Free face masks for cancer patients

Thoracics.org has received a request from a U.S. based law firm that specializes in Environmental Law (asbestos, toxic exposures, and other medical harm). They are offering free face masks for all of our American readers with cancer, or caring for loved ones with cancer, during the Covid-19 pandemic.

The Environmental Litigation Group (ELG) is based in Birmingham, Alabama.

While we appreciate their generous offer to our readers, this is not an endorsement of their services (which we have no way of evaluating.) Thoracics.org receives no additional financial or other support from this company.

However, on behalf of patients everywhere, we say Thank you.

Link for face masks

Ten years of Thoracics.org

It’s our ten year anniversary of thoracics.org! It’s an amazing milestone for us.

Ten years of interviews, case reports and the latest research and developments in thoracic surgery.. Ten years of trying to connect patients with the information they need – ten years of sharing information from around the globe.

We have worked very hard to remove many of the barriers that hinder the widespread reporting of new developments; whether due to language barriers or a long-standing western bias in publishing.

We have also tried to put the human faces on this work, work that is done by individuals, and people around the world, for the purpose of helping others. We need to know the names and faces of our heroes. We need to know about the long hours, all-night surgeries, skipped meals, lost times with families and all the other personal sacrifices that these people undertake willingly, on a daily basis.

While we have been quiet for the last several months, during the Covid-19 pandemic, that doesn’t mean that thoracic surgery has. Surgeons around the world, have continued to operate, take care of patients, conduct research and advance the field, in the midst of one of the worst global pandemic in modern times.

So we will be highlighting some of this work in the coming days. We will also pay homage to the brave healthcare workers and surgeons during this pandemic.

HITHOC: the Indian experience

This 2019 article from the Indian Journal of Surgical Oncology covers a very tiny group of patients undergoing HITHOC during an 8 1/2 year period has serious limitations (with a total of only seven patients having HITHOC) but it’s still worth a few minutes of our readers time, particularly if the reader’s interest in HITHOC hasn’t translated into practice yet.

Patel et. al.  do a very nice job of describing their inclusion criteria, as well as the surgical techniques utilized in this study, where patients underwent either pleurectomy/ decortication (P/D) or extrapleural pneumonectomy (EPP) with/ without HITHOC.

In fact, it’s one of the better overviews of the procedure that’s been published in recent years.  This praise must be tempered by the fact that HITHOC is paired with two very high morbidity/ mortality procedures in this study.  P/D and EPP alone are difficult-to-tolerate procedures, and for that reason, are limited to a small subset of eligible patients.  Multiple studies by the leaders in the area of HITHOC such as Reid, Isik etc.  have already demonstrated that HITHOC can be effective without EPP.

For readers, there are some other serious limitations in their study.  Despite having a tiny sample size, the HITHOC and non-HITHOC groups are not comparable.  It is figuratively; apples to oranges.  

The non-HITHOC group was primarily made up of pleural mesothelioma patients, and based on that diagnosis alone – would have been expected to do worse post-operatively.  Yet, we don’t know if they did (do worse or not).

One of the reasons that we don’t know if the pleural mesothelioma patients outlived the HITHOC treatment group is that measurements were discordant as well.  The authors talk about 24 month and 36 month survival in the non-HITHOC group, but apparently, didn’t even follow the HITHOC group after 9 months. (Or chose not to present their data after nine months, which is, worse. )

The authors do acknowledge this, in their discussion, but also point out that two of the HITHOC patients (one a 40 year old female*) had extensive, infiltrating disease processes and poor pre-operative functional statuses.

It’s an interesting read for the most part, but it begs for follow-up so we will reach out to Patel etl. al. and update readers with any response.

Reference article

Patel MD, Damodaran D, Rangole A, et al. (2019). Hyperthermic Intrathoracic Chemotherapy (HITHOC) for Pleural Malignancies-Experience from Indian CentersIndian J Surg Oncol. 2019;10(Suppl 1):91–98. doi:10.1007/s13193-018-0859-y  [link to free full text].

*There are two charts that nicely display all the characteristics of patients in both groups. Interestingly, in this HITHOC group, both of the female patients presented with more advanced disease many, many months after initial diagnosis.  The 40F patient is clearly a last ditch ‘salvage’ patient, so her six month survival time after surgery would be better measured against more palliative procedures.

New year, New Opportunities

live case
Attendees at a recent conference watching live surgery

Welcome to 2020! 

Update! 4/8/2020: Editor’s note:

– 2020 is cancelled… well, maybe 2020 isn’t but it certainly feels like it with a large part of the world on lockdown as we fight this pandemic.  So – roll forward to 2021 for conferences..and stay safe everyone!

In answer to some of the most frequent inquiries on thoracics.org, we have compiled a list of this year’s recommended thoracic surgery conferences.

Recommendations are based on multiple factors:

Timely content and topics (let’s not rehash the indications for  3 port VATS anymore, it’s not a novel technique)

Utility of content (is it practice-changing information?  Is there a hands-on skills lab? Is it relevant?  Or is half the conference a group of pulmonologists showing off their toys and talking about making inappropriate referrals for SBAR?)

International content/ International participation – Is there a good mix of speakers?  Where are they from?  Are the experts actually the experts in that area?  Or is it just a bunch of North Americans talking to hear themselves talk?  What about audience participation?  

What about the topics themselves?  Do they represent a variety of practice settings and conditions?  Is there any discussion of relevant regional diseases or conditions (like XDR/ MDR TB cases and other regionally-based thoracic diseases)

DSC_0042
Same old speakers on the thoracic surgery circuit? Or someone with something new to say?

Thoracics.org recommends:  (in date order)

March 5th – 7th, 2020  – 4th Vienna -ESTS Laryngotracheal course  in Vienna, Austria.  The course includes a cadaver lab to practice hands-on skills.  The full program is here, and includes a wide range of topics in laryngeal surgery, as well as presentation of data from several large centers.

April 6th – April 8th, 2020 –  2nd ESTS-ERS Collaborative Course on Thoracic Oncology: Pleura, Mediastinum, Rare Tumours in Hamburg, Germany.  Click here for full program.  (The website is clunky, so the links are set up to take readers directly to registration and program information).

November 13th – November 14th, 2020 – STS/ EACTS/ ESTS Latin American Thoracic Surgery– Rio de Janiero, Brazil.  There isn’t a lot of information published yet on this year’s conference, but STS has made a huge effort in the last few years to push this conference and be more inclusive of Latin America, so it’s probably worth a go.  (note: thoracics.org staff has attended the Latin American cardiac surgery conference in the past).

VATS International is always on the recommended list – once we have final date and program information, we will add it here.

 

Treating Empyema:  Changing the algorithm for better patient care

This fear of thoracotomies dwarfs the very real risks of prolonged illness and debility.  

The story of empyema is as old as surgery itself.  Hippocrates himself describes treating empyema with chest tube placement.  However, over the years – the urge to treat this condition with the expediency and urgency it requires, has waned.  With the advent of antibiotics came the idea of a “wait and see” philosophy.  When the alternative was a thoracotomy, this could be forgiven.  In the age of uniportal VATS, it is not.

Current treatment algorithm (with basic variations)

Patient w/ parapneumonic  effusion/ empyema –> antibiotics –> still sick –> more antibiotics –> still sick –> chest tube (or pigtail placement)  –> fibrinolytics then —-> If treatment fails, consult thoracic surgery

The current treatment algorithm, which often starts as several weeks of outpatient antibiotics, (usually initiated for treatment of community acquired pneumonia that develops into a parapneumonic effusion), that engenders an even longer period after subsequent follow up chest x-rays, then CT scan fail to show improvement.

A pneumonia in late September, becomes an effusion in October, then progresses to empyema as various strategies are attempted and fail.  One antibiotic is switched to another, a pigtail is placed in radiology (with partial results), then perhaps, a larger tube, and fibrinolytics.  Then, only then – is the thoracic surgery service consulted.

At this point, the patient has been sick for several days to weeks.   As they remain sick, there is a decline in both nutritional and functional status.  The “spry” and youthful 75-year-old becomes a mostly bedridden and frail elderly patient.  This too, works against the patient and their recovery, as internal medicine physicians and pulmonologists are reluctant to refer this now frail patient due to the perceived rigors of surgery.  This fear of thoracotomies dwarfs the very real risks of prolonged illness and debility.  

For most modern-day practices, thoracotomies for decortication are a thing of the past.  Minimally invasive surgeries such as VATS or uniportal VATS have replaced the large incisions of the 1980’s and reduced, if not eliminated, the incidence of morbidity and mortality related to this procedure.  But our treatment algorithms haven’t kept up with surgical advances.

Proposed treatment algorithm:

Patient sick –> CT scan showing effusion –> thoracic surgery consultation with uniportal VATS for any effusion/empyema

Uniport VATS, (which is basically a glorified tube thoracostomy with anesthesia and a camera) allows for more than drainage of fluid from the pleural cavity. It also allows visualization, for better evacuation of infected material.  Surgeons are able to target areas of loculation; and complete a full decortication, if necessary.   While the use of anesthesia may add a degree of risk for the frailest of patients, it is the anesthetic/ and analgesic effects that allow for optimal patient positioning, and instrument manipulation, allowing for better results that bedside tube thoracostomy alone.

Why then, are we, the thoracic surgery service still only receiving consultations at the 23rd hour?  Why isn’t the literature pushing for a change in perspective, or a change in practice?

Current literature on empyema

Chin, Redden, Hsu and Driel (2017, 2013) published a Cochrane review of multiple randomized control trials comparing outcomes for tube thoracostomy versus VATS.  However, this review, which found in favor of VATS, was primarily based on pediatric studies.

Notably, this Cochrane review (which did not include uniportal VATS), showed decreased mortality and length of stay in the thoracotomy and multi-port VATS groups compared with the tube thoracostomy group.

Another Cochrane study, Cootes et al. (2009), which also demonstrated a decreased length of stay, and decreased duration of chest tube placement with VATS) was withdrawn due to questions about inclusion criteria.

The remainder of the existing studies

The remainder of studies published since the Cochrane database review had similar limitations.  A German study published in 2017 (Segerer et al.) that reviewed 645 children throughout the country that presented with empyema and showed no different in the length of stay.  But only 7% of these children underwent surgical procedures compared to 46.9% that underwent lesser procedures (thoracentesis or chest tube placement).

A more recently published study, Tanbrawarsin et al. (2018) showed a decreased incidence in recurrent bacterial empyema in patients who underwent surgery, but it is difficult to apply these findings to our algorithm, since it was based on just 34 patients, and was not randomized.  Furthermore, all advanced empyema patients received open thoracotomies.  Some patients also underwent thoracoplasties, which is a procedure not commonly used in many parts of the world, including the North America.

Patients deserve better

While the published data appears to remain undecided on the algorithm, it is clear, our patients deserve better.  They deserve an approach that is timely, and effective.  There is significant data that demonstrates that early surgical intervention improves outcomes.  But unless thoracic surgeons present an overwhelming mountain of evidence [at pulmonary and internal medicine conferences] that uniportal VATS is superior to lesser therapies, patients with empyemas will continue to receive lesser therapies, first, before we receive the thoracic surgery consult.

They deserve the opportunity to rapidly return to health and full function.  For that, we need to commit to performing and reporting more research aimed at looking at the most effective treatment for empyema.  We, in thoracic surgery, know that that the answer is not more of the same; increasingly ineffective antibiotic regimens and a long convalesce.  Now, we have to prove it, and publish it, over and over, to get past the persistent belief that risk of surgery outweighs the risk of continued illness.

Now, we need to conduct and publish studies, and reviews that compare nonsurgical treatment with uniportal VATS (excluding the dread thoracotomy) and looking for meaningful end points beyond mortality.  Studies need to look at the length of stay, chest tube duration, morbidities related to either treatment (deconditioning, blood transfusions, DVT, malnutrition, etc. ) as well as both the 30-day recurrence and re-admission rate.

Surgeons, this is your call to action.

 

References (with links to full text articles when possible)

Cootes et. al. (2009) Surgical versus nonsurgical management of empyema.  Cochrane database.  Paper withdrawn.

Redden, Chin, & Van Driel (2013, 2017).  Surgical versus nonsurgical management of empyema.  Cochrane database.

Segerer, et al. (2017).  Therapy of 645 children with parapneumonic effusion and empyema – a German nationwide surveillance study.  Pediatric Pulmonol 2017 Apr, 52 (4): 540-547.

Shresthra et. al. (2011).  Evolving experience in the management of empyema thoracis.  KUMJ 2011 Jan-Mar 9 (33) 5-7.   In this study, 82% of patients treated with tube thoracostomy eventually needed thoracotomy.  Full text link not available.

Tanbrawasin, A. et al. (2018).  Factors associated with recurrent bacterial empyema thoracis.  Asian J. Surg 2018 Jul, 41(4) 313-320.

There are multiple studies showing early surgical intervention improves outcomes in empyema, but only a single selection was placed within the editorial above.

Troubleshooting at the 6th Uniportal VATS course in Potsdam

Potsdam, Germany

potsdam2.jpg

Many of the modern masters of thoracic surgery were in Potsdam, Germany this June to discuss a myriad of topics in this year’s course until the heading of Troubleshooting.  The lecturers included Dr. Diego Gonzalez Rivas, the inventor of the uniportal VATS technique, Dr. Alan Sihoe, a renown expert from Hong Kong, Dr. Timothy Yang from Shanghai Pulmonary Hospital, Dr. Marco Scarci, the creator of International VATS, and our host, Dr. Mahmoud Ismail.  The course included both wet and dry labs so that surgeons unfamiliar with these techniques had an opportunity to apply what they learned during this and other sessions.

Standout presentations

Transcervical Uniportal VATS

Noted surgeon, and acknowledged expert in the area of transcervical VATS, Dr. Zielinski of Poland also gave a presentation on the transcervical uniportal approach, which is performed in the anterior cervical (neck) area.   Using this collar incision, Dr. Zielinski is able to perform uniportal VATS for thymectomies and mediastinal operations as well as some lobectomies (generally upper lobes) and lung resections.

Dr. Zielinski talked about the challenges for this technique as well as the indications/ contraindications and potential complications while presenting data on his latest series of 32 patients. He gave surgical tips and tricks for using the transcervical approach, and how to avoid the most common complications.

There was a full session on setting up a uniportal VATS program with multiple speakers – along with troubleshooting the most common mistakes that surgeons (and their staff and administrators) make while starting a new uniportal VATS.  They also talked about addressing the learning curve and ways to avoid common mistakes that occur during this period.

Common Complications after uVATS

Dr. Stefano Margaritora talked about how to prevent, detect and treat common complications after uniportal VATS.  Drawing on his experience with over 1250 uniportal cases, Dr. Margaritora discussed the most common causes of bleeding such as dislodgement of vascular clips, bronchial artery bleeding, bleeding from lymph node harvesting sites and bleeding from the chest wall.  He discussed the best ways to address this, such as use of newer anti-sliding clips, and the use of energy devices (like harmonic scalpels) for vessel sealing.

margaritora

The ways to anticipate and prevent prolonged airleaks was also reviewed.  Using anatomic fissures often lessens the incidence of airleaks post-operatively.  The prevention of subcuatneous emphysema, as well as the relatively rare complication of lung hernia was addressed.  Both of these complications can be reduced by meticulous and tight closure of the fascia at the conclusion of this procedure.

Using a serratus/ intercostal nerve block during this procedure is recommended to help reduce post-operative pain.

Dr. Firas Abu Ar spoke at several sessions – on both the use of uniportal VATS in pediatric patients as well as a case presentation on hydatid cysts.  (Thoracics.org is planning to present this case study at a later date).

Hydatid cyst
Hydatid cyst (photo provided by Dr. Firas Abu Akar)

There was a session on robotic VATs but with the exception of a discussion of preliminary trials of a robotic instrument that allows for uniportal VATS, most of the information has been presented on previous occasions.

The state of evidence for Uniportal VATS

Dr. Alan Sihoe gave an excellent presentation on the need more more randomized studies, and higher level evidence.  “The time for case presentations on uniportal VATS is over.”  As the leading academic researcher at this conference (as well as an active, practicing uniportal surgeon), and editor of multiple journals, Dr. Sihoe reminded attendees that as uniportal vats use continues to grow, and becomes a more common procedure, the types of articles surrounding the procedure need to advance as well.  It’s no longer sufficient to submit papers like case reports where the purpose of the paper is to explain the procedure, and basically say, “look at this cool case I did.”  Surgeons need to move beyond these sophomoric writings to produce high quality, high value papers that add to the body of scientific literature around uniportal VATS.  He then gave the audience specific, helpful guidelines and advice on designing, writing and submitting articles for publication.

live case
Attending watching the first of two live cases

After the didactic portion was completed, there were two live cases streamed from the local hospital for surgeons to review along with the dry and wet labs.

ebus
a Mexican surgeon using one of the newest tumor located/ marking systems during one of the dry labs

Note to readers:  This will be the last article on uniportal VATS training. This topic has been extensively covered thru this and other posts here at thoracics.org.  For more information on the essentials of uniportal VATS training, please review our archives under meetings and conference coverage.

Additional references

Eckland K, Gonzalez-Rivas D. (2016).  Teaching uniportal VATS in Coruña.  J Vis Surg. 2016 Mar 11;2:42. doi: 10.21037/jovs.2016.02.25. eCollection 2016.  PMID:29078470

A closer look at HITHOC in Germany

A look of HITHOC in two programs in Germany, Freiburg and Regensburg

While there are a reported 17 centers in Germany performing the HITHOC procedure, this, dear readers, is the tale of two cities.

Over the years, finding information and making contact with surgeons performing the HITHOC procedure has been a long, expensive and time-consuming affair.  Emails, interview requests and research questions frequently go unanswered.  Expensive trips abroad for in-person interviews  sometimes end up with all-too-brief meetings with disappointing results.  But illuminating, and informative interviews and in-depth discussions about HITHOC are worth the inconvenience.

After the publication of a brief English language abstract for a larger article in German that hinted at research outcomes for multiple facilities, thoracics.org reached out several times to the authors (Ried et al, 2018) for further comment.

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

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

sign
Heading south to Freiburg im Breisgau

Our journey starts just a few hours south of Frankfurt, in the picturesque city of Freiburg im Breisgau, in the Black Forest region of Germany best known for Cuckoo clocks, the Brothers Grimm fairy tales chocolate cake, and thermal spas.  Freiburg is the largest city in this region.  It’s a charming locale with a history that extends back to medieval times despite Allied bombing in a more recent century.

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

 

Frieburg is also home to a University Hospital and the Robert Koch clinic of thoracic surgery.  Dr. Bernward Passlick is the Director and head surgeon of this department.

clinic sign

Dr. Passlick is the reason thoracics.org has come to this charming but sleepy college town.  After several months of written correspondence, thoracics.org arrived in Freiburg to here more about the HITHOC program from Dr. Passlick himself.

However, from the first initial comments from the department secretary who lamented that the length of HITHOC cases was “a waste of operating room time” [because multiple other cases could be done in the time it takes to perform one HITHOC case], to the actual meeting with Dr. Passlick, nothing proceeded as expected.  Dr. Passlick was uninterested, and unwilling to discuss HITHOC.  He reported that he did approximately 15 cases a year, retains no outcomes data and has no interest in publishing any results from these cases.  However, despite the apparent lack of any documentation or statistics on HITHOC cases performed at the facility in Freiburg, he states that the ‘average’ survival is 2 to 3 years with some long-term survivors at six years or more, post-procedure.  [When asked when he had no interest in publishing data showing six year survival, Dr. Passlick had no answer.  We sat in silence for a few minutes, until I thanked him for his time and left.]

He briefly mentioned that his real interest lay in the area of treating multiple pulmonary metastasis using laser assisted resection via open thoracotomy.  The laser resection technique allows for greater lung sparing in patients with multiple (and presumably, bilateral) pulmonary metastases from other primary cancers such as advanced colon, renal or breast cancer.  He uses this technique for patients with five or more pulmonary metastasis, and reports he has operated on patients with as many as 20 to 25 metastatic pulmonary lesions.  He didn’t have any statistics on this procedure to share, but did offer that he has a paper scheduled for publication soon.  So, a bit disheartened, and thus unenlightened, it was time to leave Freiburg.

canals
the canals of Freiburg in the historic district

Leaving the Black Forest, we head east – into Bavaria with miles of rolling hills dotted with windmills, vineyards and solar panels, past Munich and then north into the area where the Danube, the Naab and the Regen rivers meet. This is Regensburg, a city that was founded by the Celts.  The Romans later built a fort here in 90 CE.  The remains of a later Roman fort are readily seen in the historic city center.

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

But as charming as the city of Regensburg is, we aren’t here for sightseeing.   Our next stop is another HITHOC program.  It’s not the biggest in Germany, not by far, but it is a very well established program that is grounded in evidence-based practice, protocols and on-going scientific inquiry and research.

We are here to interview Dr. Hans – Stefan Hofmann, the head of the thoracic surgery department at both the University hospital and the large, private Catholic hospital in town.  Dr. Hofmann along with his colleague, Dr. Michael Reid.

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Re-assuredly, the interviews were more familiar territory.  Dr. Hofmann was very friendly, and forth-coming.  Dr. Hofmann reports that their HITHOC volumes are fairly small, and attributes this to plateauing rates of pleural mesothelioma.  (The majority of the HITHOC cases were initially performed for pleural mesothelioma, but there have been an increasing number of cases treating advanced thymomas (stage IV) with HITHOC as well as limited cases of pleural carcinosis.

In some of these thymoma cases, the patient undergoes a staged procedure, with mediastinal exploration performed as the first step.  In some cases, the Regensburg facility receives patients after they have undergo mediastinal lymph node dissection at another facility.

Hofmann
Dr. Hans – Stephan Hofmann, Director of Thoracic Surgery

His program has been performing HITHOC for over ten years, using a combination of cisplatin and doxirubin with a cycle time of 60 minutes.  He reports a low rate of complications and points to the multiple publications by his colleague, Dr. Reid for outcome data.  Dr. Reid has another couple of articles in press including another paper, that explains their renal protection protocol, [in addition to Reid’s earlier work in 2013, listed below].

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

Of course, the visit wouldn’t be complete without a trip to the operating room.  While it wasn’t a HITHOC case, Dr. Hofmann was performing a robotic -assisted thoracoscopic surgery on a patient requiring lung resection for adenocarcinoma.  As the patient was already medicated when I entered the operating room – there are no operating room photos.   The case proceeded quickly, efficiently with no intra-operative complications and minimal EBL.

HofmannOR
Outside the operating room

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

We won’t talk about that a lot here – it’s not the right forum, but for readers who would like more information about Dr. Hofmann, or are interested in surgery with Dr. Hofmann (or Dr. Gonzalez Rivas, Dr. Sihoe or any of the other modern Masters of thoracic surgery), we  are happy to assist you.  Contact me at kristin@americanphysiciansnetwork.org

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

Selected citations

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

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

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

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

 

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

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

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

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

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

 

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

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

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

International VATS 2018: Better than before – Extreme Fast track thoracic surgery

Some of the videos are silly, cheesy even…  But ugly track suits aside…

The results are, in arguably, wonderful.  Patients eating, drinking, walking, and relaxing just an hour after major lung surgery.

Dr. Joao Carlos Das Neves Pereira is a Brazilian thoracic surgeon, who has been the primary author and leader on several articles, and programs for what he is calling ‘extreme fast track thoracic surgery’.   He was also one of the featured speakers at International VATS 2018.  “Better than before” is his model.  “Patient empowerment’ is his ideology.

His presentation was easily the best in show, so to speak.. What’s more remarkable about his results are – that this isn’t new.  He’s been doing it for more than a decade.  In fact, he published an article on his experience in the European Journal of cardio-thoracic surgery was back in 2009.  And now he is responsible for the implementation of a multi-disciplinary program at two hospitals on two continents – one on Paris, France and the second in Sao Paulo, Brazil.

So what does he do?  How does he do it?  And why aren’t the rest of us doing it?

What he does:  “Feed & walk”

Change the existing surgical traditions:

  • no prolonged fasting
  • no cold operating rooms
  • no IV opioids

He does this with a multifaceted program that starts several weeks before surgery; with a comprehensive nutrition, smoking cessation and and an exercise regimen.

The night before:

  • Aromatherapy with lavender / Orange to promote sleep.
  • Avoid benzodiazepines

On the morning of surgery

  • patients are able to drink liquids within two hours of surgery, preventing dehydration and eliminating the need for IV fluids (no starving!)

During surgery

  • Normothermia
  • Multi-modality approach for anxiety/ nausea/ vomiting / pain
  • Opioid-free

Patient analgesia and anesthetic is treated with a combination of approaches including hypnosis, pre-emptive oral medications, BIS for awake anesthesia, minimally invasive airways.  Patients are only given very short acting medications such as ketamine, or propofol combined with local anesthesia.  By avoiding narcotics, there is a reduction in both sedation, and GI complications post-operatively.

Patients who are able to readily wake up after surgery and who haven’t had narcotics that adversely affect bowel function) are able to eat and drink immediately after surgery.

Post-operative

  • Immediate extubation (once the specimen is out of the chest)
  • Immediate feeding
  • Immediate exercise
  • “Hands free” care:  No IV lines, oral medications only, patient controlled and opioid free.

Patients are encouraged to wear their own clothing before going to the exercise room, the outside garden or walking the halls.  Post-operative pain management consists of oral medications only, and is augmented by physical therapy, acupuncture, aromatherapy and massage.  Friends and family are instructed in the proper massage techniques so that they are able to participate in the patients care (also shortage of massage therapists).  Patient recovery is enhanced by conviviality: patients don’t spend time in the rooms, alone or in bed.  Patients are welcome to spend time in open spaces, aromatherapy areas, exercise rooms, a japanese style garden, an indoor garden and a tea room.  Patients are encouraged to socialize and spend time with other patients.

While some of these ideas are novel, there is no magic surgical technique, and no miracle drug to account for these results – which are arguably better the most of ours.  But it’s not just aromatherapy, it’s a philosophy of care.

More importantly, what Dr. Das Neves Pereira and his colleagues have; that many of us find difficult to replicate – is patient buy-in.   We can call it “Patient empowerment” but it’s the part that many of us continue to struggle with.

But Dr. Das Neves Pereira’s lecture leaves us with more questions as well as answers..

Would this work for your practice?  And why aren’t the rest of us already doing it?  Will the patients accept it?

For the answer to this – we have to look at our own practices, in the here and now, in late 2018.    A recent issue of the thoracic journal of disease did just that, devoting an entire issue to ERAS (enhanced recovery and fast track programs) while providing blueprints for anesthesiologists, nursing and physical therapists.  But for many of us, the pat and simple answer is something like this:

“While most of my patients wouldn’t mind some aromatherapy or a massage after surgery, the unfortunate truth is that few would participate in a pre-operative program stressing diet and exercise.  Even fewer patients would sign on for a program that restricts narcotics.  Many of us already know this about our patient populations because we try routinely to incorporate more holistic practices into our treatment in a daily basis.  While holistic premises and alternative treatments make billions of dollars in the United States (under the guise of prevention) it’s still a culture that is highly dependent on fast, and immediate remedies and a strong belief that very little post-operative pain is acceptable or tolerable.  For every one patient that would embrace the philosophies of extreme rehabilitation, there would be another 200 screaming at the nurses for IV dilaudid.”

Much of the research actually confirms this view:

British researchers, Rogers et al. (2018) had a similar experience, noting in their recent publication that benefits of enhanced recovery protocols were dependent on compliance (and adherence) to protocols – particularly in regards to pre-operative dietary modification, and early post-operative ambulation.  Refai et al. (2018) have attempted to address these issues with a comprehensive patient education component. However, their publication does not address whether these interventions increased compliance and reduced patient stress or anxiety.

Does this mean that we are skeptical of extreme rehabno, not at all!  Interest, participation and development in fast track thoracic surgery programs continues to grow despite these obstacles.

In fact, the tightening of many federal and state restrictions on narcotics due to the American opioid crisis may make this the best time in modern American medical history to bring this ideas and approaches to our patients (Bruera & Del Fabbio, 2018, Herzid, 2018).   It also means that many of us have some preliminary hurdles and preconceived notions  (on all sides)  to overcome to engage our patients, nurses, therapists and fellow medical professionals to get their buy-in on the idea.  We might be over a decade behind – but it’s not too late to start today.

References:

Das-Neves-Pereira, et al. 2009).  Fast track rehabilitation for lung cancer lobectomy: a five year experience.  European Journal of Cardio-thoracic surgery, 36 (2009) 838-392. primary reference article.

Additional references:

Bruera, E. & Del Fabbio, E. (2018). Pain management in the era of the opioid crisis.  Am Soc Clin Oncol Educ Book 2018 May 23 (38): 807-812.

D’Andrilli, A. & Rendina, E. (2018). Enhanced recovery after surgery and fast-track in video-assisted thoracic surgery lobectomy: preoperative optimisation and care-plans.  Journal of visualized surgery, 2018:4 (4).

Herzid, S. (2018). Annals for hospitalists Inpatient Notes: Managing acute pain in the hospital in the face of the opioid crisis.  Annals of internal medicine 169(6): H02-H03.

Rogers, et. al (2018).  The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer.  Journal of thoracic and cardiovascular surgery.  155(4) April 2018: 1843 -1852.

European Society of Anaesthesiology. “Hypnosis/local anesthesia combination during surgery helps patients, reduces hospital stays, study finds.” ScienceDaily. ScienceDaily, 21 June 2011.

From the Journal of thoracic disease – special issue:  Supplemental issue #4 2018

Ardo et. al. (2018). Enhanced recovery pathways in thoracic surgery.

Bertani et al. (2018). A comprehensive protocol for physiokinesis therapy and enhanced recovery after surgery in patients undergoing video assisted thoracoscopic surgery: lobectomy.

Picconi, et. al. (2018). Enhanced recovery pathways in thoracic surgery from Italian VATS group: perioperative analgesic protocols. 

Refai et. al. (2018). Enhanced recovery after thoracic surgery: patient information and care-plans.

At VATS International 2017

Royal College of Physicians –

London, UK

Friday, October 20, 2017

While around 100 thoracic surgeons are gathered here this morning for the start of the 4th VATS International conference, there are another 500 viewers watching Dr. Eric Lim (UK) deliver his opening remarks on a live stream video feed on CTSnet.org.

Dr. Lim, who is one of the dynamic young thoracic surgeons leading the charge into minimally invasive thoracic surgery (MITS) reviews the state of the current evidence VATS and other MITS techniques, and the role of research in advancing thoracic surgery.  Today’s lecture is delivered in a more measured, and calculated manner  in comparison to his more fiery orations in the past – but the message remains the same: Surgeons need to remain engaged and participate in the research because if we don’t, and if we continue to stay in the operating room while other specialties define the outcomes, than we (and our patients) will continue to be short-changed by competing specialties.

0900 – 2017-10 Current and future research topics – Lim (International VATS symposium)

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Dr. Eric Lim on the future of thoracic surgery

While the conference started off with a call to research – once the topic of robotic -assisted thoracic surgery (RATS) was introduced, it wasn’t long before there was a quick shot across the bow.

Dr. Piergiorgio Solli (Italy) was delivering a well-thought out review of the current literature of RATS with the question: Why are they using robotics (despite a lack of evidence?)

0940 – Piergiorgio Solli VATS versus RATS

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Dr. Piergiogio Solli talks about the widespread use of robotic assisted surgery despite a lack of evidence to support its use.

He was cut short in his review by the American surgeon, Dr. Robert Cerfolio.  Dr. Cerfolio, the ‘Gordon Gekko’ of thoracic surgery, and world-reknown RATS surgeon took that moment to issue a challenge to the podium, “and how many robotic surgeries have you done?”   He then continued to defend the use of RATS stating that using RATS was like buying expensive luxury items (tailored suits, custom shoes, first -class airline tickets, etc.) by stating, “It costs more money because it’s good”

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Dr. Robert Cerfolio

That was all that it took for Dr. Lim to enter back into the fray, asking ,”Is it one million [dollars] good?” (referring to the excessive start up and operating costs).

Cerfolio:   “It costs more because it’s better” stated the self-proclaimed surgeon of the industry.  “You don’t know it’s better because you haven’t done enough.”

The gloves are off my friends.  Welcome to the 4th session of VATS International.vats_2017_logo

Guest post: Dr. Migliore and the IV Mediterranean Symposium on Thoracic Oncology

Dr. Marcello Migliore reports on the highlights from the recent Mediterranean Symposium on Thoracic Oncology

A great success the IV Mediterranean symposium in Thoracic Oncologic surgery. One hundred and eighty participants including thoracic and general surgeons, oncologists, and medical students attended the symposium.

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IV Med Symposium in Thoracic Surgery: Speakers and the Students of the Faculty Medicine of the University of Catania

The symposium was organized to pose the basis for new research studies in advanced lung and esophageal cancer. The Rector of the University Prof Francesco Basile pointed out that the symposium is becoming a fixed international scientific appointment of the surgical thoracic community. It was noted that many research and thoracic publications which were done in Sicily in the 50ies and 60ies were only published locally or in Italy, meaning that  many of these very good publications remain unknown internationally.

From the general discussion it was noted that it is necessary to prolong survival in patients with advanced stage lung cancer to obtain a global better survival in patients with lung cancer; unfortunately still today 60-70 % of patients arrive to us with a “non surgical” cancer. Although surgery has been always not considered for stage IV lung cancer, recently, new hope is emerging.

Initially the precious value of radiology and the recent emerging role of immunology confirmed the necessity of a multidisciplinary team to treat this group of patients. New technologies such as HITHOC, the same technique which has been used for mesothelioma, could help to prolong survival in a multimodality therapy in patients with stage IV lung cancer. A recent study  involving 33 patients with advanced lung adenocarcinoma with pleural dissemination that a 6-month, 1-year and 3-year progression-free survival rates for the HITHOC group were 87.0%, 47.8% and 24.3%, while those of surgery group were 44.4%, 33.3% and 0.0%, respectively (1,2) Nevertheless, as for mesothelioma (3) it is imperative not to give false hope, but a “real” hope is mandatory only within a well design study. Surgery for N2 disease remains at the moment under investigation as there are conflictual data, but a single N2 not bulky metastasis could be an indication for surgery without neoadjuvant chemotherapy. Surgery for oligometastasis is feasible but a multidisciplinary decision is necessary, and this is essential when complex surgeries for locally advanced lung cancer is planned; long term survival depend from a well posed surgical indications, and it should not based on personal opinion (4). Advantages of the precision technique has been carefully presented by Michael Mueller from Vienna and Pierluigi Granone from Rome.

Prof Antoon Lerut from Leuven presented the tremendous experience with 3000 esophagectomies with the main conclusion that this complex surgery must be done in centralized centers where experience is present. Although minimally invasive and robotic surgery techniques are feasible by expert hands in some patients with advanced lung cancer, it is evident that randomized trials are necessary before their wider use in clinical practice. Semih Halezeroglu from Istambul presented his experience with uniportal VATS pneumonectomy, and commented that many patients with advanced lung cancer who undergo extended operation do not survive as expected, and therefore some indications should be at least revised to avoid usefulness operations. Finally, the personal feeling is that “individualized” surgery, which seems to be more human to me, for advanced lung and esophageal cancer could become more common in the next years.

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From the left to the right: Prof Luigi Santambrogio, Prof Semih Halazeroglu, Prof Marcello Migliore, Prof Antoon Lerut, Prof Michael Mueller

References

  1. Yi E, Kim D, Cho S, Kim K, Jheon S. Clinical outcomes of cytoreductive surgery combined with intrapleural perfusion of hyperthermic chemotherapy in advanced lung adenocarcinoma with pleural dissemination. Journal of Thoracic Disease. 2016;8(7):1550-1560. doi:10.21037/jtd.2016.06.04.

  2. Migliore M, Calvo D, Criscione A, et al. Cytoreductive surgery and hyperthermic intrapleural chemotherapy for malignant pleural diseases: preliminary experience. Future Oncol 2015;11:47-52. 10.2217/fon.14.256

  3. Maat APWN et al. Is the patient with mesothelioma without hope? Future Oncology 2015; 11(24s):11-14. November 2015

  4. Treasure T, Utley M, Ian Hunt I. When professional opinion is not enough. BMJ: British Medical Journal 2007; 334.7598: 831.

 

 

Now accepting submissions for the Thoracics.org VATS International Award

The first ever Thoracics.org Award to recognize innovation and achievement in thoracic surgery is now accepting submissions.

The Thoracics.org  VATS International Award

Thoracics.org is pleased to announce our first international award for innovation and achievement in thoracic surgery.  This award is designed to recognize and encourage research and publication in the area of VATS, including uniportal VATS.

This award is being offered by thoracics.org for a previously unpublished paper, study or case report on any aspect of thoracic surgery involving VATS (video-assisted thoracoscopic surgery).  Topics can include case reports on complex cases, use of VATS in specific populations or disease conditions,  unpublished research results / retrospective analyses or similar themes.

This award will be presented at the VATS International conference in London, UK on October 20 – 21, 2017.

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Award Sponsors

This year we are honored to be sponsored by VATS International and Dr. Marco Scarci.

VATS International 2017 – We’ve written about this conference in the past, so thoracics.org is very excited to be able to present the Thoracics.org award at the 2017 conference.  This year’s roster of speakers and topics includes some of our favorites, as well as introducing some timely new topics such as certification in minimally invasive thoracic surgery.

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The Thoracics.org award to be presented at VATS International 2017

Dr. Marco Scarci  – Dr. Scarci is a thoracic surgeon at the University Hospital of London and the founder of VATS International.

Rules:

Deadline: All submissions must be received by June 1, 2017 at 8 am eastern standard time.

Authorship: Papers must be the work of a sole author, and each author may only submit one entry. Entries are limited to practicing specialty thoracic surgeons, and surgeons completing their thoracic surgery fellowships. This contest is not open to general practice surgeons, or non-thoracic surgery specialties.

Originality:  All entries must consist of previously unpublished work.  Evidence of prior publication of material submitted for consideration is grounds for immediate disqualification.

Entry format: Entries consist of three (3) parts; the paper, the title page and the CV. Incomplete or partial entries may be ineligible for the award.

A.  Paper specifications:

Papers must be written in English.

Maximum length is ten pages double-spaced with a 12 point font.

All submissions should be in Microsoft Word or a similar PC compatible type document. No pdfs will be accepted.  Multi-media materials such as photographs, or short video clips may be attached to the paper for inclusion in the on-line publishing format.  Video clips should be less than 10 minutes in length.  No individually identifying information should be included in submitted photographs or videos.

B.  A separate title page should be included with the essay.

This title page should contain:

-Author’s name

-Contact information including physical address, email and telephone number

-Institutional or Academic affiliation(s)

-Name and contact information of immediate supervisor

C. (Optional) – Author photograph – as a separate attachment, labeled as first initial_lastname.

D.  A current curriculum vitae (CV) should also be submitted as part the entry package, as a separate attachment.

Send all submissions to: k.eckland@gmail.com

Publication:

All entries are submitted for publication at thoracics.org as a guest post. These posts will be published with the author of each paper to remain anonymous until the award winner has been announced. The winner of the Thoracics.org Award will be posted on thoracics.org on August 1st, 2017.

Following the announcement of the name of the recipient of the Thoracics.org Award, on-line articles will be amended to include author information, including name, affiliation, location and author photograph (if included with the original submission).

Judging:

Judging of the entries received will be done by a panel of thoracic surgeons. The names of the members of the panel will be revealed at the awards ceremony. While visitors to thoracics.org may comment on published entries, these comments will not be part of the judging criteria.

The Award:

Thoracics.org award
Thoracics.org award

The award will be presented in person at the 2017 VATS International conference in London, England.

In addition to receiving recognition within the international thoracic surgery community, the award recipient will receive*:

  • Complimentary registration to the 4th annual VATS International conference in London, UK. This course is one of the best courses on uniportal and minimally invasive thoracic surgery and includes content on uniportal vats, robotic surgery, awake and nonintubated surgery, and other minimally invasive techniques.  The lectures are given by the masters of these techniques, including the master of uniportal surgery, Dr. Diego Gonzalez. This year’s preliminary line up of speakers and topics looks like another stimulating session of minimally invasive techniques interspersed with timely discussions on current issues in VATS (Registration courtesy of VATS International).
  • A copy of the new textbook, Core topics in thoracic surgery.

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Core topics in thoracic surgery

Core Topics in Thoracic Surgery provides accessible and concise coverage of the topics most often encountered in thoracic surgery practice. This handbook will guide the reader through revision of the topics covered in the FRCS(CTh) examination, and also covers more specialist topics in detail. In-depth technical sections offer guidance for difficult procedures, with useful commentaries from leading surgeons. A broad range of thoracic surgery issues are examined, with the latest evidence and information relevant to the speciality presented in a clear fashion. Combining an easy-to-use revision guide for trainees and a comprehensive reference text for cardiothoracic surgeons and recently appointed consultants, this is a one-stop guide to thoracic surgery. Authored by leading experts in the field, this resource will be invaluable to cardiothoracic surgeons, respiratory physicians and specialist nurses seeking to refresh or expand their knowledge of this field.   (Textbook courtesy of Dr. Marco Scarci).

 

Additional sponsors include:

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ctassistlogo

*Corporate and individuals wishing to co-sponsor this award may contact k.eckland@gmail.com

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Grena Ltd. presents new vascular clips for thoracic resection

Ever had a clip slip in surgery? New vascular clips to help prevent massive hemorrhage and loss of vascular control from clip slippage.

There is a big push towards cost-saving measures in many operating rooms – by changing back from clips to suture, or using existing energy devices (such as the harmonic scalpel electrocautery device) to replace GIA staplers, clips, and other closure devices.  Despite the pressure from financial departments, vascular clips and staplers continue to be popular in thoracic resections.  For many surgeons, the idea of using a harmonic device alone for vascular control is an uncomfortable one.  (The rule of thumb for using energy devices is to avoid using these devices on any vessels with a diameter larger than one-half the length of tip of the device.)

In other cases, such as large caliber arterial vessels such as the pulmonary artery or control of acute hemorrhage, cautery devices are often contraindicated.

During the recent conference in Peru, Marc Moneaux of Grena, Ltd. gave a presentation on the newest generation of vascular clips designed to address some of the problems with the existing clips, mainly clip dislodgement.  The new clip, called with Click aV Plus clip has been endorsed by several prominent thoracic surgeons including Dr. Diego Gonzalez Rivas and Dr. Alan Sihoe.

At VATS International 2016, attendees were able to try out these new clips in the hands-on lab.

The new clips are noted for having teeth, which make these clips less prone to slippage or dislodgement.

Along with Dr. Gonzalez Rivas’ celebrity surgeon endorsement comes the Click’a V Plus Gonzalez Rivas 45′ clip appliers.

gonzales-rivas-clip-applier-big

VATS decortication for Tuberculosis

In this post, we present a new video byTurkish thoracic surgeon, Dr.Cagatav Tezel on VATS decortication for tuberculosis.

There’s a new video over at VUmedi by Turkish thoracic surgeon, Dr. Cagatay Tezel.  In this video, as well as a related article over at CTSnet, Dr. Tezel talks about modern day surgical treatment for tuberculosis related complications.  Tuberculosis, unlike measles, polio or other diseases associated with the 19th (and earlier centuries) has not faded into the past, despite the availability of a (partially effective) tuberculosis vaccine.  Tuberculosis continues to carry a heavy morbidity and mortality burden globally. In fact, for all of the news media surrounding Ebola, HIV, SARS and Bird/ swine and various flu, Tuberculosis is the real killer; and is responsible for 1.8 million deaths a year*.

Complicated multi-drug regimens and poor patient adherence have resulted in the development of new strains of resistant TB.  Decreased immune resistance in specific populations such as diabetics, or patients with HIV infection has resulted in a greater number of people with active disease.  This means, that thoracic surgery remains a critical component in the treatment of this deadly disease.

Surgical treatment of Tuberculosis and TB related complications

As long time readers know, Thoracics.org has been following the rise of multi-drug resistant (MDR-TB) and extreme/ extensive drug resistant (XDR-TB) versions of the age-old scourge of the ‘white plague‘ as well as the evolution of the surgical treatment of this disease, from the early era of thoracoplasty, as well as more modern treatment of TB related empyemas such as VATS.

In fact, the surgical treatment of tuberculosis is the foundation on which the thoracic surgery specialty emerged, out the operating theaters of TB sanitariums around the world. However, as the development and successful use of antibiotics spread from the late 40’s thru the 50’s and 60’s – surgery took a backseat to drug therapy.  The development of these drug resistant strains means that it is imperative that the thoracic surgery community continue to research, innovate and operate on patients with tuberculosis.

We welcome articles and video submissions on this topic from our colleagues around the world.

*Several statistics give the annual death toll at 2 to 3 million.We have cited the most recent WHO figures above.

Additional articles/ posts/ references

Mystery Diagnosis: Pleural Plaques

The Tuberculosis Vaccine: information about the vaccine, and who should get it (according to current CDC recommendations).

Freixinet JG1, Rivas JJ, Rodríguez De Castro F, Caminero JA, Rodriguez P, Serra M, de la Torre M, Santana N, Canalis E. (2002).  Role of surgery in pulmonary tuberculosis.  Med Sci Monit. 2002 Dec;8(12):CR782-6.

Somocurcio JG1, Sotomayor A, Shin S, Portilla S, Valcarcel M, Guerra D, Furin J. (2007).  Surgery for patients with drug-resistant tuberculosis: report of 121 cases receiving community-based treatment in Lima, Peru. Thorax 2007 May;62(5):416-21. Epub 2006 Aug 23.  A particularly interesting article, with an in-depth look at the surgical treatment outcomes in patients with MDR TB. Mortality was 5.0 % in this study.

Man MA1, Nicolau D. (2012). Surgical treatment to increase the success rate of multidrug-resistant tuberculosis.  Eur J Cardiothorac Surg. 2012 Jul;42(1):e9-12. doi: 10.1093/ejcts/ezs215. Epub 2012 Apr 24.

Park SK, Kim JH, Kang H, Cho JS, Smego RA Jr. (2009). Pulmonary resection combined with isoniazid- and rifampin-based drug therapy for patients with multidrug-resistant and extensively drug-resistant tuberculosis.   Int J Infect Dis. 2009 Mar;13(2):170-5. doi: 10.1016/j.ijid.2008.06.001. Epub 2008 Sep 2.

 

Highlights from the 3rd VATS International

If you can only attend one thoracic surgery conference, shortlist VATS International.

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Attendees with Dr. Marco Scarci (2nd from the left)

VATS International

VATS International (previously known as Cambridge VATS) is the brainchild of Mr. (Dr.) Marco Scarci.  The Italian surgeon recently made the switch from NHS Papsworth (Cambridge) to the historic Royal London Hospital.  Each year, Dr. Scarci gathers the world’s specialists on minimally invasive surgery to meet here in the United Kingdom to share knowledge and practice techniques for traditional VATS, uniportal approaches (standard and subxyphoid) and robotic surgery.

This is the third year of the conference and it’s reputation for dynamic speakers and controversy continues.  With over 100 attendees, and a wide range of global participation as well as live surgery sessions and a wet lab, Dr. Scarci has had runaway success despite some last-minute challenges posed by his recent defection from the Cambridge facility.  (Having met several members of the rather staid and traditional thoracic surgery department at Cambridge, Dr. Scarci, with his emphasis on minimally invasive surgery, is undoubtedly better-suited to the London-based facility).

Excellent lecture content, dynamic speakers

There were several excellent speakers, making it difficult to narrow the selections for presentation here.  The obvious standout was Dr. Lim, (as discussed in a previous post).

As one of the course directors, and the inventor of the uniportal approach, Dr. Diego Gonzalez Rivas gave several lectures on the technique aspects of uniportal VATS.

Dr. David Waller followed up with a lecture entitled “Intra-operative problems in VATS lobectomy: Avoidance and Management.”  He discussed complicating patient factors such extensive adhesions, anthrocotic lymph nodes,  anatomical variance and incomplete fissures that increase the complexity of uniportal cases.  He also identified common surgical problems such as difficulty identifying the target lesion, development of large air leaks and inadvertent damage to hilum or bronchus with strategies to prevent & manage these issues.  He reviewed surgical techniques on bleeding control/ major vascular injury as well as absolute indications for surgical conversion such as equipment failures, airway injuries and stapler jams.  In closure, he also warned against using conversion rate as an outcome measure.  It was a fairly dry lecture despite being an interesting and important topic.

Among the remaining speakers, the overwhelming theme of change, and evolution along with an underlying sense of defiance continued. These surgeons are here to discuss, learn and practice uniportal surgery even if more traditional surgeons don’t approve.

Some of the best presentations were:

Dr. Alan Sihoe, (Hong Kong) gave a modified lecture called “Reasons not to perform uniportal VATS lobectomy”. This lecture which was adapted from a previous lecture from last year’s conference also addressed criticism of uniportal VATS.  He reviewed the existing literature on uniportal surgery which suggests that uniportal surgery is a safe alternative to other surgical approaches.

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Dr. Alan Sihoe

 

During the lecture, Dr. Sihoe encouraged surgeons to move past case reports to performing higher level research such as randomized control studies to create evidence in the area of uniportal surgery.  He also encouraged participation in the European database, to gather prospective data on uniportal surgery.  Until there is a larger body of literature utilizing higher levels of evidence, uniportal surgery will continue to face significant (and justifiable) criticism as a fad procedure.  While it wasn’t a ground-breaking lecture by any means, it was also a reminder for thoracic surgeons to think like a researcher.  It was a good follow-up on Dr. Lim’s opening lecture.

Dr. Gaetano Rocco (Italy).

Dr. Rocco, one of the pioneers of the uniportal approach, continued the discussion of the need for evolution and adaptation but with a different approach in a talk entitled, “VATS major pulmonary resection for (very) senior surgeons.  He extended an olive branch to older, experienced thoracic surgeons with limited experience with VATS.  His lecture discussed the ways to remediate older surgeons, and build their skills and comfort level in performing VATS procedures.  His lecture offered a clear-cut and concrete , step-wise curriculum and self-assessment tool for surgeons looking to improve their VATS skills, starting with VATS lobectomy.

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Dr. Gaetano Rocco (left)

 

Dr. Ali Khan (India) delivered two lectures, the first on operating room technology, but it was the second on uniportal surgery for inflammatory and infectious diseases that really piqued my interest.  Part of this is due to my interest in the surgical treatment of tuberculosis, and my great appreciation for empyema as a surgical disease.  Most readers know that reducing the time from presentation/ diagnosis of empyema to surgical decortication is one of my goals in daily practice, so any reminder that the morbidity/ mortality of decortications have been greatly reduced by minimally invasive surgery is always welcome.

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Dr. Ali Khan

 

Honorable mention:  Dr. Alex Brunelli, “Fast track enhanced recovery for MITS”.  Basically a talk on care plans with specific markers for timely progression and discharge.  While this is standard fare for nurses, the use of care plans for many surgeons is unfamiliar territory.  It would have been nice if the care plans were available as a handout for surgeons who are still fine-tuning their own programs.  It also would have been nice for a better breakdown of how specific items reduced the length of stay (how/ how much) or decreased the rate of complications.  Nice to mention care plans but better to have measurable and specific examples.

After the extensive lecture series on the first day of the conference, the second day was devoted to live surgery cases and the practice lab.

Wet Lab 

Since animal research of any kind is tightly controlled in the United Kingdom, 3D printed models were used for the wet lab portion of the course.

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3D model of thoracic cavity

This is the first time that this type of model has been used.  While the green plastic  housing looks rudimentary, on closer inspection of the ’tissue’ inside, one gets a better appreciation for the models.  The tissue is soft, and sponge-like.  The lung doesn’t inflate but appears more lifelike than other models.

I don’t have the patience or temperament to shoot video footage, but I did record a couple of seconds so readers could have an idea what the wet lab portion of the course is like.  In the video, Dr. Sihoe is instructing two trainees on the proper technique.

 

Despite its relative youth, VATS International remains one of the best conferences on minimally invasive surgery, inferior to none.  This conference is highly recommended and considered superior to many of the traditional conferences on the topic  (such as the annual Duke conference), due to lecture content on timely topics and controversial issues.  The hands-on wet lab and participation by internationally recognized and globally diverse speakers makes this conference more valuable to attendees looking for exposure to newer surgical techniques.

Thoracics.org 2017 wish list

What would I like to see next year?  As mentioned above, VATS International is one of the better courses available for surgeons interested in uniportal, subxyphoid and other minimally invasive techniques.  But there is still more content I’d like to see –  on nonintubated and awake surgery, for example.

However, with regards for this year’s speaker, an anesthesiologist from Papsworth Hospital, this topic would be better covered by one of the “masters” of the field; Dr. Eugene Pompeo of the Awake Surgical Group or Drs. Hung & Chen.  The “Papsworth Experience” per se is limited to heavy sedation/ general anesthesia without mechanical ventilation.  Patients still have LMAs and are heavily sedated.  One of the main benefits of nonintubated anesthesia is the ability to operate on the medically fragile.  It would be enlightening to hear more about operating on this population from more experienced clinicians.  One of the topics that has been essentially ignored in the literature on this topic, is the implications for thoracic surgeons, anesthesiologists,  operating room and recovery room staff on operating on this population of sicker patients.  I think readers would like to hear about the new challenges in managing patients that were previously inoperable due to serious co-morbidities.

A discussion on developing or actualizing a formal certification process with examination for minimally invasive surgery with suggested curriculum, and case log requirements would be a nice addition.  Blackmon et al. published a credentialing guideline but it’s a multi-part overly complex document full of “levels” of competency.  I’d like to see a discussion on the development of an actual certification to be offered by a surgical licensing body or surgical society.  Since the American agencies would probably take another 20 years to consider the idea, perhaps one of the guest speakers’ native society would be more willing to take on this project?

I’d also like to see at least a limited amount of content on esophageal surgery.  I know, I know..While practice areas for thoracic surgeons vary around the globe, with the rapid rise in esophageal cancer, a lecture on the role of minimally invasive surgical techniques for esophageal surgery would be a great addition to the current roster of topics, particularly if it was given by one of the modern masters of esophageal surgery like Dr. Benny Weksler or Dr. Roy Chen.

Lastly, one of the most enjoyable aspects of this conference is the truly international flavor.  Watching a surgeon from Israel demonstrate uniportal techniques from a practice site in Shanghai brings home the importance of global collaboration.  Hearing surgeons from India, Brazil, France and Canada present data on their practices is critical to gain perspective, and exchange ideas.  It also helps prevent attendees from falling into the trap of “we’ve always done it this way.”  This concept could be expanded to include designated global snapshots, to highlight research or data in specific geographic areas, like Dr. Khan’s lecture on uniportal approaches for infectious and inflammatory disease.

A full lecture on cost containment techniques for surgeons practicing in hardship areas would be a great topic.  Dr. Sihoe touched on the issue during one of his lectures, but since I’ve heard other surgeons talk about the limitations posed by having only one thoracoscope, I’d love to see an equipment representative give a lecture on maintaining thoracoscopes, where to donate old scopes or how to rehab these scopes for a second life.  A talk about modifying existing surgical instruments for surgeons who can’t afford the Scanlan set would be helpful as well.  One of the reasons these courses have been so successful it the fact that they are technically based, so adding a section like this might help spread the uniportal technique to a whole socio-economic and geographic segment of patients that it might not otherwise reach.

This last item might be a tall order for Dr. Scarci and his group but he’s done pretty well thus far.

 

Act differently or watch thoracic surgery die

Dr. Eric Lim challenges thoracic surgeons to remain relevant with a call to action at the 3rd VATS International conference in London, England

“Act different or watch thoracic surgery die”

With that dramatic shot across the bow, the dynamic and forthright Mr. (Dr.) Eric Lim of Royal Brompton Hospital opened the third VATS International conference.   In a lecture entitled,  “The Why of advancing minimally invasive surgery,”  Dr. Lim put out a call to action to thoracic surgeons around the world, in an effort to remain relevant.

In an increasingly competitive world of thoracic oncology,  nonsurgical options like stereotactic radiotherapy, and the developing MRI proton beam therapy  are gaining traction for the treatment of early stage lung cancers.   These nonsurgical treatments are gaining publicity and popularity due to the efforts of radiation oncologists.

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The PCI of Lung Cancer Treatment

Reminding thoracic surgeons of the plight of their cardiac counterparts, Dr. Lim taunted the audience that having superior long-term outcomes does not guarantee success in a consumer-driven market.   Public and medical perception is shaped not only by clinical research findings, but by the inherent bias introduced by the authors of these publications.  As he explained, this bias, along with a public desire for simplicity, has driven the overwhelming success of percutaneous angioplasty (PCI)  and declining rates of cardiac surgery despite well-documented research studies and clear evidence demonstrating the overwhelming superiority of coronary artery bypass grafting (CABG) for long term survival.  Thoracic surgeons must not fall into the trap of complacency and arrogant belief in surgical superiority  that has plagued cardiac surgery if we want the specialty to survive.

Dr. Lim has identified three behaviors of thoracic surgeons that are harming the specialty:

  1. Refusal to look at the evidence –  thoracic surgeons must be willing to continuously review, understand and accept new clinical evidence and publications.  Evolving and emerging treatments have changed many of the cornerstones of thoracic surgery, and core concepts of 1980’s thoracic oncology management need to give way to the increasingly body of knowledge favoring VATS resections,  neo-adjuvant treatments, and improved outcomes.

An important caveat to this – is the need for Surgeon led research, and clinical trials to help eliminate the medical bias that has crept into much of the existing literature.  Surgeons need to stop allowing other specialties to control the narrative.  This is what allowed cardiologists to introduce concepts such as “non-inferiority” when research studies failed to show the benefit of cardiology interventions.

These research trials need to compare surgical interventions with non-surgical treatments.  Our inter-specialty debates over which surgical technique need to take a backseat to studies designed to compare relevant outcomes like long-term survival and cancer recurrence if we want to demonstrate surgical superiority over medical treatments.  “We need to stop arguing about which surgical technique and favor surgery over other therapies,” Dr. Lim explains.

  1. Refusal to engage with industry – industry drives and funds innovation. If we want to continue to develop wireless technologies, robotics and other innovations for use in minimally invasive surgery, thoracic surgeons must be willing to engage and participate with industry.

3.  Refusal to evolve – this is a fundamental problem plaguing thoracic surgery and addressing this issue is the underlying theme of many of the presentations at this year’s course. Dr. Lim has also addressed this refusal to evolve previously.  Surgeons need to evolve, and be willing and able to change their surgical practices based on evidence and clinical guidelines.  The failure to adopt VATS as the primary surgical approach in thoracic surgery in North America, and Europe despite decades of evidence and  clear clinical guidelines favoring this approach is a symptom of this failure to evolve.

The future of thoracic surgical oncology

How will thoracic surgery survive?  We already know that surgical excision offers the best long-term outcomes for our patients.  But as we have seen, having ‘right’ on your side isn’t enough.

Make surgery the most attractive option

For surgery to succeed, thoracic surgeons need to focus on making surgery safer and more acceptable to our patients.  Many patients prefer surgical removal on a philosophical level, but this preference is being eroded by promises of “easy” with SABER and newer chemotherapy regimens.

One of the benefits of surgery versus many of the newer treatments is that surgery is a single treatment versus multiple episodes of care.  If we can make that single encounter better for our patients, with shorter hospital stays, less pain/ less trauma and less risk, then surgery will remain the first and preferred treatment option for lung cancer.

 

Interview with the master: Dr. Benny Weksler

Talking to Dr. Benny Weksler about Minimally invasive esophagectomies, robotic surgery, lung cancer screening and life in the mid-south.

Memphis, Tennessee  USA

Recently, I had the great pleasure and privilege to have  a sit down interview with one of the thoracic surgeons whose work I have long admired.   Loyal readers will certainly recognize the name, Dr. Benny Weksler, one of the modern masters of esophageal surgery.

Minimally invasive esophagectomies (MIE)

He is best known for his minimally invasive esophagectomies which take much of the pain (literally) out of the traditional surgical resection for esophageal cancer. The minimally invasive esophagectomy is the VATS approach to esophagectomy, using smaller 2 to 3cm ‘ports’ instead of large incisions.

In classic thoracic surgery, large open incisions such as the Ivor Lewis esophagectomy were the best way to optimize survival for patients with this aggressive cancer.  However, the traditional open surgery itself is particularly arduous and has been likened to the “open heart surgery” of the thoracic specialty.  The Ivor Lewis in particular is two full-sized surgeries; a full thoracotomy combined with a transverse laparotomy.  While it has been utilized for decades for excellent visualization, staging and resection, the recovery is a long, painful process.

Dr. Weksler in the mid-south

It’s been just over three years since Dr. Benny Weksler was recruited to start a new thoracic surgery program at The University of Tennessee – West Cancer Clinic – Methodist Hospital System here in Memphis, Tennessee.  It’s been a big change, and a bit of an eye-opening experience for the Brazilian native and famed thoracic surgeon who has spent much of this career in the northeast.   Prior to this, he was part of the renowned University of Pittsburgh Medical Center under the famed Dr. James Luketich.  Since Dr. Weksler’s move, he’s still adjusting to the warmer weather here, which is one of the things he likes best about the area along with the traditional Memphis music scene, which the city is famous for.

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Memphis is more than just the home of Elvis Presley

It’s also been a time of great changes and innovations for Memphis and the University of Tennessee, as well.  Dr. Weksler started the first thoracic surgery service line for the UT – Methodist Hospital system, which is actually the first real dedicated thoracic surgery service line in the Memphis area – which extends across a tri-state area that also covers parts of northern Mississippi and western Arkansas.

Memphis, Tennessee at night
Memphis, Tennessee at night

Why is this important and what does it mean for Memphis?

Prior to Dr. Weksler’s arrival, patients were either referred to private cardiothoracic surgery practices in Memphis, they went to larger cities with bigger academic centers or they unwittingly trusted their health to a non-specialty surgeon.  Neither of those options were ideal, but now patients in the northern Mississippi delta – metro Memphis area can receive state-of-the-art, surgical excellence close to home.  For some patients, this is a matter of life or death.

Now the program is growing; so much so, that Dr. Weksler has two full-time thoracic surgeons and is actively looking for a third.  With the addition of the third surgeon, Dr. Weksler hopes to expand the UT program to serve local veterans at the Memphis VA.

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University of Tennessee affiliated – Methodist Hospital (official UT photo)

While Dr. Weksler doesn’t embrace the principles of uniportal surgery, his work on esophagectomies more than makes up for it.  In fact, Dr. Weksler is one of the leading surgeons in the United States for minimally invasive esophagectomies.  As discussed in previous posts, an experienced esophageal surgeon is critical for patient survival.  (Bare Minimum competency for any esophageal surgeon is 25 cases a year – it’s not a surgery for your ‘average’ thoracic surgeon or any general surgeon).

Memphis’ newest secret weapon against cancer (too bad no one knows that he’s here)

In fact, his presence here in Memphis, among otherwise limited surgical services, is like finding a diamond while scavenging for supper in a metal dumpster in a hundred degree heat.  In addition to being one of the foremost surgeons for esophageal disease (cancer and benign esophageal disease like achalasia), Dr. Weksler is also an experienced robotic surgeon.

As a newcomer to town, Dr. Weksler is having to re-build his practice volumes.  As he explains, “We do about 30 esophagectomies a year, and I also see approximately 60 patients with esophageal cancer that cannot be operated on.  100% of our esophagectomies since I have been here were done minimally invasive”.  

I can only speculate as a knowledgeable outsider that these surgical volumes reflect the lack of the general public and referring physicians knowledge about Dr. Weksler’s presence in the mid-south.  Dr. Weksler is the type of surgeon that patients will travel across the country to see.  My guess is that many of these potential patients are still traveling to Pittsburgh.

New ideas, new programs and new service lines

Dr. Weksler brings with him new ideas and new programs aimed at treating all Memphians.  This includes community programs aimed at underserved and at-risk communities.  One of these programs focuses on the diagnosis and treatment of lung cancer in African -American communities, which are disproportionately affected by advanced lung cancer, particularly in middle-aged males.  By creating and implementing screening programs in these communities, Dr Weksler and his team are able to diagnose and treat lung cancers at earlier stages and improve patient survival.  Despite being in its infancy, the program (which does not have a formal name) has screened over 100 patients and diagnosed eight cancers.

If you are a Memphis resident and would like information on this screening program or lung cancer screening:  Contact the Lung Cancer Screening Navigator at Dr. Weksler’s office at 901-448- 2918.

Changing the art of Medicine & Surgery in Memphis

Dr. Weksler has been instrumental in creating at atmosphere of multidisciplinary collaboration.  For example, programs have been streamlined and designed with patients in mind, to be the most effective, informative and efficient.  This means that patients receive a “one stop shopping” experience as Dr. Weksler describes it.  Patients are able to see their medical oncologist, thoracic surgeon and radiation oncologist on the same visit.  All patients and their cases are presented at tumor board, to determine that treatment is individualized to the patient’s condition, functional status and tumor type which adhering to the clinical guidelines and evidence-based practice to optimize patient outcomes and long-term survival.

Q & A with Dr. Weksler – What patients should expect

Dr. Weksler talked to me at length about this multidisciplinary team approach as well as what patients should expect when they come to Methodist/ West Cancer center for care.

Question: What is the general process/ timeline for patient who has been referred to your clinic for evaluation?

Dr. Weksler:   When patients come into the multidisciplinary clinic, patients / families with esophageal cancer will leave the office with a pretty good idea of what is going to happen. Depending on the work up done before they see me [which includes identification of tumor/ cancer staging], we will do the radiation therapy simulation the following
week, and start chemotherapy and/or radiation therapy the next week.

Question:  What diagnostics/ medical records should they bring with them?

Dr. Weksler:  We would like to see all available records, including previous surgeries, all scans, PET/ CT scans, barium esophagram, endoscopy report and all biopsy reports.

Question:  What should patients anticipate? (will they get feeding tubes prior to surgery, etc)?

Dr Weksler: Most patients will get a port for chemotherapy*.   We place feeding tubes in patients that loss more than 10% of their weight, or if they suffer from severe dysphagia. Patients can expect a 5 week course of chemotherapy and/or radiation therapy, followed by an interval of 6 to 8 weeks, followed by surgery.

*Editor’s note: A port is a long-term but temporary and completely removable central intravenous access for chemotherapy administration.  It is placed underneath the skin with no cords, or lines visible externally.  Feeding tubes are also temporary tubes that are easily removed/ reversible but help the patient to maintain adequate nutrition necessary for healing.

Dr. Benny Weksler, MD , Thoracic Surgeon

He has multiple offices including the West Cancer Center.  For an appointment, please contact 901-448-2918.

Unfortunately, while Dr. Weksler and his thoracic surgery program are state-of-the-art, the Methodist website is not. 

Additional references and resources (this is a selective list)

1. Oncologic efficacy is not compromised, and may be improved with minimally invasive esophagectomy.
Berger AC, Bloomenthal A, Weksler B, Evans N, Chojnacki KA, Yeo CJ, Rosato EL.
J Am Coll Surg. 2011 Apr;212(4):5606; discussion 5668. doi:  10.1016/j.jamcollsurg.2010.12.042. PMID: 21463789

2. Outcomes after minimally invasive esophagectomy: review of over 1000 patients.
Luketich JD, Pennathur A, Awais O, Levy RM, Keeley S, Shende M, Christie NA, Weksler B, Landreneau RJ, Abbas G, Schuchert MJ, Nason KS.  Ann Surg. 2012 Jul;256(1):95103.
doi: 10.1097/SLA.0b013e3182590603.  PMID: 22668811  Free PMC Article – attached.  Recommended reading.  If you are only going to read one article on MIE, this is a nice project looking at a large number of patients.

3. Major perioperative morbidity does not affect long-term survival in patients undergoing esophagectomy for cancer of the esophagus or gastroesophageal junction.
Xia BT, Rosato EL, Chojnacki KA, Crawford AG, Weksler B, Berger AC.
World J Surg. 2013 Feb;37(2):40815.  doi: 10.1007/s0026801218236.
PMID: 23052816

4. The revised American Joint Committee on Cancer staging system (7th edition) improves prognostic stratification after minimally invasive esophagectomy for esophagogastric adenocarcinoma.
Zahoor H, Luketich JD, Weksler B, Winger DG, Christie NA, Levy RM, Gibson MK, Davison JM, Nason KS.  Am J Surg. 2015 Oct;210(4):6107.
doi: 10.1016/j.amjsurg.2015.05.010. Epub 2015 Jun 26.  PMID: 26188709

5. Minimally invasive esophagectomy in a 6 year-old girl for the sequelae of corrosive esophagitis.
Majors J, Zhuge Y, Eubanks JW 3rd, Weksler B.
J Thorac Cardiovasc Surg. 2016 Jun 22. pii: S00225223(
16)305657.  doi: 10.1016/j.jtcvs.2016.06.011. [Epub ahead of print] No abstract available.
PMID: 27406439

 

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

Cusco,  Peru

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Dr. William Guido Gerrero

One of the guest lecturers at the 2nd VATS Peru Uniportal Master course is Dr. William Guido Gerrero from Costa Rica. Dr. Guido talked about the challenges of implementing a minimally invasive thoracic surgery program in the small central american nation that boasts a total population of less than 5 million.

Despite the small population and the low surgical volumes that accompany it; Dr. Guido is one of ten thoracic surgeons in Costa Rica, who are affiliated with two thoracic surgery departments within the nation.

Dr. Guido initially performed his first two uniportal cases with some trepidation.  The first cases were simple biopsies and drainage of pleural effusions.  He then performed his first lobectomy but it was a slow tedious process.  After that experience, he traveled to Shanghai, and the Shanghai Pulmonary Hospital to attend and train with Dr, Diego Gonzalez Rivas  in the wet lab, practicing cases on live animals.

At Hospital Rafael Angel Calderon Guardia

Dr. Guido primarily operates in a 350 bed hospital in the capital city of 1.4 million habitants.   The thoracic surgery unit consists of eight beds, and cases are performed three days a week with an annual case volume of around 350 cases.

Majority of cases by Uniportal VATS

The majority of surgical cases  (67%, includes all types of cases) are performed using the uniportal approach.  31% of the remainder are performed via a traditional ‘open’ approach with only 2% of cases performed using traditional (multiport) VATS.  This discrepancy is explaned by Dr. Guido in that there is currently only one thoracoscope in the hospital, and it is not always available.  He predicts that the rate of uniportal VATS cases will soon increase, as the second thoracoscope is scheduled to arrive in just a few weeks, followed by a third thoracoscope next year.  These equipment limitations are not the only challenges for Dr. Guido and his fellow thoracic surgeons.

Low volumes, suboptimal equipment and a lack of institutional support

The low volume of surgical cases and a lack of institutional support are also problems.  Unfortunately, it’s harder to convince the medical community of the value of uniportal VATS (and thus boost surgical volume) than it is to order new equipment. Despite these limitations, Costa Rica also manages to maintain a struggling lung transplantation program, that performs approximately two transplants per year, with five patients with pulmonary fibrosis and pulmonary hypertension currently on the waiting list.

Excellent care, at home

Dr. Guido hopes that many of these problems can be resolved in the future.  He wants Costa Rican patients to feel that they can stay in Costa Rica for their thoracic surgery without making any sacrifices in care.  He’s already lost one patient to Dr. Gonzalez Rivas himself (when the patient traveled to Spain for surgery) and another to the United States (where the patient ended up getting an open thoracotomy).  Losing a patient to the Master of Uniportal Surgery himself is inevitable, but losing a patient to a country where the patient received an inferior procedure at an exorbitant cost is a bit harder to swallow.

Best of luck to Dr. Guido and his colleagues.

At VATS Peru 2016

Cusco, Peru

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Day One of the VATS Peru 2016 Conference was a primer for surgeons interested in learned and performing uniportal VATS.  Dr. Gonzalez Rivas’ lectures formed the basis of theory and principles of uniportal thoracoscopic surgery, with additional lectures by Dr. William Guido, Dr. Timothy Young and Dr. Deping Zhao.

Surprisingly, many of the surgeons at the event informed me that they already use some uniportal techniques in their practice.  But they came here to Cusco, Peru to learn more from the Master of Uniportal surgery himself, Dr. Diego Gonzalez Rivas before attempting more complicated and complex surgical cases like sleeve resections.  Others came to learn more about nonintubated surgery in their uniportal patients.  The remainders were the core group of surgeons who came to get their first taste of uniportal surgery.

Some came from the local areas; from Lima, from Chile, and Ecuador.  Others came from other parts of Latin America; from Mexico and Costa Rico.  There was even a practicing surgeon from the United States, who realized that if he wanted to pursue the most advanced surgical techniques and minimally invasive surgery in thoracic surgery, that he couldn’t do it at home.  That’s a big paradigm shift for a surgeon from a nation that tends to think if it wasn’t invented in the United States, that it doesn’t exist, or has no merit.   It is also, from my perspective, a welcome change.

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With Dr. Tim Young, Dr. Diego Gonzalez Rivas and Dr. William Guido

In the five years that I have been travelling the globe, writing about surgical innovation, I am usually alone in my quest, in seeking innovation outside of  American medicine.  That’s not to say we(Americans)  don’t have our own great surgeons – I can easily rattle off quite a few – but it’s an acknowledgment that surgical innovation (or any innovation in general) is not the exclusive domain of the United States.   That sounds like a fairly basic principle, but one that is rarely seen in practice. American doctors and nurses just don’t attend international events to learn.  They only attend to teach – and often leave as soon as their lecture is complete, ensuring that an accidental opportunity to be exposed to new ideas is minimized.

So it was a pleasure to meet the surgeon from California, who took time off from a perfectly successful practice performing routine thoracotomies, to learn more about uniportal surgery at this and another upcoming master course.

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Why you should have your thoracic surgery at the university affiliated hospital

While working on a recent interview with one of the New Masters of Thoracic Surgery, I talked about one of his biggest contributions to his local community, which was establishing the first dedicated thoracic surgery program in that city.  Then I realized that maybe readers wouldn’t know what that was important.. This article came from that interview 

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Memphis, Tennessee at night

Big hospitals, little hospitals.  Major health systems and community facilities battle it out of our insurance dollars.  Private wings, VIP suites, catered meals and fancy robots all try and lure patients in the doors.  As a writer of several books based on the business of medical tourism – I’ve seen that the appeal of glistening marble floors, free fancy coffees and an aura of exclusivity can trump the principles of safe and effective patient care when it comes to attracting paying patients.  This is acutely evident in the surgery wars; the wars to attract referrals between private practice and academic medicine (which usually, but not always – has less glamorous facilities**).  But for a person facing a large, and possibly life-saving thoracic surgery, we need to explore the differences that are more than just skin-deep.

Subspecialty interest and skill

The difference between a true thoracic surgery program and a cardiothoracic surgery private practice group is often marked by the degree of continuing competence,  subspecialty interest and skill in minimally invasive techniques. (For more about the overall differences between general thoracic and cardiothoracic surgery, read here.)  This post is discussing the pitfalls of the private practice medical group and surgical referral patterns.  Surgical partners in a lucrative practice don’t have continuing education requirements, but residencies do.  In order to teach surgical residents, the attendings themselves need to be well-versed in the latest operating techniques and surgical outcomes research.

Where the patients come from

Private practice groups get their patients thru an ‘old boy network’ particularly in cities with few strong ties to university medical centers.  Patients don’t just walk thru the door to see a thoracic surgeon – they are referred to one.  Most people have never even heard of a thoracic surgeon before they or a loved one needs one.

As we talked about in one of our very first posts, “Who is performing your thoracic surgery?” – just because you need thoracic surgery, that doesn’t guarantee that a patient will see an actual board certified thoracic surgeon.

In a referral based system, patients are often not referred based on the skills or merits of the surgeon in the operating room, his rates of post-operative infection or even the health system affiliations – but by his charm, wit or connections on the social scene.  In a city like Memphis, which is awash in old money, southern tradition and the Junior League, this means that patients are referred to the surgeon based on the friendships amongst wives, college fraternity friendships or 6 am tee-off times.

Cardiothoracic versus general thoracic

Often times, the surgeon is not particularly gifted or even interested in modern lung or esophageal surgery techniques, meaning that the surgeon is most likely to revert to large thoracotomies or median sternotomies because that’s where his comfort lies.  There is no standard or requirement to master minimally invasive techniques, so often these surgeons don’t.  It’s not a criticism of cardiothoracic surgery, but a basic reality.  A heart surgeon wants to be a heart surgeon.  He doesn’t necessarily want to do lung or esophageal surgery, but he might not turn away these cases either, because everyone likes to make a living.

In comparison, a dedicated thoracic surgery program, particularly in an academic setting; is made up exclusively of thoracic surgeons who live and breathe general (noncardiac) thoracic surgery.  This is what they do, this what they want to do, this is what they have always wanted to do.  Academic settings also have more stringent requirements (in general) regarding maintaining clinical and educational competencies.  These surgeons are learning or teaching the newer techniques, reading and writing the literature and actively pursuing advances in the field.  This dedication is important for more than the most obvious reason – sure, you want your surgeon to be competent in the operating room – but you also want him to be knowledgeable and skilled outside of it.

Academic centers with general thoracic surgery programs are more likely to have a protocol based, formalized multidisciplinary approach to thoracic disease.   This means that patients are treated by a team of specialists in a cooperative fashion.  There are no conflicts between what the oncologist wants to do and what the surgeon wants.   If the patient needs pre-operative radiation or chemotherapy, it’s coordinated in conjunction with surgery, so that the patient receives care in a timely and organized fashion based on the current treatment recommendations and clinical research**.

But American medical care is the best in the world, right?

Multidisciplinary approach, evidence-based practice, ongoing academic research and continuing surgical education: All of these themes don’t sound extraordinarily unusual to readers because I have been discussing and presenting surgeons who work within these types of programs for years here at Thoracics.org.

Not the norm

But it’s actually not the norm in the United States, which means that many American patients get woefully inadequate, outdated or just plain uncoordinated care.  These patients have more pain, more suffering, longer lengths of stay, more complications and less quality of life than any of the patients who have been cared for by just about any surgeon ever mentioned on this site.  Patients at the University of Pittsburgh, Duke, University of Virginia or John Hopkins were getting great care, but patients here in Memphis, Las Vegas or any of the other cities or regions without these types of  specialized programs, weren’t and often still aren’t.

When added to the growing shortages in this specialty area, an appointment with a trained thoracic surgeon may become an elusive endeavor.  Especially if patients don’t know to ask.

* A thoracic surgery program that focuses on diseases and conditions of the lungs, esophagus and mediastinum.

** There are several academic medicine facilities that have managed to boast their own celebrity style perks, like the VIP wings at John Hopkins.

 

This June: NYU School of Medicine & Robotic Thoracic Surgery

Details about the upcoming Robotic thoracic surgery course at NYU this June.

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New York University School of Medicine has an upcoming CME course on Robotic Thoracic Surgery this June (10th & 11th).  The day and a half course will be held at NYU Langone Medical Center in New York City.

The conference covers robotic surgery basics as well as lectures on robotic esophagectomies and mediastinal surgery.  Robotic master surgeon, Dr. Robert Cerfolio will be giving two presentations.

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Dr. Robert Cerfolio with a Latin American thoracic surgeon at a conference in Orlando, Florida 2015

Dr. Inderpal Sarkaria from the renown University of Pittsburgh Esophageal & Lung Surgery Institute will be giving a presentation on esophagectomies by the robotic approach.  Dr. Sarkaria is the newest thoracic surgeon at the UPMC program run by Dr. James Luketich.

While it is a short conference, it’s a chance for interested thoracic surgery professionals to learn more about establishing a robotic surgery program.  It is also part of a larger robotic surgery conference, the Second Annual NYU Langore Multi-Specialty Robotic Surgery Course.

All robotic surgery enthusiasts, fellows and interested surgeons – can register for the course here.  Allied health professionals are encouraged to attend.

 

Advanced Course on Major Pulmonary Resections through Uniportal VATS

Learn Uniportal VATS from the masters – with a hands-on wet lab..

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Attendees at the November 2015 course

La Coruna. Espana

Beyond the theoretical

The Advanced course on uniportal VATS differs from the rest of the courses covered here at Thoracics.org in that it goes beyond didactic lectures and surgical demonstrations.  The three day course, sponsored by Johnson & Johnson is one of the few to offer hands-on training in a one-day ‘wet lab’.

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Dr. Dario Amore (Hospital Monaldi, Naples, Italy) operates under the watchful eye of Dr. Maria Delgado of Hospital Universitario de Coruna.

During the lab portion of this course, attendees are encouraged to perform several lobectomies using the uniportal approach while being proctored by several well-experienced surgeons including Dr. Diego Gonzalez Rivas himself, and his surgical colleagues (Dr. Maria Delgado Roel, Dr. Mercedes Del la Torre and Dr. Ricardo Fernando Prado).   These surgeons make up the world famous thoracic surgery department at the Coruna University Hospital.  They are joined by Dr. Miguel Congregado, another Spanish surgeon from Seville, who is also well experienced in uniportal VATS.

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Course attendees with Spanish mentoring surgeons:Dr. Maria Delgado (3rd from left), Dr. Mercedes de la Torre (center) and Dr. Ricardo Prado (far right).  Dr. Miguel Congregado (first row)

While there have been multiple discussions among STS and other organizations regarding the minimum training required for surgeons to be credentialed and to practice Uniportal VATS and other advanced surgical techniques in their respective hospitals – the wet lab gives no doubt as to the need for ‘hands-on’ experience for even experienced VATS surgeons*.

Lecture content becomes reality

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Visiting surgeons during didactic component

Powerpoint discussions, video demonstrations and even the most engaging lectures on bleeding complications quickly take center stage once surgeons enter the lab.

For surgeons who have spent their time watching Dr. Gonzalez Rivas perform a complete lymph node dissection in under 9 minutes, the lab is eye opening.

Despite being cautioned during lectures on preventing and managing bleeding the day before, as well as short review immediately prior to entering the lab, essential pre-operative preparations on surgical trays are noticeably absent in the lab.  None of the two man teams takes the time to place spongesticks on their mayo stands or make any other modifications to their instruments prior to making the initial incision.

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Attendees experience the reality of bleeding complications during initial attempts at Uniportal VATS

One by one – with two notable exceptions, each of the 8 teams encounters catastrophic bleeding – injuries to the pulmonary arteries, accidental tears to the vena cava and other major problems.  But that’s why they are here: to become familiar with uniportal surgery, its specialized instruments while being guided by experienced uniportal VATS surgeons.  One by one, the surgeons remember the mantra of Dr. Diego Gonzalez Rivas: “Don’t panic!” as they maneuver and do the best to re-establish hemostasis. Surgeons practice placing stitches in the PA, and repairing the great vessels.  All remember the first lesson Uniportal VATS – hold pressure. Some manage these complications quickly with relative ease, others struggle initially and some fail entirely.

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Bleeding is not the only possible complication for novice uniportal surgeons

Others, like the pair of general surgeons from the Netherlands demonstrate that despite a steep learning curve, success is possible with uniportal VATS.  After initially learning traditional VATS in 2008, these surgeons had just 5 uniportal cases under their belt prior to coming to this course.  However, each of their cases were completed quickly and without complications.

The wet lab was followed by a day of live-surgery performed by Dr. Gonzalez Rivas – where attendees could ask questions about his techniques during the operations.  Their new found experience in the web lab served as a useful framework for their questions and observations.

*Dr. Gonzalez Rivas and his colleagues recommend attending several courses, followed by a web-lab and then finally, proctoring with an experienced Uniportal VATS surgeon.

Interested in learning uniportal VATS?

  • Start by familiarizing yourself with the basics – watch YouTube and other surgical demonstration videos like the Virtual VATS uniportal lobectomy on December 3rd 2016, read articles and reviews.
  • Attend conferences and moderated discussions on the technical aspects of uniportal VATS
  • Observe ‘live-surgery’ events – like the week long courses at Shanghai Pulmonary Hospital
  • Attend wet lab courses
  • Finally, arrange for mini-residencies or mentoring at home facility as you begin to implement these techniques into your own practice.  Be prepared to encounter bleeding and other complications and remember: Don’t panic!

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.

Single port sleeve right upper lobectomy

the latest video from Dr. Diego Gonzalez Rivas demonstrating a sleeve lobectomy via single port surgery

On the heels of the recent conference in Hong Kong, one of our favorite surgeons (and presenter at the 1st Asian single port surgery conference), Dr. Diego Gonzalez Rivas has sent another link to one of his more recent cases – Single port lobectomy  – Sleeve resection after chemotherapy.

Conference Spotlight lecture: Dr. Gulliermo Cueto Robledo

Dr. Cueto as our featured speaker today at the National Conference of the Mexican Society of Pulmonology and Thoracic Surgery talking about pulmonary embolism.

Cancun, Mexico

The highlighted speaker for the conference today is the dynamic Dr. Gullermo Cueto Robledo of the General Hospital of Mexico City.  Dr. Cueto presentation was “Diagnostic opportunities in Pulmonary Embolism.”

Dr. Cueto at the 2012 Congreso Nacional de Neumologia y Cirugia de Torax

It was a standing room only crowd for his presentation on the incidence, mortality, diagnosis and treatment of pulmonary embolism.

Dr. Cueto reviewed the incidence of pulmonary embolism which occurs approximately 909, 753 times a year in the United States, with an estimated 296,370 deaths directly attributed to this phenomenon (2005, Journal of Thromboembolism & Hematology).

In a recent study at the Institute of Cardiology in Mexico City by Sandoval, 22.4% of all autopsies showed evidence of pulmonary embolism.

While many of the risk factors are well-known cardiovascular disease risks (obesity, hypertension, diabetes, smoking, elevated cholesterol) as well as traditional risk factors such as cancer/ malignant processes, venous stasis/ immobility, recent surgery and airline (or other travel) greater than two hours – Dr. Cueto discussed how pulmonary embolism is often overlooked.  He reviewed the existing criteria for predicting embolism risk such as the Wells, Winky (Geneva) scores, as well as the shortfalls of each of these scores, which often rely on subjective criteria on the basis of the individual applying the criteria.  He also talked about a recent paper suggesting a strong correlation between ST changes in aVR and presence of a right BBB in addition to the traditional S1Q3T3 finding on electrocardiogram.

He states that the strength of the D-dimer is not in it’s diagnostic capability but in it’s prognostic ability, as the elevated values at specific thresholds can be used to correlation both the location and risk of mortality.

Despite the advent of multi-modality imaging studies the gold standard remains the V:Q scan which is the only diagnostic tool to clearly rule out the presence of pulmonary emboli, along with the advantages and disadvantages of traditional and helical CT scans in addition to MRA (magnetic resonance imaging with angiography.)  He reports that initial enthusiasm for MRA has dampened due to multiple limitations in use as well as poor picture quality in comparison to other modalities. The main limitations of the multi-detector helical CT scan remain the inaccessibility and unavailability of this modality at many facilities due to cost.

He also reviewed the recently published guidelines from the American College of Chest Physicians (Chest, 2012) include very specific recommendations including initiation of thrombolytic and anti-coagulant therapies prior to formal or radiographic diagnosis in patients at high risk despite their classification of evidence as 2C.  These changes come due to recent studies showing adverse outcomes with delayed onset of treatment, with a marked shift around the twenty hour mark after the onset of the initial thrombotic event.  As he mentioned previously, since the majority of patients may demonstrate either vague or absent symptomatology on the onset of massive pulmonary embolism, these guidelines attempt to streamline and advance treatment that may be otherwise delayed by diagnostic testing.

References

(2012).  Antithrombotic treatment of venous thromboembolism.  ACCP guidelines.  Chest, 2012, supplement, 141(2) e4195 – e4945.

(2009).  Air travel and risk of thromboembolismAnn Internal Medicine 151 – 180: 190.  Review of the literature showing an 18% increase for every two- hour interval of travel.