Bogota – Thoracic Surgery

Case Report: Hilar mass resection using single port thoracoscopy with Dr. Diego Gonzalez – Rivas

in the operating room with Dr. Diego Gonzalez Rivas for single port thoracoscopic (uniportal) surgery.

Hilar mass resection using single port thoracoscopy with Dr. Diego Gonzalez – Rivas

K. Eckland & Andres M. Neira, MD

Instituto Nacional de Cancerlogia

Bogota, Colombia

Surgeon(s): Dr. Diego Gonzalez Rivas and Dr. Ricardo Buitrago

Dr. Diego Gonzalez Rivas demonstrates single port thoracoscopy

Case History:

59-year-old female with past medical history significant for recurrent mediastinal mass previously resectioned via right VATS. Additional past medical history included prior right-sided nephrectomy.

Pre-operative labs:

CBC: WBC 7230 Neu 73% Hgb:14.1 Hct 37 platelets 365000

Pt 12.1 / INR1.1 PTT: 28.3

Diagnostics:

Pre-operative CT scan: chest

Procedure: Single port thoracoscopy with resection of mediastinal mass and lymph node sampling

After review of relevant patient history including radiographs, patient was positioned for a right-sided procedure. After being prepped, and draped, surgery procedure in sterile fashion. A linear incision was made in the anterior chest – mid clavicular line at approximately the fifth intercostal space. A 10mm port was briefly inserted and the chest cavity inspected. The port was then removed, and the incision was expanded by an additional centimeter to allow for the passage of multiple instruments; including camera, grasper and suction catheter.

Dr. Gonzalez Rivas and Dr. Ricardo Buitrago at National Cancer Institute

The chest cavity, pleura and lung were inspected. The medial mediastinal mass was then identified.

As previously indicated on pre-operative CT scan, the mass was located adjacent and adherent to the vessels of the hilum. This area was carefully dissected free, in a painstaking fashion. After freeing the mediastinal mass from the hilum, the remaining surfaces of the mass were resected. The mass was fixed to the artery pulmonary and infiltrating it) . The mass was removed en-bloc. Care was then taken to identify, and sample the adjacent lymph nodes which were located at stations (4, 7 and 10).

Following removal of the tumor and lymph nodes, the area was re-inspected, and the lung was re-inflated. A 28 french chest tube was inserted in the original incision, with suturing of the fascia, subcutaneous and skin layers.

Hemostasis was maintained during the procedure with minimal blood loss.

Patient was hemodynamically stable throughout the case, and maintained appropriate oxygen saturations. Following surgery, the patient was awakened, extubated and transferred to the surgical intensive care unit.

Post-operative: Post-operative chest x-ray confirmed appropriate chest tube placement and no significant bleeding or pneumothorax.

Immediate post-operative film (chest tube visible)

Patient did well post-operatively. Chest tube was discontinued on POD#2 and discharged home.

Discussion: Since the initial published reports of single-port thoracoscopy, this procedure has been applied to an increasing range of cases. Dr. Gonzalez and his team have published reports demonstrating the safety and utility of the single-port technique for multiple procedures including lobectomies, sleeve resections, segmentectomies, pneumonectomies and mediastinal mass resections. Dr. Hanao Chen (Taiwan) has reported several successful esophagectomies using this technical, as well as bilateral pleural drainage using a unilateral single-port approach.

Contrary to popular perception, the use of a single-port versus traditional VATS procedures (three or more) is actually associated with better visibility and accessibility for surgeons. Surgeons using this technical have also reported better ergonomics with less operating fatigue related to awkward body positioning while operating.

The learn curve for this surgical approach is less than anticipated due to the reasons cited above, and has been cited at 5 to 20 cases by Dr. Gonzalez, the creator of this approach.

The main limitations for surgeons using this technique is often related to anticipated (but potentially unrealized) fears regarding the need for urgent conversion to open thoracotomy. In reality, many of the complications that may lead to urgent conversion, such as major bleeding, are manageable thoracoscopically once surgeons are experienced and comfortable with this approach.

Dr. Gonzalez and his colleagues have reported a conversion rate of less than 1% in their practice. Subsequent reports by Dr. Gonzalez and his colleagues have documented these findings.

Other barriers to adoption of this technique are surgeon-based, and may be related to the individual surgeon’s willingness or reluctance to adopt new techniques and technology. Many of these surgeons would be surprised by how this technique mimics open surgery.

The successful adoption of this technique by numerous thoracic surgery fellows shows the feasibility and ease of learning single-port thoracoscopy by surgeons interested in adopting and advancing their surgical proficiency in minimally invasive surgery.

The benefits for utilizing this technique include decreased length of stay, decreased patient discomfort and greater patient satisfaction.

References/ Additional Readings

Bertolaccini, L., Rocco, G., Viti, A. & Terzi, A. (2013). Surgical technique: Geometrical characteristics of uniportal VATS. J. Thorac Dis. 2013, Apr 07. Article from thoracic surgeons at the National Cancer Institute in Naples, Italy explains how the geometric advantages of uniportal VATS improves visibility and spatial perception over traditional VATS, and mimics open surgery.

Calvin, S. H. Ng (2013). Uniportal VATS in Asia. J Thorac Dis 2013 Jun 20. Article discussing the spread of uniportal techniques in Taiwan, China and other parts of Asia.

Chen, Chin-Hao, Lin, Wei-Sha, Chang, Ho, Lee, Shih-Yi, Tzu-Ti, Hung & Tai, Chih-Yin (2013). Treatment of bilateral empyema thoracis using unilateral single-port thoracoscopic approach. Ann Thorac Cardiovasc Surg 2013.

Gonzalez Rivas, D., Fieira, E., Delgado, M., Mendez, L., Fernandez, R. & De la Torre, M. (2013). Surgical technique: Uniportal video-assisted thoracoscopic lobectomy. J. Thorac Dis. 2013 July 4.

Gonzalez Rivas, D., Delgado, M., Fieira, E., Mendez, L. Fernandez, R. & De la Torre, M. (2013). Surgical technique: Uniportal video-assisted thoracoscopic pneumonectomy. J. Thorac Dis. 2013 July 4.

Rocco, G. (2013). VATS and uniportal VATS: a glimpse into the future. J. Thorac Dis. 2013 July 04. After coming across several articles by Dr. Gaetano Rocco, and actively pursuing several other publications by this Italian thoracic surgeon, I have become increasingly convinced that Gaetano Rocco, along with Dr. Gonzalez Rivas is one of the world’s leading innovators in thoracic surgery. Hopefully, cirugia de torax will be able to catch up to Dr. Rocco at some point for an in-depth discussion.

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

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

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

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

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

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

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

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

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

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

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

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

Additional publications on single-port thoracoscopy (Dr. Gonzalez Rivas)

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

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

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

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

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

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

Dr. Gonzalez Rivas, Johnson & Johnson and Single-port thoracic surgery

the 2013 S.W.A.T conference, presented by Johnson & Johnson. Featured presenters Dr. Diego Gonzalez Rivas and Dr. Paula Ugalde discuss single port thoracoscopy and topics in minimally invasive surgery

Very pleased that despite the initial difficulties, we are able to provide information regarding the recent conference.

Talking about Single-port surgery in Bogotá, Colombia – 2013 S.W.A.T. Summit

Dr. Diego Gonzalez Rivas and Dr. Paula Ugalde were the headliners at the recent Johnson and Johnson thoracic surgery summit on minimally invasive surgery. Both surgeons gave multiple presentations on several topics. They were joined at the lectern by several local Colombian surgeons including Dr. Stella Martinez Jaramillo (Bogotá), Dr. Luis Fernando Rueda (Barranquilla), Dr. Jose Maineri (Venezuela) Dr. Mario Lopez (Bogotá) and Dr. Pardo (Cartagena).

Thoracic surgeons at the 2013 S.W.A.T Summit in Bogota, Colombia. Drs. Gonzalez-Rivas and Dr. Paula Ugalde are center, front-row

Target audience missing from conference

The audience was made up of thirty Latin American surgeons from Colombia, Costa Rica and Venezuela. This surgeons were hand-picked for this invitation-only event. Unfortunately, while Johnson and Johnson organized and presented a lovely event; their apparent lack of knowledge about the local (Colombian) thoracic surgery community resulted in the exclusion of several key surgeons including Dr. Mauricio Velasquez, one of Colombia’s earliest adopters of single-port thoracoscopy. Also excluded were the junior members of the community, including Dr. Castano, Dr. Carlos Carvajal, and current thoracic surgery fellows. It was an otherwise outstandingand informative event.

However, this oversight represents a lost-opportunity for the parent company of Scanlon surgical instruments, the makers of specialized single port thoracoscopic instrumentation endorsed and designed by Dr. Gonzalez-Rivas himself, including the Gonzalez-Rivas dissector.

The Gonzalez - Rivas dissector, photo courtesy of Scanlon International — The Gonzalez – Rivas dissector, photo courtesy of Scanlon International

As discussed in multiple publications, previous posts as well as during the conference itself, it is these younger members who are more likely to adopt newer surgical techniques versus older, more experienced surgeons. More seasoned surgeons may be hesitant to change their practices since they are more comfortable and accustomed to open surgical procedures.

Despite their absence, it was an engaging and interesting conference which engendered lively discussion among the surgeons present.

Of course, the highlight of the conference actually occurred the day before, when Dr. Gonzalez- Rivas demonstrated his technique during two separate cases at the National Cancer Institute in Bogotá, Colombia. (Case report).

Dr. Gonzalez-Rivas and Dr. Ricardo Buitrago performing single port thoracoscopy at the National Cancer Institute

Featured presenters:

Dr. Diego Gonzalez – Rivas is a world-renown thoracic surgeon jointly credited (along with Dr. Gaetano Rocco) with the development of single-port thoracoscopic (uni-port) surgery. He and his colleagues at the Minimally Invasive Surgery Unit in La Coruna, Spain give classes and lectures on this technique internationally. Recent publications include three papers in July alone detailing the application of this surgical approach, as well as several YouTube videos demonstrating use of this technique for a wide variety of cases.

Dr. Paula Ugalde, a Chilean-borne thoracic surgeon (from Brazil) who gave several presentations on minimally-invasive surgery topics. She is currently affiliated with a facility in Quebec, Canada.

Refuting the folklore

Part of the conference focused on refuting the ‘folklore’ of minimally-invasive procedures. Some of these falsehoods have plagued minimally-invasive surgery since the beginning of VATS (in 1991), such as the belief that VATS should not be applied in oncology cases. The presenters also discussed how uniportal VATS actually provides improved visibility and spatial perception over traditional VATS (Bertolaccini et al. 2013).

However, Gonzalez-Rivas, Ugalde and the other surgeons in attendance presented a wealth of data, and publications to demonstrate:

– VATS is safe and feasible for surgical resection in patients with cancer. (Like all surgeries, oncological principles like obtaining clear margins, and performing a thorough lymph node dissection need to be maintained).

– Thorough and complete lymph node dissection is possible using minimally invasive techniques like single-port surgery. Multiple studies have demonstrated that on average, surgeons using this technique obtain more nodes than surgeons using more traditional methods.

– Large surgeries like pneumonectomies and sleeve resections are reasonable and feasible to perform with single-port thoracoscopy. Using these techniques may reduce morbidity, pain and length of stay in these patients.

– Rates of conversion to open surgery are very low (rare occurrence). In single-port surgery, “conversion” usually means adding another port – not making a larger incision.

– Learning curve fallacies: the learning curve varies with each individual surgeon – but in general, surgeons proficient in traditional VATS and younger surgeons (the “X box generation”) will readily adapt to single-port surgery.

– Bleeding, even significant bleeding can be managed using single-port thoracoscopy. Dr. Gonzalez Rivas gave a separate presentation using several operative videos to demonstrate methods of controlling bleeding during single-port surgery – since this is a common concern among surgeons hesitant to apply these advanced surgical techniques.

Additional References / Readings about Single-Port Thoracoscopy

Scanlon single-port thoracoscopy kits – informational brochure about specially designed instruments endorsed by Dr. Gonzalez Rivas.

Dr. Diego Gonzalez Rivas – YouTube channel : Dr. Gonzalez Rivas maintains an active YouTube channel with multiple videos demonstrating his surgical technique during a variety of cases. Below is a full-length video demonstrating the uniportal technique.

Additional posts at Cirugia de Torax about Dr. Diego Gonzalez- Rivas

2012 interview in Santiago, Chile –

Dr. Gonzalez-Rivas “TedTalk” –

SITS lobectomy – discussion on previous publication/ case report.

Dr. Gonzalez Rivas and the future of thoracic surgery

Upcoming conference in Florida – information about registering for September conference for hands-on course in single-port thoracoscopic surgery with Dr. Gonzalez-Rivas

Youtube video for web conference on Single-port thoracoscopic surgery

Bertolaccini, L., Rocco, G., Viti, A. & Terzi, A. (2013). Surgical technique: Geometrical characteristics of uniportal VATS. J. Thorac Dis. 2013, Apr 07. Article from thoracic surgeons at the National Cancer Institute in Naples, Italy explains how the geometric advantages of uniportal VATS improves visibility and spatial perception over traditional VATS, and mimics open surgery.

Calvin, S. H. Ng (2013). Uniportal VATS in Asia. J Thorac Dis 2013 Jun 20. Article discussing the spread of uniportal techniques in Taiwan, China and other parts of Asia.

Gonzalez Rivas, D., Fieira, E., Delgado, M., Mendez, L., Fernandez, R. & De la Torre, M. (2013). Surgical technique: Uniportal video-assisted thoracoscopic lobectomy. J. Thorac Dis. 2013 July 4.

Gonzalez Rivas, D., Delgado, M., Fieira, E., Mendez, L. Fernandez, R. & De la Torre, M. (2013). Surgical technique: Uniportal video-assisted thoracoscopic pneumonectomy. J. Thorac Dis. 2013 July 4.

Rocco, G. (2013). VATS and uniportal VATS: a glimpse into the future. J. Thorac Dis. 2013 July 04. After coming across several articles by Dr. Gaetano Rocco, and actively pursuing several other publications by this Italian thoracic surgeon, I have become increasingly convinced that Gaetano Rocco, along with Dr. Gonzalez Rivas is one of the world’s leading innovators in thoracic surgery. Hopefully, cirugia de torax will be able to catch up to Dr. Rocco at some point for an in-depth discussion.

While I advance criticism of this event – it was a fantastic conference. My only reservations were to the exclusivity of the event. While this was certainly related to the costs of providing facilities and services for this event – hopefully, the next J & J thoracic event will be open to more interested individuals including young surgeons and nurses.

Robotic surgery with Dr. Ricardo Buitrago, thoracic surgeon

Robotic (thoracic) surgery comes to Clinica de Marly in Bogota, Colombia

A year and a half ago, I interviewed and spent some time with Dr. Ricardo Buitrago at the National Cancer Institute, and Clinica de Marly while doing research for a book about thoracic surgeons. At that time, Dr. Buitrago stated he was interested in starting a robotic surgery program – and was planning to study robot-assisted thoracic surgery with Dr. Mark Dylewski.

buitrago 009 — Dr. Ricardo Buitrago in the operating room, April 2011

Fast forward 1 year – when I received a quick little email from Dr. Buitrago telling me about his first robotic surgery at the Clinica de Marly. At that point, I sent Dr. Buitrago an email asking if I could come to Colombia and see his robotic surgery program to learn more about it. We had several phone conversations about it and I also outlined a research proposal to gather data on thoracic surgery patients and outcomes at high altitude, to which he enthusiastically offered to assist with. Thus began my current endeavor, in Bogota, studying with Dr. Buitrago.

Now – after completing a proctoring period with Dr. Dylewski, Dr. Buitrago has more than a dozen independent robotic surgeries under his belt. He has successfully used the robot for lobectomies, mediastinal mass resections and several other surgeries.

As part of my studies with Dr. Buitrago – I’ve made a video for other people who may be interested in robotic surgery with the DaVinci robot and what it entails.

Hope you enjoy.

Protected: Register to participate in high altitude research project

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Simposia Internacional: Advances en Cancer Pulmonar y Mesotelioma

Highlights from the recent conference on Advances in Lung Cancer and Mesothelioma

Instituto Nacional de Cancero
Bogota, Colombia

Dr. Ricardo Buitrago and Dr. Juan Carlos Garzon, Thoracic Surgeons

This one day conference put on by the National Cancer Institute in Bogotá, Colombia highlighted the latest research and techniques of treating lung cancer and mesothelioma.

It was headlined by a trio of invited lecturers, Dr. Carlos Jimenez, MD, Pulmonologist (MD Anderson, Houston, TX), Dr. Garrett Walsh, MD, Thoracic surgeon (MD Anderson, Houston, TX) and Dr. Mark Dylewski, MD, Thoracic surgeon (Baptist Health/ South Miami Hospital – Center for Robotic Surgery).

Dr. Ricardo Buitrago (who readers will be hearing more about in the coming months) and Dr. Rafael Beltran were the moderators for the conference.

Dr. Jimenez spoke on the topics of endobranchial ultrasound and fine needle (Wang) aspiration for lymph node biopsy as an adjuvant of mediastinoscopy for cancer staging, as well as ‘medical thoracoscopy’ or pleuroscopy. (While I will never share his views of pleuroscopy being part of the role/ scope of pulmonology – it was an interesting presentation.)

The presentations of Dr. Walsh and Dr. Dylewski served as beautiful counter-balance to each other and demonstrated the spectrum and breadth of thoracic surgery in the treatment of thoracic diseases.

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

While Dr. Dylewski presented the latest data from his experiences performing over 355 cases by robotic approach, Dr. Walsh spoke about performing large open cases with an interdisciplinary team to treat later stage cancers (T3, T4 respectively) and the ability to resect cases that are often referred for medical treatment due to local metastasis to adjacent organs.

Other notable speakers included Dr. Stella Martinez who debated the advisability of surgical treatment of Malignant Pleural Mesothelioma (MPM) in response to another presentation by Dr. Walsh, as well as a discussion by Dr. Humberto Varela of the utility of specific diagnostic modalities for the detection and staging of malignant pleural mesothelioma.

Surgery at altitude, part I

Calling all thoracic surgeons – particularly those in La Paz, Quito, Bogota and Mexico City.. We have an opportunity for collaborative research.

One of our newest endeavors is a research project on thoracic surgery at moderate altitude. We’ve completed our review of existing literature, and developed our patient parameters and data collection points.

The main base of our operations is Flagstaff, Arizona, which is located at 7000 ft. (2,000 meters) making it the highest altitude cardiothoracic program in the United States. The Flagstaff site has several strengths in that much of our patient population comes from the surrounding areas; which are located at both higher and lower elevations. However, one of the weaknesses in Flagstaff is our small patient population – as a single surgeon site devoted to both cardiac and thoracic surgery – our lung surgery volumes are fairly small.

Right now, I am doing some of the preliminary work with the hospital – meeting with staff to apply for IRB approval, and formalizing the data collection process. I am also interested in recruiting surgeons from other sites to participate in data collection. Dedicated thoracic surgeons with large thoracic surgery practices would be ideal – and all results will be published and presented by surgeon/ and site.

We are particularly interested in recruiting surgeons from the following areas:

1. La Paz, Bolivia

2. Quito, Ecuador

3. Bogotá, Colombia

4. Mexico City, DF – Mexico

These four cities combined house many millions of people living at moderate altitudes, and would help provide for a wider and more expansive collection of data on patients undergoing thoracic surgery. Demographic differences (such as pre-existing thoracic diseases, incidence of heavy cigarette smoking, etc.) of geographic locales will also allow for further points of comparison.

Please contact Cirugia de Torax if you are interested in participating. All participating surgeons and institutions will receive credit (in accordance to level of participation) in any and all subsequent professional and scientific publications.

You can also contact me, K. Eckland, directly at : k.eckland@gmail.com. Please place ‘cirugia de torax’ or ‘altitude project’ in the sibject line.

High Altitude Surgery, part I

As our writer returns to moderate altitude in the foothills of the Andes, we take a look at the published research related to altitude illnesses and surgery.

This seemed like a timely entry here at Cirugia de Torax, as I return from Bogotá, Colombia (the third highest capital city in the world.) However, while the concept of surgical constraints due to elevation is not new; but today we will discuss definitions and explore the published literature. I’d also like to apologize to my readers – much of the available medical literature in not available as a free text, so while I am able to access and reference this information – I can not post links to the full articles themselves.

First, we need to define some terms when we talk about altitude, since most of the research is actually looking at very high (versus moderate altitude). This is important because as you will see, very few people are living at, and even fewer people are having surgery at these heights.

Definitions of Altitude: from Muzo, Tulco & Cymerman (2004).

Very-High Altitude: 4250 – 6000 meters elevation (13,943 ft to 19,685 ft): There are few permanent cities at this altitude. At the upper range of very high altitude cities, you are essentially talking about ‘base camp’ settlements of Mount Everest and places like Wenzhuan (Tibet) which is listed as the world’s highest city at an elevation of 16,467. (There is some controversy over this status, as La Riconada, Peru at 16,728 ft. (5100 meters) also claimed status as the highest city. There are no cities with any significant size (greater than just a few thousand residents) at this elevation. However, the majority of altitude research has been conducted at the very high and high altitude elevations.

High-Altitude: 2500 meters – 4249 meters
(8,202 ft to 13,940 ft): this classification includes several larger cities / population centers including three capital cities:

La Paz, Bolivia (est. elevation ranging from 3200 meters to 3,650 meters in different portions of the city) population of metro area: 2.3 million.

Quito, Ecuador (est. elevation 2800 meters or 9186 feet) population: 1.4 million

Bogotá, Colombia (2660 meters, 8727 feet) population: 10 million

According to the majority of scientific and medical literature, physiological adaptation, high altitude effects and illnesses usually do not occur until people reach an altitude of 2500 meters or greater. (However, the authors acknowledge that in certain individuals – these effects can occur at relatively low elevations (1,000 meters).

Moderate Altitude: 1000 meters to 2500 meters (3900 feet to around 8000 ft) This is actually the level that most of the people who are concerned about the effects of elevation live and operate at. This includes Denver, Colorado; Lake Tahoe, California/Nevada; Flagstaff, Arizona and several other American cities in the Sierra Nevada Mountain Range. It also includes several Alpine cities (while the alps themselves are around 4400 – 4800 meters, most of the cities are in the valleys, and most lay at around 1500 meters.)

Low Altitude: below 1000 meters.

References:

Heart. 2006 Jul;92(7):921-5. Epub 2005 Dec 9. Safety and exercise
tolerance of acute high altitude exposure (3454 m) among patients with coronary artery disease. Schmid JP, Noveanu M, Gaillet R, Hellige G, Wahl A, Saner H. (Switzerland)

Chest. 1995 Nov;108(5):1292-6. The safety of air transportation of
patients with advanced lung disease. Experience with 21 patients requiring lung transplantation or pulmonary thromboendarterectomy. Kramer MR, Jakobson DJ, Springer C, Donchin Y. (Israel).

Br J Sports Med. 1995 Jun;29(2):110-2. Poor ventilatory response to mild hypoxia may inhibit acclimatization at moderate altitude in elderly patients after carotid surgery. Roeggla G, Roeggla M, Wagner A, Laggner AN. (Austria).

Thorax. 1995 Jan;50(1):22-7. Doppler assessment of hypoxic pulmonary vasoconstriction and susceptibility to high
altitude pulmonary oedema. Vachiéry JL, McDonagh T, Moraine JJ, Berré J, Naeije R, Dargie H, Peacock AJ. (Belgium)

Ann Surg. 1897 Sep;26(3):297-306. II. A Preliminary Comparison
of Methods and Results in Operative Surgery at the Sea Level (New York) and in Places of High Altitude (Denver). Powers CA. (Note the date of publication – 1897 – we’ve been looking at this issue for quite a long time.)

West J Med. 1995 Aug;163(2):117-21. Sea-level physical activity and acute mountain sickness at moderate altitude. Honigman B, Read M, Lezotte D, Roach RC. – This is an interesting study which looks (observational by survey only) at the physiological responses of conference participants from low elevations upon reaching higher elevations (3000 meters in this study / 9,840 ft). The study compared the incidence of altitude sickness/ symptoms among people who defined themselves as physically fit/ physically active (using standardized criteria) versus more sedentary individuals. In total, 28% of the 200+ participants reported three or more symptoms of acute mountain sickness, but surprisingly, there was no difference in incidence among the physically fit (at sea-level) group and the more sedentary group which belies much of the current folklore related to altitude sickness.

Muza, Tulco & Cymerman (2004). Altitude Acclimatization Guide.

Essenbag, V., Halabi, A. R., Churchill-Smith, M & Lutchmedial, S. (2003). Air transport in Cardiac Patients. Chest 2003 Nov; 124(5): 1937-45. McGill University, Montreal, Canada.

Altitudes of World Cities – there are some discrepancies with altitudes listed here and other reference materials.

The 25 Highest US cities

In our next post we will talk more about this research, what it means, and what research is still needed to examine the effects of high altitude surgery, particularly in thoracic patients.

Talking with Dr. Juan Carlos Garzon

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

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

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

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

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

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

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

garzon crop - Copy — Dr. Juan Carlos Garzon

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

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

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

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

The Thoracic Surgeons of Bogota

After living and working in Bogota, Colombia for the last five months as part of a separate project, I have decided that the story of the thoracic surgeons of Bogota needs to be told. I have been interviewing surgeons from multiple specialities day in and day out for months, but it the personal stories and the practice patterns of these thoracic surgeons that have emerged, which speak to me as a writer. It seems only natural after spending so much time with these fine surgeons to want to write a separate book, dedicated to these surgeons.

However, this book is not a fawning promotion brochure but a detailed glimpse into the behaviors, practices and history of thoracic surgery in Bogota.
Unlike my previous books, this is not a book about surgical tourism, though it would be incomplete without that information. Rather it is a brief narrative of the story of their daily lives, professional and personal and my perspectives as a stranger in the midst of these men and women.
I hope to complete The Thoracic Surgeons of Bogota by August, but I will keep you informed on my progress.

K. Eckland

8 May 2011