced the amount of patients subjected to surgery, though the exact magnitude of the reduction is difficult to quantify.

Intrapleural therapy to aid the drainage also can negate the need for surgical evacuation. A large randomized study (n = 454) and subsequent meta-analysis have shown no benefit from intrapleural streptokinase therapy alone.[39•,46] However, the combined intrapleural use of tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) to breakdown adhesions and thin pus has synergistic benefits in preclinical models.[47,48] This has led to a factorial trial of intrapleural tPA and DNase in patients with pleural infection. Preliminary results from the MIST-2 study (presented at the British Thoracic Society 2009 scientific meeting[49]) appear promising: tPA and DNase improved radiological clearance of pleural abnormalities and reduced hospital stay. Only 5% of patients treated with this combination required surgical debridement.

Second, surgical decortication postempyema is grossly overemployed. Many centers submit patients to surgical decortication because of residual radiologic changes, even when sepsis had subsided. This practice is not supported by current clinical practice guidelines, which recommend surgery only in patients with persistent sepsis and a residual pleural collection despite appropriate drainage and antimicrobial therapy.[50] Longitudinal follow-up data from large clinical studies showed that residual pleural opacities will resolve with time, as the inflammatory changes settle.[39•,51] This is akin to radiographic parenchymal changes in patients with pneumonia.

Third, conventional teaching advocates large bore chest tube drainage for empyema and, in many centers, large drains are inserted only by thoracic surgeons. Traditionally, the main arguments for large catheters have been a better drainage rate, especially in draining pus, and a lower blockage rate. However, no evidence-based data concur with this supposition.[52•] The difference in drainage rate for pus is not significant once the size of internal diameter of the catheter reaches at least 8F or above (~12–14F external diameter). Rates of drain blockage in empyema, another conventional concern, are similar in published literature between large and small bore drains; and regular flushing of small bore catheters often overcomes the problem of blockage.[53]

Empyema fails to drain most commonly because of multiple septations, a hurdle which large drains will not overcome; increasing numbers of studies now show that larger drain size does not increase efficacy, even in empyema. In their study, analysing data on 405 patients with empyema, Rahman et al.[52•] showed no significant difference in mortality, need for subsequent thoracic surgery, length of hospital stay, lung function or radiographic resolution in patients with chest tubes of varying sizes (<10F, 10–14F, 15–20F or >20F).

The main drawback of the large bore catheters is pain secondary to the larger incision and subcutaneous/transpleural tract required, as reported in several series.[52•,54] Others have shown higher rates of infection with large tubes.[55,56]

Surgery for Malignant Pleural Effusions

As many as 100 000 patients in Europe develop a malignant pleural effusion from lung cancer alone[57] and 150 000 cancer patients in USA have a malignant pleural effusion each year.[58] Little evidence suggests thoracic surgery has a salient therapeutic role in malignant effusion management, even though it is often employed worldwide.

Pleurodesis is considered the best therapy wherever suitable and, in head-on comparisons, talc has been shown to be superior to bleomycin, tetracycline or doxycycline.[59–65] The optimal route for delivery of talc is controversial.

Talc poudrage administered by VATS is traditionally thought to be more effective than bedside slurry instilled via a chest tube. However, talc induces pleural mesothelial damage with subsequent pleural inflammation and symphysis, rather than acting as a glue;[66–69] therefore, the supposed even distribution which results from insufflation is not essential for successful pleurodesis. Radioactive isotope studies have shown that talc can distribute around the pleural cavity by respiratory motions even if administered as slurry.[70]

All randomized trials to date have failed to show a benefit of thoracoscopic talc poudrage over bedside chemical pleurodesis; three recent studies have compared talc poudrage with talc slurry,[71•,73,74] and one, by Mohsen et al.,[72] with povidone iodine. These are outlined in Table 1.[71•,72–74]

Table 1. Recent trials comparing talc slurry and bedside chemical pleurodesis

Reference; study design Patient number Primary cancer (TP/TS) Length of follow up Outcome measures Result
Dresler et al. [71•]; TP=251 Lung: 89/93 Until death Recurrence rate at 30 days: No significant difference
RCT TS=250 Breast: 59/56 TP: 145/251 Similar success rates at 30 days (75%) and efficacy at 6 months (50%)
TS: 126/250 (P=NS)
Yim et al. [74]; TP=28 Lung: 18/15 Until death Recurrence rate: No significant difference
RCT TS=29 Breast: 6/9 TP: 1/28
GIT/other: 4/5 TS:3/29
Terra et al. [73]; TP=30 Breast: 15/19 6 months Postpleurodesis lung expansion No significant difference in Clinical outcome complications or quality of life
RCT TC=30 Lung: 11/6 Radiological recurrence
Lymphoma: 2/1 Clinical recurrence (requiring intervention):
Unknown: 1/1 TP: 5/30
Other: 1/3 TS: 4/30
Mohsen et al. [72]; TP=22 All breast 4 years Recurrence requiring intervention: No significant difference
RCT PI=20 TP: 2/22
PI: 3/20

GIT, gastrointestinal; NS, not significant; PI, povidone iodine; RCT, randomized controlled trial; TP, talc poudrage; TS, talc slurry

The largest trial by Dresler et al.[71•] showed that talc poudrage at thoracoscopy induced significantly more complications than talc slurry pleurodesis. Rates of pneumonia requiring antibiotics, respiratory failure, bronchopleural fistulae, requirement for blood transfusion, atelectasis requiring more than two bronchoscopies, dysrhythmia, deep vein thrombosis, pulmonary embolism and postoperative death rates were all increased in the talc poudrage compared with the bedside talc slurry group.[71•] Success rates of both techniques were similar (~75%) at 30 days after procedure. Efficacy reduced with time to approximately 50% at 6 months and a suggestion of a trend toward talc slurry being more effective.[71•]

Indwelling Pleural Catheters

One major recent advance has been the increased utility of indwelling pleural catheters (IPC). These may be inserted as a day-case procedure, with local anesthesia and conscious sedation, thus reducing hospital time and avoiding the risks inherent to a general anaesthetic. It is now the preferred treatment method for patients with an underlying trapped lung and those who fail initial pleurodesis.[75] Extending the use of IPC as a first-line treatment for patients with malignant pleural effusion is the subject of randomized trials in Europe. Recent series suggest that bedside insertion of IPC by pulmonologists or interventional radiologists is as well tolerated as surgical placement in the operating rooms.[76]

Surgery for Malignant Pleural Mesothelioma

Perhaps the most aggressive pleural surgery performed nowadays is EPP. EPP is usually part of trimodality treatment in combination with chemotherapy and hemithoracic radiotherapy. Little high-quality evidence supports its use.

Even in the most experienced centers and despite surgical advances, the perioperative mortality rate remains approximately 4%.[77] Other centers have observed similar findings; e.g. Rice et al.[78] had 8% mortality in 100 cases of EPP; Stewart et al.[79] had 7% mortality in 74 patients and Hasani et al.[80] had 11% mortality in a series of 18 patients. There is also significant associated morbidity: Sugarbaker et al.[77] report a complication rate in excess of 60%, a finding echoed by Schipper et al.[81] (who also report a 3-year survival rate of only 14%). Life-threatening complications affect 25% of patients, including surgical complications requiring re-exploration (7%), cardiac arrest/myocardial infarction (5%), prolonged intubation (8%), deep vein thrombosis and renal failure.[77] Late mortality (days 30–180) is significant, killing as many patients as in the first 30 days in one report. Additional morbidity arises from the chemotherapy and radiotherapy arms of the trimodality regime.

Despite this unacceptable safety profile, the trimodality approach does not cure mesothelioma. Alarmingly, though not surprisingly, Weder et al.[82] reported worsening of quality of life in patients who underwent EPP, especially in physical, psychological and activity scores for at least up to 6 months after surgery. Although improved long-term survival has been claimed, the data are almost certainly a result of selection bias.

The Mesothelioma and Radical Surgery (MARS) trial was designed to address the role of EPP as a component of trimodality treatment in malignant mesothelioma.[83] Even in the 300 patients believed to be potentially suitable and referred, only 50 were ultimately eligible after screening and were randomized; further confirming that EPP, even if useful, is applicable only to a minority of patients and will not make an impact on the global burden of mesothelioma.[84]

Increasing data confirmed that EPP has a worse outcome than less radical surgery, for example pleurectomy/decortication. Flores et al.[85] showed in a large but nonrandomized series that patients who underwent pleurectomy had improved survival compared with those who underwent EPP. Nakas et al.[86] reported significant improvements in pain and dyspnea with VATS pleurectomy/decortication (n = 67) compared with EPP (n = 112), with improved 30 day mortality (VATS group 7.1% vs. EPP 23%), reduced hospital stay (14.3 days vs. 36.6 days) and overall mean survival (14.0 months vs. 11.5 months) in patients aged more than 65 years.

The most striking data to show the lack of surgical benefits came from Flores et al.,[87] who in a large retrospective series showed a median survival of 14.3 months in patients undergoing EPP (n = 208) compared with 15.8 months (n = 176) following pleurectomy/decortication. Both were only marginally better than the median survival for patients (n = 174) who underwent explorative thoracotomy and were found to have extensive and inoperable disease (12.7 months).

Mesothelioma is not a solitary tumor but spreads along serosal surfaces. Surgery is not likely therefore to provide cure, as has been the observation to date. Because of the lag time between exposure and disease onset, the patients are often elderly with significant comorbidity, and current data do not support aggressive operations.

Surgery for Chylothorax

Although dietary manipulation may reduce chyle flow, patients with refractory chylothoraces often require surgical ligation of the thoracic duct if this fails, necessitating either VATS or thoracotomy. Increasing reports suggest that percutaneous thoracic duct embolization using fluoroscopic guidance may be effective and can obviate the need for invasive surgery.[88,89]

Surgery for Pneumothorax

The majority of pneumothoraces can be managed without surgery. Patients with small primary spontaneous pneumothoraces (PSP) or with no symptoms, regardless of the size of the pneumothorax, may be safely treated with observation alone. Guidelines recommend initial pleural aspiration for patients with PSP and significant symptoms, and that any patient with a secondary spontaneous pneumothorax (SSP) has an intercostal chest drain inserted.[41]

No evidence exists on which to base timing of referral for surgical intervention in patients with an ongoing air leak. International guidelines recommend that an opinion is sought within 2–5 days; however, this timeline is largely arbitrary.[41,90]

Several retrospective studies argue against early surgical treatment. One retrospective review (n = 115) reported spontaneous resolution rates of 74% and 100% for those with PSP at 7 and 15 days, respectively; and 61% and 79% (at 7 and 14 days, respectively) for patients with SSP. Only five patients required surgical intervention.[91] Two further studies of PSP showed that only 37% had an air leak at presentation, resolving in two thirds of cases within 1 week without intervention.

Ferraro et al.[92] compared conservative (including tube thoracostomy) to surgical intervention (apical resection with either pleurectomy of pleural abrasion) for 366 patients with 508 episodes of spontaneous pneumothorax (239 patients with PSP, 127 with SSP). No significant difference was noted between the two groups in terms of recurrence rates.

Other nonsurgical approaches under exploration include ambulatory management with chest tube and one-way valve, and pleuroscopy. For patients with SSP, who are more likely to have a prolonged air leak and less likely to tolerate surgical intervention, prolonged observation, intercostal catheter drainage and use of flutter valves may preclude the need for surgery. Medical thoracoscopy as an alternative to VATS has increasingly been used for the management of spontaneous pneumothorax. Tschopp et al.[93] in a RCT compared the efficacy of VATS pleurodesis (via abrasion or talc poudrage) to poudrage via medical thoracoscopy, showing no difference in long-term recurrence rate (approximately 5%).


For centuries, different surgical procedures have been used for various pleural diseases, without any quality data to prove their benefits over conservative alternatives. Surgery has associated perioperative risks and costs; and residual pain is not uncommon. To date, the randomized studies on surgical approaches have not shown a significant advantage in the settings of pleural infection, malignant effusions and mesothelioma. Pulmonologists should be aware of the evidence that supports surgical interventions, or the lack of it, in order to make well-informed clinical decisions and optimize patient care.


Key Points

  • The overall aim of medical practice is to diagnose and treat with the least invasive methods.
  • There is a paucity of randomized evidence to support surgical intervention for many pleural diseases and physicians need to be aware of this in order to make well-informed clinical decisions to optimize patient care.
  • Radical surgery, especially extrapleural pneumonectomy, is not justified for patients with mesothelioma.
  • Advances in pleural research suggest parity or improved outcomes with less interventional approaches for patients with empyema.


  1. Light RW. Pleural diseases. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2007.
  2. Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. J Thorac Cardiovasc Surg 1963; 45:141–145.
  3. Rahman NM, Ali NJ, Brown G, et al. Local anaesthetic thoracoscopy: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65(Suppl 2):ii54–ii60.
  4. Furrer M, Rechsteiner R, Eigenmann V, et al. Thoracotomy and thoracoscopy: postoperative pulmonary function, pain and chest wall complaints. Eur J Cardiothorac Surg 1997; 12:82–87.
  5. Dajczman E, Gordon A, Kreisman H, Wolkove N. Long-term postthoracotomy pain. Chest 1991; 99:270–274.
  6. Blanc FX, Atassi K, Bignon J, Housset B. Diagnostic value of medical thoracoscopy in pleural disease: a 6-year retrospective study. Chest 2002; 121:1677–1683.
  7. Boutin C, Rey F. Thoracoscopy in pleural malignant mesothelioma: a prospective study of 188 consecutive patients. Part 1: Diagnosis. Cancer 1993; 72:389–393.
  8. Davidson AC, George RJ, Sheldon CD, et al. Thoracoscopy: assessment of a physician service and comparison of a flexible bronchoscope used as a thoracoscope with a rigid thoracoscope. Thorax 1988; 43:327–332.
  9. Debeljak A, Kecelj P. Medical thoracoscopy: experience with 212 patients. J Buon 2000; 5:169–172.
  10. Fielding D, Hopkins P, Serisier D. Frozen section of pleural biopsies at medical thoracoscopy assists in correctly identifying benign disease. Respirology 2005; 10:636–642.
  11. Fletcher SV, Clark RJ. The Portsmouth thoracoscopy experience: an evaluation of service by retrospective case note analysis. Respir Med 2007; 101:1021–1025.
  12. Hansen M, Faurschou P, Clementsen P. Medical thoracoscopy, results and complications in 146 patients: a retrospective study. Respir Med 1998; 92:228–232.
  13. Janssen JP, Ramlal S, Mravunac M. The long-term follow up of exudative pleural effusion after nondiagnostic thoracoscopy. J Bronchol 2004; 11:169–174.
  14. Lee P, Hsu A, Lo C, Colt HG. Prospective evaluation of flex-rigid pleuroscopy for indeterminate pleural effusion: accuracy, safety and outcome. Respirology 2007; 12:881–886.
  15. Macha HN, Reichle G, von Zwehl D, et al. The role of ultrasound assisted thoracoscopy in the diagnosis of pleural disease. Clinical experience in 687 cases. Eur J Cardiothorac Surg 1993; 7:19–22.
  16. McLean AN, Bicknell SR, McAlpine LG, Peacock AJ. Investigation of pleural effusion: an evaluation of the new Olympus LTF semiflexible thoracofiberscope and comparison with Abram’s needle biopsy. Chest 1998; 114:150–153.
  17. Menzies R, Charbonneau M. Thoracoscopy for the diagnosis of pleural disease. Ann Intern Med 1991; 114:271–276.
  18. Munavvar M, Khan MA, Edwards J, et al. The autoclavable semirigid thoracoscope: the way forward in pleural disease? Eur Respir J 2007; 29:571–574.
  19. Oldenburg FA Jr, Newhouse MT. Thoracoscopy. A safe, accurate diagnostic procedure using the rigid thoracoscope and local anesthesia. Chest 1979; 75:45–50.
  20. Sakuraba M, Masuda K, Hebisawa A, et al. Diagnostic value of thoracoscopic pleural biopsy for pleurisy under local anaesthesia. ANZ J Surg 2006; 76:722–724.
  21. Schwarz C, Lubbert H, Rahn W, et al. Medical thoracoscopy: hormone receptor content in pleural metastases due to breast cancer. Eur Respir J 2004; 24:728–730.
  22. Simpson G. Medical thoracoscopy in an Australian regional hospital. Intern Med J 2007; 37:267–269.
  23. Smit HJ, Schramel FM, Sutedja TG, et al. Video-assisted thoracoscopy is feasible under local anesthesia. Diagn Ther Endosc 1998; 4:177–182.
  24. Tassi G, Marchetti G. Minithoracoscopy: a less invasive approach to thoracoscopy. Chest 2003; 124:1975–1977.
  25. Wilsher ML, Veale AG. Medical thoracoscopy in the diagnosis of unexplained pleural effusion. Respirology 1998; 3:77–80.
  26. Waller DA, Hasan A, Forty J, Morritt GN. Videothoracoscopy in the diagnosis of intrathoracic pathology: early experience. Ann R Coll Surg Engl 1994; 76:123–126.
  27. Hooper C, Lee YC, Maskell N. Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65(Suppl 2):ii4–ii17.
  28. Loddenkemper R. Thoracoscopy: state of the art. Eur Respir J 1998; 11:213–221.
  29. Leung AN, Muller NL, Miller RR. CT in differential diagnosis of diffuse pleural disease. AJR Am J Roentgenol 1990; 154:487–492.
  30. Qureshi NR, Rahman NM, Gleeson FV. Thoracic ultrasound in the diagnosis of malignant pleural effusion. Thorax 2009; 64:139–143.
  31. Liang QL, Shi HZ, Wang K, et al. Diagnostic accuracy of adenosine deaminase in tuberculous pleurisy: a meta-analysis. Respir Med 2008; 102:744–754.
  32. Scherpereel A, Lee YC. Biomarkers for mesothelioma. Curr Opin Pulm Med 2007; 13:339–443.
  33. Tung A, Porcel JM, Bilaceroglu S, et al. Biomarkers in pleural disease. US Respiratory Diseases 2011 (in press).
  34. Davies HE, Sadler RS, Bielsa S, et al. Clinical impact and reliability of pleural fluid mesothelin in undiagnosed pleural effusions. Am J Respir Crit Care Med 2009; 180:437–444.
  35. Davies HE, Nicholson JE, Rahman NM, et al. Outcome of patients with nonspecific pleuritis/fibrosis on thoracoscopic pleural biopsies. Eur J Cardiothorac Surg 2010; 38:472–477.
  36. Venekamp LN, Velkeniers B, Noppen M. Does ‘idiopathic pleuritis’ exist? Natural history of nonspecific pleuritis diagnosed after thoracoscopy. Respiration 2005; 72:74–78.
  37. Farjah F, Symons RG, Krishnadasan B, et al. Management of pleural space infections: a population-based analysis. J Thorac Cardiovasc Surg 2007; 133:346–351.
  38. Landreneau RJ, Keenan RJ, Hazelrigg SR, et al. Thoracoscopy for empyema and hemothorax. Chest 1996; 109:18–24.
  39. Maskell NA, Davies CW, Nunn AJ, et al. U.K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 2005; 352:865–874.
    • In this double-blind randomized placebo-controlled trial of 454 patients, no improvement in mortality, rate of surgery or length of hospital stay was shown with the intrapleural administration of streptokinase among patients with pleural infection.
  40. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65(Suppl 2):ii18–ii31.
  41. Sonnappa S, Cohen G, Owens CM, et al. Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema. Am J Respir Crit Care Med 2006; 174:221–227.
  42. St Peter SD, Tsao K, Spilde TL, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J Pediatr Surg 2009; 44:106–111.
  43. Bilgin M, Akcali Y, Oguzkaya F. Benefits of early aggressive management of empyema thoracis. ANZ J Surg 2006; 76:120–122.
  44. Wait MA, Sharma S, Hohn J, Dal Nogare A. A randomized trial of empyema therapy. Chest 1997; 111:1548–1551.
  45. Cameron R, Davies HR. Intra-pleural fibrinolytic therapy versus conservative management in the treatment of parapneumonic effusions and empyema. Cochrane Database Syst Rev 2004:CD002312.
  46. Tokuda Y, Matsushima D, Stein GH, Miyagi S. Intrapleural fibrinolytic agents for empyema and complicated parapneumonic effusions: a meta-analysis. Chest 2006; 129:783–790.
  47. Light RW, Nguyen T, Mulligan ME, Sasse SA. The in vitro efficacy of varidase versus streptokinase or urokinase for liquefying thick purulent exudative material from loculated empyema. Lung 2000; 178:13–18.
  48. Simpson G, Roomes D, Heron M. Effects of streptokinase and deoxyribonuclease on viscosity of human surgical and empyema pus. Chest 2000; 117:1728–1733.
  49. Rahman NM, Maskell NA, Davies CWH, et al. Primary result of the second multicentre intrapleural sepsis (MIST2) trial; randomised trial of intrapleural tPA and DNase in pleural infection [abstract]. Thorax 2009; 64: A1.
  50. Davies HE, Davies RJ, Davies CW. Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65(Suppl 2):ii41–ii53.
  51. Diacon AH, Theron J, Schuurmans MM, et al. Intrapleural streptokinase for empyema and complicated parapneumonic effusions. Am J Respir Crit Care Med 2004; 170:49–53.
  52. Rahman NM, Maskell NA, Davies CW, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest 2010; 137:536–543.
    • This analysis of patients with pleural infection shows that smaller bore chest tubes cause less pain than larger tubes, inserted using blunt dissection, with no impairment of clinical outcome.
  53. Davies HE, Merchant S, McGown A. A study of the complications of small bore ‘Seldinger’ intercostal chest drains. Respirology 2008; 13:603–607.
  54. Clementsen P, Evald T, Grode G, et al. Treatment of malignant pleural effusion: pleurodesis using a small percutaneous catheter. A prospective randomized study. Respir Med 1998; 92:593–596.
  55. Benton IJ, Benfield GF. Comparison of a large and small-calibre tube drain for managing spontaneous pneumothoraces. Respir Med 2009; 103:1436–1440.
  56. Parulekar W, Di Primio G, Matzinger F, et al. Use of small-bore vs large-bore chest tubes for treatment of malignant pleural effusions. Chest 2001; 120:19–25.
  57. Ferlay J, Autier P, Boniol M, et al. Estimates of the cancer incidence and mortality in Europe in 2006. Ann Oncol 2007; 18:581–592.
  58. Marel M, Zrustova M, Stasny B, Light RW. The incidence of pleural effusion in a well defined region. Epidemiologic study in central Bohemia. Chest 1993; 104:1486–1489.
  59. Diacon AH, Wyser C, Bolliger CT, et al. Prospective randomized comparison of thoracoscopic talc poudrage under local anesthesia versus bleomycin instillation for pleurodesis in malignant pleural effusions. Am J Respir Crit Care Med 2000; 162(4 Pt 1):1445–1449.
  60. Fentiman IS, Rubens RD, Hayward JL. A comparison of intracavitary talc and tetracycline for the control of pleural effusions secondary to breast cancer. Eur J Cancer Clin Oncol 1986; 22:1079–1081.
  61. Haddad FJ, Younes RN, Gross JL, Deheinzelin D. Pleurodesis in patients with malignant pleural effusions: talc slurry or bleomycin? Results of a prospective randomized trial. World J Surg 2004; 28:749–753.
  62. Hamed H, Fentiman IS, Chaudary MA, Rubens RD. Comparison of intracavitary bleomycin and talc for control of pleural effusions secondary to carcinoma of the breast. Br J Surg 1989; 76:1266–1267.
  63. Noppen M, Degreve J, Mignolet M, Vincken W. A prospective, randomised study comparing the efficacy of talc slurry and bleomycin in the treatment of malignant pleural effusions. Acta Clin Belg 1997; 52:258–262.
  64. Ong KC, Indumathi V, Raghuram J, Ong YY. A comparative study of pleurodesis using talc slurry and bleomycin in the management of malignant pleural effusions. Respirology 2000; 5:99–103.
  65. Zimmer PW, Hill M, Casey K, et al. Prospective randomized trial of talc slurry vs bleomycin in pleurodesis for symptomatic malignant pleural effusions. Chest 1997; 112:430–434.
  66. Genofre EH, Vargas FS, Antonangelo L, et al. Ultrastructural acute features of active remodeling after chemical pleurodesis induced by silver nitrate or talc. Lung 2005; 183:197–207.
  67. Idell S, Pendurthi U, Pueblitz S, et al. Tissue factor pathway inhibitor in tetracycline-induced pleuritis in rabbits. Thromb Haemost 1998; 79:649–655.
  68. Kennedy L, Harley RA, Sahn SA, Strange C. Talc slurry pleurodesis. Pleural fluid and histologic analysis. Chest 1995; 107:1707–1712.
  69. Marchi E, Vargas FS, Acencio MM, et al. Evidence that mesothelial cells regulate the acute inflammatory response in talc pleurodesis. Eur Respir J 2006; 28:929–932.
  70. Mager HJ, Maesen B, Verzijlbergen F, Schramel F. Distribution of talc suspension during treatment of malignant pleural effusion with talc pleurodesis. Lung Cancer 2002; 36:77–81.
  71. Dresler CM, Olak J, Herndon JE, et al. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest 2005; 127:909–915.
    • In this phase III study of 501 patients, no difference was seen in pleurodesis efficacy between thoracoscopic talc poudrage and talc slurry tube pleurodesis.
  72. Mohsen TA, Zeid AA, Meshref M, et al. Local iodine pleurodesis versus thoracoscopic talc insufflation in recurrent malignant pleural effusion: a prospective randomized control trial. Eur J Cardiothorac Surg 2010 [Epub ahead of print].
  73. Terra RM, Junqueira JJ, Teixeira LR, et al. Is full postpleurodesis lung expansion a determinant of a successful outcome after talc pleurodesis? Chest 2009; 136:361–368.
  74. Yim AP, Chan AT, Lee TW, et al. Thoracoscopic talc insufflation versus talc slurry for symptomatic malignant pleural effusion. Ann Thorac Surg 1996; 62:1655–1658.
  75. Roberts ME, Neville E, Berrisford RG, et al. Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65(Suppl 2):ii32–ii40.
  76. Suzuki K, Servais EL, Rizk NP, et al. Palliation and pleurodesis in malignant pleural effusion: the role for tunnelled pleural catheters. J Thorac Oncol 2011 (in press).
  77. Sugarbaker DJ, Jaklitsch MT, Bueno R, et al. Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies. J Thorac Cardiovasc Surg 2004; 128:138–146.
  78. Rice DC, Stevens CW, Correa AM, et al. Outcomes after extrapleural pneumonectomy and intensity-modulated radiation therapy for malignant pleural mesothelioma. Ann Thorac Surg 2007; 84:1685–1692.
  79. Stewart DJ, Martin-Ucar AE, Edwards JG, et al. Extra-pleural pneumonectomy for malignant pleural mesothelioma: the risks of induction chemotherapy, right-sided procedures and prolonged operations. Eur J Cardiothorac Surg 2005; 27:373–378.
  80. Hasani A, Alvarez JM, Wyatt JM, et al. Outcome for patients with malignant pleural mesothelioma referred for trimodality therapy in Western Australia. J Thorac Oncol 2009; 4:1010–1016.
  81. Schipper PH, Nichols FC, Thomse KM, et al. Malignant pleural mesothelioma: surgical management in 285 patients. Ann Thorac Surg 2008; 85:257–264.
  82. Weder W, Stahel RA, Bernhard J, et al. Multicenter trial of neo-adjuvant chemotherapy followed by extrapleural pneumonectomy in malignant pleural mesothelioma. Ann Oncol 2007; 18:1196–1202.
  83. Treasure T, Tan C, Lang-Lazdunski L, Waller D. The MARS trial: mesothelioma and radical surgery. Interact Cardiovasc Thorac Surg 2006; 5:58–59.
  84. Treasure T, Waller D, Tan C, et al. The mesothelioma and radical surgery randomized controlled trial: the Mars feasibility study. J Thorac Oncol 2009; 4:1254–1258.
  85. Flores RM, Pass HI, Seshan VE, et al. Extrapleural pneumonectomy versus pleurectomy/decortication in the surgical management of malignant pleural mesothelioma: results in 663 patients. J Thorac Cardiovasc Surg 2008; 135:620–626.
  86. Nakas A, Martin Ucar AE, Edwards JG, Waller DA. The role of video assisted thoracoscopic pleurectomy/decortication in the therapeutic management of malignant pleural mesothelioma. Eur J Cardiothorac Surg 2008; 33:83–88.
  87. Flores RM, Zakowski M, Venkatraman E, et al. Prognostic factors in the treatment of malignant pleural mesothelioma at a large tertiary referral center. J Thorac Oncol 2007; 2:957–965.
  88. Cope C, Kaiser LR. Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients. J Vasc Interv Radiol 2002; 13:1139–1148.
  89. Cope C. Management of chylothorax via percutaneous embolization. Curr Opin Pulm Med 2004; 10:311–314.
  90. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001; 119:590–602.
  91. Chee CB, Abisheganaden J, Yeo JK, et al. Persistent air-leak in spontaneous pneumothorax: clinical course and outcome. Respir Med 1998; 92:757–761.
  92. Ferraro P, Beauchamp G, Lord F, et al. Spontaneous primary and secondary pneumothorax: a 10-year study of management alternatives. Can J Surg 1994; 37:197–202.
  93. Tschopp JM, Brutsche M, Frey JG. Treatment of complicated spontaneous pneumothorax by simple talc pleurodesis under thoracoscopy and local anaesthesia. Thorax 1997; 52:329–332.Papers of particular interest, published within the annual period of review, have been highlighted as:
    • of special interest
    •• of outstanding interest
    Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 293).

Professor Y.C.G.L. receives research grants from the Western Australian Health Department (State Health Research Advisory Council), Sir Charles Gairdner Research Funds, Raine Medical Research Foundation and the Cancer Council of Western Australia.

Curr Opin Pulm Med. 2011;17(4):247-254. © 2011 Lippincott Williams & Wilkins

We’ll be talking about each of these concepts/ treatments in turn in future posts with related research, and published literature.  However, it is immediately apparent in reviewing this work that the authors selectively chose their references to reflect their pre-existing viewpoints – and that much of data on which their conclusions are based is considerable outdated.  While we respectfully appreciate the historical perspectives inherent in thoracic surgery – this type of ‘data culling’ is a deceptive practice.

Lung Resection in the Elderly – the Harvard/ Keating experience

a new article published in Cancer, and summarized at Medscape talks about the importance of Lung Resection for long-term survival in Lung Cancer.

Re-posting an article on the benefits of early surgical intervention on elderly patients with early stage lung cancers from This is a nice article summarizing the research study conducted by Dr. Nancy Keating at Harvard Medical School in Boston, MA.  A link to the original research abstract is here, but no free full-text available.

This article that highlights the importance of surgery – even for patients that primary care physicians and others may not immediately think of as great surgical candidates (frail elderly, COPD, other illnesses.)

Unfortunately, they didn’t address WHO was doing the surgeries – was it thoracic surgeons in high resection geographic areas (on the higher risk patients) as is often the case?  Were surgeries in the areas with lower resection rates more likely to be done by general surgeons who are less experienced in operating on more frail thoracic patients?  [all thoracic patients are frail to some decrease given the nature of the condition – so specialty trained thoracic surgeons are usually much more experienced in caring for these patients].  It would have been nice to know.

Surgery Rates tied to Lung Cancer Outcomes in the Elderly

David Douglas (Medscape)

NEW YORK (Reuters Health) Aug 24 – People with early non-small cell lung cancer (NSCLC) live longer if they’re in regions of the U.S. where doctors perform more surgeries for that indication, according to a new study.

The link between higher surgery rates and better survival held true even for frailer patients.

“We found that areas with high rates of surgery tended to operate on older and sicker patients, yet still had better outcomes for early-stage lung cancer than areas with lower use of surgery,” said senior investigator Dr. Nancy L. Keating in an email to Reuters Health.

“These data suggest that areas with lower surgery rates may benefit from higher rates of surgery,” she said.

Dr. Keating, from Harvard Medical School in Boston, said, “Resection has by far the highest chance of cure.”

But, she noted, “It may be that fear of harm (surgeons being concerned about causing poor outcomes) may be leading to relative underuse of this effective treatment.”

“While there are some patients for whom the risks certainly outweigh the benefits,” she added, “those patients may be fewer than some physicians recognize.”

Dr. Keating and colleagues studied a population-based cohort of more than 17,000 Medicare beneficiaries at least 66 years old who were diagnosed with stage I or II NSCLC during 2001 to 2005.

Using Surveillance, Epidemiology, and End Results (SEER) data, they compared areas with high and low rates of curative surgery for early stage lung cancer.

Fewer than 63% of patients had operations in low-surgery areas, whereas more than 79% did in high-surgery areas, according to a July 28th online paper in Cancer.

The high-surgery areas saw more operations on older patients and in those with chronic obstructive pulmonary disease (COPD).

The one-year lung-cancer-specific mortality rate was 12% in the high-surgery regions and 17% in low-surgery. The adjusted odds ratio for each 10% increase in the surgery rate was 0.86. There were similar findings for all-cause mortality.

Original article reference information:

Cancer. 2011 Jul 28. doi: 10.1002/cncr.26363. [Epub ahead of print]. Improved outcomes associated with higher surgery rates for older patients with early stage nonsmall cell lung cancer.  Gray SW, Landrum MB, Lamont EB, McNeil BJ, Jaklitsch MT, Keating NL.

New Regional Thoracic Surgery Center: Ontario, Canada

Creation of a new ‘regional thoracic surgery center’ in Hamilton, Ontario highlights some of the issues we’ve talked about here before: high volume centers, optimizing outcomes, decreasing wait times, and quality/ consistency of care.

The new agreement to create a ‘regional thoracic surgery center’ in the Hamilton area of Ontario, Canada highlights some of the things we’ve been talking about here at Cirugia de such as the importance of having thoracic surgery performed by thoracic surgeons, and improved outcomes with more complex cases (esophagectomy, pneumonectomy) being performed at high volume centers.

Since this center is in Canada – it is also important to note that this change will decrease waiting times (initial presentation to treatment) for patients.  For people unfamiliar with socialized medicine – these waiting periods can be significant.  The article phrases this differently, stating time of initial presentation to diagnosis – which can have a different meaning – (or if the diagnosis is made from surgical tissue, essentially the same.)  However, that time was 95 DAYS (or over three months) and has now been reduced to 35 days.

In other Thoracic Surgery news – I am currently researching articles on high-altitude lung surgery, so there may be a gap in between postings as I continue to review the existing data.

Latest research findings: Mesothelioma

new research results from the University of Pennsylvania on the treatment of pleural mesothelioma.

The University of Pennsylvania reports the latest results of a small study involving 28 patients with pleural mesothelioma.

This limited study compared combination treatment using photodynamic therapy along with a lesser lung surgery (14 patients) in comparison to extrapleural pneumonectomy alone (14 patients).  22 of the 28 patients also received chemotherapy.

Patient population: 28 patients – 12 /14 patients in either group with advanced (stage III/IV ) disease

Results:  Extrapleural pneumonectomy group had a median survival of 8.9 months.  The combination photodynamic/ surgery group median survival exceeded two years (when the study ended).

Take away message for readers:  It’s too early, and the study groups are far too small for us to generalize these findings.  However, these preliminary results are encouraging and should prompt more, larger scale studies / trials looking at photodynamic therapy as adjuvant therapy along with thoracic surgery for pleural mesothelioma.


Update: 06/15/2011:

the mesothelioma study from PA just got picked up by a major wire service, so expect to read and hear a lot more about it.

Update: 08/15/2014: has asked that I link with their site.  They offer some informational services for people facing mesothelioma.  Please let me know if this site is spam-plagued or otherwise dubious and I will remove the link (the site is a bit ‘shiny’ and circular for my taste.)

Only TIME will tell: Esophagectomy

There is a new trial on the horizon that sounds promising; the Traditional Invasive versus Minimally Invasive Esophagectomy (TIME). It’s a timely study indeed as the rates of esophageal cancer in western countries continues to increase, due to GERD and obesity.

I really don’t like the ‘cutesy’ way research trials have been named for the last ten years or so – but in this case – I will just have to look past it.  There is a new trial on the horizon that sounds promising; the Traditional Invasive versus Minimally Invasive Esophagectomy (TIME) trial based in the Netherlands.  It is a multi-center trial taking place at six hospitals in Europe.  This trial will compare both morbidity and mortality in patients undergoing traditional esophagectomy (Ivor Lewis) and patients undergoing minimally – invasive (thoracoscopy combined with laparoscopy) after both sets of patients receive adjuvant chemotherapy.  (This approach differs from the transhiatal esophagectomy developed at the University of Michigan in the 1970’s).

The researchers are planning for a five-year follow-up to compare both immediate post-operative complications / mortality with long-term effects (QoL) and cancer recurrence.

The full article is detailed on Medscape. (Also published in BMC Surgery. 2011;11 ).   This couldn’t come at a more appropriate time, with recent data showing an abrupt rise in the incidence of esophageal cancer.

In an article (Chustecka) dated from September 2010, British researchers at Cancer Research UK reported a 50% increase in diagnoses of esophageal cancer in the last 25 years, particularly in men in their 50’s. (with an incidence of 14.4 men per 100,000, to put it into perspective, up from 9.9 in 1983.)

More concerning, is the fact that the prevalence of the types of cancer are changing.  Previously, the majority of esophageal cancers were caused by squamous cell carcinoma which is linked to smoking and alcohol use.  This study, along with an American study, shows an increasing incidence of adenocarcinoma, which is more commonly attributable to gastroesophageal reflux (Barrett’s esophagus). Researchers  (Dr. Mark Orringer) estimate that the incidence of adenocarcinoma of the esophagus has increased by 350% in the last thirty years – and is directly related to huge increases in obesity.  It now accounts for over 85% of esophageal cancers in the USA.

We’ll bring you more as the trial continues, and preliminary results are reported.

(Dr. Mark Orringer, who was quoted in the original medscape article from 2007 is one of several pioneering surgeons in thoracic surgery.  He invented two of the surgical techniques in use today; the aforementioned transhiatal esophagectomy and the Collis -Nissen hiatal hernia repair.)

Lung cancer patients die awaiting surgery

the health care crisis hits home: prolonged waiting times for patients with lung cancer results in the deaths of several patients in Canada – and this scenario is projected to be repeated in the USA and Europe due to surgeon shortages and limited access to health care.

In disturbing news from Canada, as reported by the Vancouver Sun in April 2011, as part of an ongoing court case, an estimated 250 lung cancer patients died awaiting surgery due to prolonged wait times. In this case, the thoracic surgeon, Dr. Ciaran McNamee had previously complained to hospital administrators at Capital Health in Alberta, Canada about the prolonged waiting times patients were experiencing due to insufficient operating room facilities. For his patient advocacy efforts, Dr. McNamee was fired, and slandered as experiencing ‘mental health issues.’ Dr. NcNamee also alleges that other doctors who complained about the problem were also punished or paid off to keep silent about the problem while their patients suffered.

While in this case, the prolonged wait times were caused by insufficient operating room facilities, in the future the problem may be more directly related to the lack of thoracic surgeons themselves.

May 13, 2011

I admire Dr. McNamee for his convictions and patient advocacy in the face of serious repercussions.  I wrote to him at Brigham Womens & Childrens Hospital in Boston, where he is now a professor of surgery as part of the thoracic surgery program to extend an invitation to submit a guest post.  (He specializes in esophagectomies along with VATS which are two subjects we always like to hear more about here at cirugia de torax.)

October 30, 2011 – the Calgary Herald updated this story among controversy over the original comments by Dr. McNamee and his successor, Dr. Tim Winton.

March 2, 2012 – The Vancouver Sun reports that the Canadian politicians continue to argue over the issue but do very little to address these allegations and the shortage of health care services affecting Alberta residents.

Robotic Thoracic Surgery

today, we are looking at the research and case reports related to the use of the Divinci robot for robot-assisted thoracic surgery..

I’m not sure if this should be filed under the Future of Thoracic Surgery – or news, since it won’t be long before more surgeons are performing their surgeries using the DiVinci robot.

I’ve already met a surgeon here in Bogota who has been training to start performing his lung surgeries using this technology.

It’s still a pretty new application of this robot – though reports go back to 2000, but it’s been slow to catch on in this specialty. The Divinci, which has been used for several years; in urology, gynecology and cardiac surgery is an expensive, large, unweldly machine so it takes consider time, and expense to get the necessary training and skills to use it appropriately.
However, one of the surgeons I know in Fresno, at the Stanford Cardiothoracic Surgery Clinic, Dr. Randy Bolton, has been using it for his cardiac cases for years..

So, today, we are looking at the research and case reports related to the use of the Divinci robot for robot-assisted thoracic surgery..

Robotic surgery for mediastinal tumors – Japan: a review of six cases including tomography, diagrams of staff positioning, and a discussion of port placement, as well as some of the problems they encountered (a lack of speciaized instruments).

The University of Illinois experience: 32 cases from 2001 – 2009 ; this study highlights some of the problems implementing new technologies – there is a significant learning curve, and it slows you down.. (The average operating time was 209 minutes). There are some color photos, so caution to the squeamish.

There are three articles pending publication on the use of robotic surgery for thoracic cases – one by Melfi, Vita, Divini and Mussi (European J Cardiothoracic Surgery)
and another, discussing 2 cases of pneumonectomy by robot by Spaggiari and Galetta that sound pretty intriguing.

I’ll see if I can update the article when the articles are more widely available.