Credentialing versus certification for minimally invasive thoracic surgery?

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

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

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

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

Certification

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

uniportal surgery
uniportal surgery

Certification versus credentialing

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

STS focuses on credentialing – not certification..

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

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

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

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

What is minimally invasive surgery?

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

How does a surgeon become a minimally invasive surgeon?

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

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

Not a mandate, just suggestions

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

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

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

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

Five levels of proficiency

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

Traditional VATS as advanced technology?

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

Source document:

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

Interview with the Brazilian Society of Thoracic Surgery

Thoracics.org talks to the Brazilian Society of Thoracic Surgery and result isn’t what you might expect.

A very different article here at Thoracics.org!  For starters, I’m the interviewee – which doesn’t happen very often.  This interview was a joint collaboration after meeting and talking about issues in thoracic surgery with several Brazilian surgeons including Dr. Sergio Tadeu Pereira, at the ALAT conference in Medellin last July.

at ALAT with Bolivian surgeon, Dr. Cristian Anuz
at ALAT with Bolivian surgeon, Dr. Cristian Anuz

Translation of interview from the December 2014 Journal of the Brazilian Society of Thoracic Surgery*:

The positive outcome of a thoracic surgery depends on several aspects, among them is the teamwork, the harmony between the various professionals involved in making decisions and actions. All experts have an instrumental part in restoring the health and maintenance the patient’s life. Each with its due importance, towards a single goal. The SBCT ratifies such thinking, and this issue of the Journal conducted an interview with K. Eckland, an acute care nurse practitioner in thoracic surgery, writer, and also the founder of Thoracics.org” – a blog about thoracic surgery with an international focus.  She has written several books on surgery in Latin America, including a community sociological examination thoracic surgery in Bogotá, Colombia.

In this conversation, K. Eckland talks about the future of thoracic surgery worldwide and recognizes the contribution of Brazilian surgeons for growth in the art.

Journal SBCT: For us at SBCT is a great pleasure to have their participation in our newspaper. How do you evaluate the specialty in Brazil?
K. Eckland: First, I would like to thank the editors this paper for the invitation to forward my message to Brazilian doctors. More importantly, I would like to serve as call to action to all the experts and future thoracic surgeons. When I look at Brazil, I see the future of thoracic surgery. While, in my own country, our thoracic surgeons are aging with an average age of 60 years, Brazil is full of young, dynamic and innovative surgeons.

Journal SBCT: This predisposition to new techniques of many the Brazilian thoracic surgeons implies an increase in research?

K. Eckland: The high fluency in minimally invasive techniques (in Brazil) combined with some of the largest academic and clinical settings worldwide, outside China, affords unique opportunities in research, development and discovery. Brazil is already home to many of the modern masters of thoracic surgery, names that resonate worldwide.

These surgeons have brought Brazil to the forefront, but it is up to the newest crop of thoracic surgeons to maintain Brazil’s forward momentum for the future.  However, this is hampered by a lack of awareness of the contributions of many Brazilian and other Latin American surgeons.

As a foreigner, writing about developments within the international surgical community, I have noted a large dearth in published research from much of Latin America including Brazil.  What research I do find, is often not widely dispersed or readily available to the rest of the world.  It has taken several years and many thousands of dollars for Cirugia de Torax to acquire and publish information about your many triumphs.  However, this is not the most efficient way for research to be disseminated.

Journal SBCT: In addition to increased investment in research, what more should be done in its assessment to mitigate this  gap in publications and contributions (to the specialty of thoracic surgery)?

K. Eckland: It’s possible to change this story from one of limited international exposure to greater recognition.  But for that to happen, several things need to occur. Firstly, the momentum must be Brazilian thoracic community to participate  and publish research on a large-scale.

Surgeons in São Paulo, for example, have unique opportunities to publish practice-changing work. The Department of Thoracic Surgery, University of São Paulo tracks more thoracic cases in a year than many American institutions have access in a decade. This gives greater impact to studies from this institution than anything that their (North) American colleagues could expect do.

Second, Brazilian surgeons need push for further publication in international journals, and in the international literature language, in English.

Lastly, surgeons need to look outside their corner of the globe and present their findings internationally and outside Latin America on a greater scale.  More groups of Brazilian surgeons should attend international conferences to gain knowledge,and take the opportunity to spread their own knowledge and research findings. Surgeons should not depend on the United States and Europe to take the lead in surgical innovation or research.

There is no reason why these findings will not occur at home, but research needs to be part of your daily practice. It should be more than reading the occasional surgical journal.  It should be a part of active problem solving and solution-seeking.

Journal SBCT: The wide practical experience associated with the host new techniques can be considered as a basis for the growth of the specialty and development more innovative research in Brazil?

K. Eckland:

For this to happen, each surgeon needs ask yourself**:

–  How can I improve my practice? – How can I improve the lives of my patients?

– What can I do to identify and document the phenomena I’m seeing?  – What we are doing now that we need to change? How can we implement these changes? How does this apply to people outside my immediate environment?

Once a potential search area is identified, other questions to ask include:

How I can improve my specialty? How can I represent my country to the world? Sometimes the answers
involve the development of new technologies, sometimes a reframing of the information we already know,
to apply the new clinical scenarios. Other times, we simply need to identify the phenomena and document it to serve as guidance to other professionals. That is what drives the research, and this combined insight with professional curiosity are essential for growth within the specialty. By embracing these concepts, we can begin a new era of thoracic surgery in Brazil and worldwide.

* Corrections to the English translation have been made for ease of reading.  This is an excerpt from a larger interview.

** This is how we identify research to discuss and publish here at Thoracics.org/ Cirugiadetorax.org

For the original article, click here.

XIX Congresso Brasileiro de Cirurgia Torácica

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If you are interested in learning more about the latest research and developments in thoracic surgery in Brazil, the annual conference is this May.

As Florida’s population booms, surgeon shortage becomes acute

As the Florida legislature and medical community considers the impending physician shortage, many of the critical concerns regarding the on-going shortage of surgeons remain unaddressed

Now that Florida is the third most populated state (behind first ranking California and # 2 Texas) in the United States with a census of almost 20 million residents, the ongoing shortage of surgeons is predicted to become more dire over the next ten years.

the thoracic surgeon: a disappearing breed?
the thoracic surgeon: a disappearing breed?

The problem is multi-factorial: Training, debt, compensation (financial and otherwise)

In a recent article by Donna Gehrke – White at the Sun Sentinel, the need for over 7,000 additional physicians (in a variety of specialties) highlights some of the difficulties in training and retaining specialty physicians in American medicine.  Lengthy training regimens coupled with high student loan debt as well as feelings of frustration and ‘burnout‘ plague a medical landscape that is already burdened with concerns over the fragile state of American health care, escalating healthcare costs and the impact of Obamacare and other recent federally mandated changes to the health care system.

“More schools” are not the answer

While Florida is responding to the impending crisis by opening new residency programs, this doesn’t address some of the more crucial concerns – high vacancy rates in existing programs, the exorbitant costs of a surgical education, and a growing dissatisfaction with current working conditions.

How about better loan repayment programs/ debt forgiveness?  Or greater access to patients (and less time dealing with paperwork/ EMR and reimbursement issues)?  Instead of lengthening/ shortening training programs and relying on computerized models, maybe consider improving the quality of American surgical training by separating the specialty into two separate tracks (like most countries)?

Florida’s shortage of thoracic surgeons: 14?

While the estimated shortage of thoracic surgeons in Florida is only projected to be 14, existing problems in retaining surgical residents and low specialty board pass rates and echos both nationwide and global shortage concerns.  With an aging population, rising rates of esophageal cancer and earlier detection (of surgically treatable) cancers, these numbers may not tell the whole story.

Additional Recommended Reading:

Gordon, D. (2014) 15 things to know about the physician shortage.  Becker’s Hospital Review (on-line).

Seaman, A. M. (2012). Surgeon’s pressures may worsen shortage.  Reuters.  As we’ve noted previously, this is not a new concern, and the latest studies and reports only confirm this data.  In fact, this report from the Robert Wood Johnson Foundation from 2011, highlights the fact that surgeon shortages are impacting emergency departments ability to provide emergency life-saving treatment.

Aliwadi, G. & Kron, Irving (2008).  The challenges facing thoracic surgeons.  Vascular disease management.  This 2008 article highlights some of the difficulties in attracting and retaining medical students and surgical residents to the cardiothoracic surgery specialty.  While mainly geared at cardiac surgery – and the issues raised by interventionalists and catheter based interventions, it also touches on some of the educational issues that affect both cardiac and general thoracic surgeons.

The latest STS guidelines on multimodality treatment of esophageal cancer

Cirugia de torax invites readers for an open discussion on the latest STS guidelines on multimodality treatment of esophageal cancer.

Guidelines for esophageal cancer?

Guidelines, guidelines, guidelines.. It seems like much of American medicine is now directed by guidelines, committees and government agencies.  We  have pay-for-performance,  “Core Measures” and even more guidelines, recommendations and requirements that attempt to pre-script the care that we provide.  This often leaves clinicians and surgeons feeling more like technicians following recipes for “cookbook medicine” to treat anonymous, “standardized” patients rather than highly skilled, extensively trained and experienced medical providers using clinical judgment, intellect and training to treat unique individuals.

Guideline fatigue, questionable “evidence” and mandated medicine

With that in mind, many healthcare providers are sick of reading and writing about “evidence-based practice recommendations and clinical guidelines”.   Some of this frustration comes from the sometimes contradictory clinical evidence regarding these mandates, such as pre-operative beta blockade.  While this medication is now mandated by the federal government, multiple studies* question the benefit of this treatment in patients undergoing noncardiac surgery.

As the debate continues to rage over this therapy, is it fair that  surgeons must continue to risk their hospital’s performance scores, and surgical reimbursement for challenging the blanket administration of this medication to their patients?**

Not all guidelines created equally

The concept of clinical guidelines have its origins in the 1960’s.  While differing political camps explain the emergence of these guidelines according to their individual bias (insurance cost-cutting versus autonomy etc.), it seems obvious that these guidelines were at least, initially, designed to improve the overall care of patients with similar diagnoses, symptoms or clinical scenarios.

But when it comes to these clinical guidelines – not all guidelines are created equally.  In addition to criticism that many clinical guidelines are poorly supported by the existing literature, or based on poor quality studies,  allegations of cronyism, obvious bias/ self-serving have plagued guideline committees  particularly in the field of cardiology.

But what does this mean for thoracic surgery?   We have our own organizational committees such as the Society for Thoracic Surgeons, (aka STS),  our own recommendations, guidelines and ratings systems (national and international database).   STS and thoracic surgery based clinical guidelines address the very lifeblood of our specialty and our clinical practice.

It behooves us as a professional specialty to read, review and know these guidelines so that we can determine when and if these guidelines serve our practices and our patients.  If not, as representatives of thoracic surgery; it is our responsibility to participate and to voice our concerns and criticisms of these guidelines.  We are the watchdogs, to prevent the over-representation of commercial interests or bias into our arena of patient care.

It is also crucial that we attempt to support the crafting of recommendations to support and adopt the best practices in thoracic surgery; after all, as practicing clinicians, we know thoracics better than any outside agencies, organizations or other specialties.  With this philosophy in mind, Cirugia de Torax invites readers to become more familiar with the latest STS guidelines.

Society of Thoracic Surgeons guidelines

Thus far, the Society of Thoracic Surgeons has published eighteen guidelines on a wide variety of topics’ from antibiotic use, to cerebral protection of infants undergoing cardiac surgery, the use of TMR, to the newest guidelines on the treatment of esophageal cancer.

Cirugia de Torax would like to invite our American and International readers to participate in a review of the most recent guidelines in our next post.  What do you think of trend towards guidelines in general?  What about the guidelines for multi-modality treatment in esophageal cancer?  Love them?  Hate them?  Any omissions or errors?  Any changes or suggestions for future versions?

Deadline for submission of commentary, criticism or other remarks  is January 15, 2015.

Notes:

* Link requires (free) subscription

** Surgeons can document a ‘variance’ on a case-by- case basis when omitting this and other prescribed core measures under a limited set of circumstances.

 

Article for Review

The Society of Thoracic Surgeons Practice Guidelines on the Role of Multimodality Treatment for Cancer of the Esophagus and Gastroesophageal Junction.

Little, Alex G. et al. (2014).  The Annals of Thoracic Surgery , Volume 98 , Issue 5 , 1880 – 1885.  pdf version.

 

Additional reference articles

1.  Weisz G1, Cambrosio A, Keating P, Knaapen L, Schlich T, Tournay VJ.  (2007).   The emergence of clinical practice guidelines. Milbank Q. Dec;85(4):691-727.

2.  The Society of Thoracic Surgeons Esophageal Cancer Guideline Series.  Mitchell, John D. et al. The Annals of Thoracic Surgery , Volume 96 , Issue 1 , 7

3.  The Society of Thoracic Surgeons Guidelines on the Diagnosis and Staging of Patients With Esophageal Cancer.  Varghese, Thomas K. et al.  The Annals of Thoracic Surgery , Volume 96 , Issue 1 , 346 – 356

Copies of all STS guidelines are available on-line here.

Highlights from Shanghai – Uniportal Surgery conference

Uniportal surgery in Shanghai

While Cirugia de Torax was unable to be in attendance and provide on location reporting and news, I would like to present some highlights from the recent event for our readers..

 

Maybe next year, I’ll see you there.

 

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

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

Dr. Diego Gonzalez Rivas
Dr. Diego Gonzalez Rivas

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

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

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

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

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

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

ALAT : The Grand Trifecta

Talking about the roles of traditional VATS, single port surgery and robots in modern thoracic surgery.

The Ethicon (Johnson & Johnson) sponsored session was by far, the best of the conference – and an excellent overview of modern technologies in thoracic surgery.

DSC_0039
starting with Dr. Ricardo Buitrago (purple tie), Dr. Diego Gonzalez Rivas (blue tie) and Dr. Mario Ghefter (pink tie) are changing the future of thoracic surgery

Dr. Diego Gonzalez Rivas

“Is uni-port surgery feasible for advanced cancers?”  Short answer: Yes.

The first speaker, was Dr. Diego Gonzalez Rivas of Coruna, Spain.  He is a world-renown thoracic surgeon and innovator of uni-port thoracoscopic surgery.  He discussed the evolution of single port surgery as well as the most recent developments with this technique, including more advanced and technically challenging cases such as chest wall resections (2013), sleeve resections/ reconstructions (2013), pulmonary artery reconstructions (2013) and surgery on non-intubated, awake patients (2014).

Experience and Management of bleeding

The biggest challenges to surgeons learning this technique is management of bleeding.  But as he explained in previous lectures, this can be overcome with a direct approach.  (these lectures and YouTube videos, Dr. Gonzalez explains the best ways to manage intra-operative bleeding.) In the vast majority of cases – this did not require deviation or conversion from the uni-port technique.)

As surgeons gain proficiency with this technique which mirrors open surgery, the only contra-indications for surgical resection of cancerous tissue (by single port) are tumors of great size, and surgeon discomfort with the technique.

Dr. Mario Ghefter

My favorite lecture of the series was given by Dr. Mario Ghefter of Sao Paolo, Brazil.  While his lecture was ostensibly about video-assisted thoracoscopy (VATS), it was more of a retrospective vision and discussion of the modern history of thoracic surgery as seen through the eyes of a 22 year veteran surgeon.

He talked about the beginnings of VATS surgery and the contributions from such legends as Cefolio and D’Amico, including the 2005 paper – and modern-day thoracic bible, “Troubleshooting video-assisted thoracoscopic lobectomy (Demmy, James, Swanson, McKenna and D’Amico).

Dr. Ghefter also talked about how improved imaging and diagnostic procedures such as PET-CT and EBUS have been able to provide additional diagnostic information pre-operatively that helps surgeons to plan their procedures and treatment strategies more effectively.

Dr. Mario Ghefter
Dr. Mario Ghefter

As a counterpoint to both Dr. Gonzalez and Dr. Buitrago, Dr. Ghefter acquitted himself admirably.  He reminded audience members that even the newer technologies have some drawbacks – both as procedures and for the surgeons themselves.

He also successfully argued (in my opinion) that while the popularity of procedures such as multiple port VATS and even open thoracotomies have dropped drastically as thoracic surgeons embrace newer technologies, there will always be a place and time for these more traditional procedures.

Dr. Mario Ghefter is the Director of Thoracic Surgery at Hospital do Servidor Público Estadual – Sāo Paulo and on staff at the Hospital Alemão Oswaldo Cruz.

Dr. Ricardo Buitrago

Native Colombian (and my former professor), Dr. Ricardo Buitrago is acknowledged as one of the foremost experts in robotic thoracic surgery in Latin America.

During his presentation, he discussed the principles and basics of use of robotic techniques in thoracic surgery.  He reviewed the existing literature surrounding the use of robotic surgery, and comparisons of outcomes between thoracic surgery and traditional lobectomy.

He reviewed several recent robotic surgery cases and the use of robotics as a training tool for residents and fellows.

While he mentioned some of previously discussed limitations of robotic surgery (namely cost of equipment) he cited recent studies demonstrating significant cost savings due to decreased length of stay and a reduced incidence of surgical complications.

He also discussed recent studies (by pioneering surgeons such as Dr. Dylewski) demonstrated short operating times of around 90 minutes.

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

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

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

The Babe Ruth of modern thoracic surgery

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

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

The answer is International collaboration and sharing of ideas

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

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

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

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

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

In other news:

Welcome to Tennessee!

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

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

Big Plans for UT and the city of Memphis

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

Related: Dr. Weksler talks about smoking cessation

Minimally invasive techniques for esophageal surgery

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

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

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

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

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

Dr. 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
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
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. Gonzalez Rivas
Dr. Gonzalez Rivas

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.

Dr. Paula Ugalde
Dr. Paula Ugalde

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 VATSJ. 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 lobectomyJ. 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.

Living legends and Cirugia de Torax

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

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

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

Making thoracic surgery accessible

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

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

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

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

Serving practicing surgeons

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

Heady aspirations

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

Patient-focused information

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

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

Avoiding ‘Google overload’

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

Connecting patients to surgeons

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

Update:  June 2019

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

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

Keeping it ‘real’

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

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

K. Eckland

The cowboys and rodeo stars of thoracic surgery

Discussing Dr. Joseph Coselli and ‘the cowboys of cardiac surgery’ along with some of our own heros of thoracic surgery here at Cirugia de Torax.

There’s a great article in this month’s Annals of Thoracic Surgery, by Dr. Joseph Coselli, from Texas Heart Institute and the Michael DeBakey Department of Surgery at Baylor.   His article, entitled,” My heros have always been cowboys” is more than just a title torn from the song sheets of Willie Nelson.  It’s a look back at both the pioneers of cardiac surgery and his own experiences as a cardiac surgeon.  He also discusses the role of surgeons, and medical practitioners in American society in general and the promises we make to both society at large and our patients.

Here at Cirugia de Torax, I’d like to take a moment to look back at the surgeons that inspired and encouraged me in this and all of my endeavors.  Some of these surgeons knew me, and some of them didn’t – but their encouragement and kindnesses have spurred a career and life that have brought immense personal and professional satisfaction.

Like Dr. Coselli, I too, took inspiration from the likes of Dr. Denton Cooley.  But our stories diverge greatly from there.  I never met Dr. Cooley and I probably never will.  But it was a related story, from my former boss (and cardiothoracic surgeon), Dr. Richard Embrey that led to an email to Dr. Cooley himself.  My boss had too trained under Dr. Cooley, Dr. Debakey and the Texas Heart Institute, the citadel of American heart surgery.   Then, somehow, along the way – Dr. Embrey stopped to work at our little rural Virginia hospital.  We were the remnants of a larger Duke cardiothoracic program but we were a country hospital all the same.

While I learned the ins and outs of surgery from Dr. Embrey (and Dr. Geoffrey Graeber at West Virginia University) on a day-to-day basis, I was also weaned on the folklore of cardiothoracic surgery – stories of the giants of history, like the ones mentioned in Dr. Coselli’s article, as well as local Duke legends who occasionally roamed the halls of our tiny ICU and our two cardiothoracic OR suites; Dr. Duane Davis, Dr. Shu S. Lin and Dr. Peter Smith.  While never working side-by-side, Dr. D’Amico’s name was almost as familiar as my own.  As the sole nurse practitioner in this facility, without residents or fellows, there was no buffer, and little social divide in our daily practice.  Certainly, this changed me – and my perceptions.  I asked the ‘stupid’ questions but received intelligent and insightful answers.  I asked even more questions, and learned even more..

These opportunities fed my mind, and nurtured my ambitions.  Not to be a physician or a doctor, but to learn as much as possible about my specialty; to be the best nurse possible in my field.  It also nurtured a desire to share these experiences, and this knowledge with my peers, my patients and everyone else who ever had an interest.

It was that tiny little email, a gracious three-line reply from Dr. Cooley himself that made me realize that I didn’t have to rely on folklore and second-hand stories to hear more.  That’s critical; because as we’ve seen (here at Cirugia de Torax) there are a quite of few of “Masters of thoracic surgery” or perhaps future giants that haven’t had their stories told.  Dr. Coselli and his fellow writers haven’t written about them yet.. So I will.

Sometimes I interview famous (or semi-famous) surgeons here, but other times, I interview lesser-known but equally talented/ innovative or promising surgeons.  All of them share similar traits; dedication and love for the profession, immense surgical talent and proficiency and sincere belief in the future of technology of surgery.

So, let’s hope that it won’t take forty more years for these surgeons to be recognized for their contributions to thoracic surgery in the way that Cooley, DeBakey and Crawford are heralded in cardiac surgery.

K. Eckland, ACNP-BC

Founder & Editor -in – chief

Thoracic surgery shortage worsens as graduates fail to pass exams

a record number of surgeons fail to pass the American thoracic surgery certification exam, in the midst of a deepening shortage of surgeons.

A new report from the (American) Board of Thoracic Surgery shows a growing number of eligible surgeons are failing the thoracic surgery certification examination.

Record Failure Rate

As stated in the article published at Family Practice News, the failure rate has doubled to 28% in just a few short years.  This comes at a critical period in American medicine as shortages in specialty surgeons have emerged around the country due to an aging workforce.  This shortage is not confined to the United States – and has been echoed in Canada, the UK and several other industrialized nations.

Decrease in resident hours = decreased surgical knowledge

This record failure rate comes in the wake of recent reforms to resident surgical education  – including several reductions in resident training hours, and the push for a condensed 6 year residency program.

Rapidly evolving surgical technology

At the same time, rapidly evolving surgical technology and research in thoracic surgery may actually require significant curriculum changes and increased length of specialty training, according to this report at Thoracic Surgery News.

But, as previously reported, the extensive training requirements for cardiothoracic surgery have led to fewer residents and widespread vacancies in residency programs as fewer and fewer surgical residents elect to devote themselves to cardiothoracic surgery due to concerns about diminishing financial returns, reduced economic opportunities, excessive student loan burdens and concerns related to the hardships of the ‘cardiothoracic lifestyle’.

Solo Cardiac, General Thoracic tracks may trump combined “Cardiothoracic”

Alternatively, North American surgeons may need to follow the example of many of their international peers and diverge into two separate tracks: cardiac surgery and general thoracic to maintain surgical proficiency without excessive education burden in an era of rapidly evolving surgical knowledge.

 

Additional Recommended Reading:

Ann Thorac Surg. 2009 Aug;88(2):515-21; discussion 521-2. doi: 10.1016/j.athoracsur.2009.04.010.

Awake Epidural Anesthesia for thoracoscopic pleurodesis

Awake epidural anesthesia for thoracoscopic pleurodesis: A prospective cohort study. a new publication from Dr. Mauricio Velasquez and his surgical team reviewing results from their 36 month study

On the heels of a recent announcement on CTSnet.org soliciting surgeon input on their experiences with non-general anesthesia for thoracic surgery procedures, Cirugia de torax is revisiting one of the surgeons we interviewed last year, Dr. Mauricio Velasquez at Fundacion Valle de Lili in Cali, Colombia.

Dr. Velasquez in the operating room with Lina Caicedo Quintero (nurse) Valle de Lili, Cali, Colombia
Dr. Velasquez in the operating room with Lina Caicedo Quintero (nurse) Valle de Lili, Cali, Colombia

The trip to Cali was primarily to discuss Dr. Velasquez’s Thoracic Surgery Registry, and to observe him performing several single port surgery cases.  However, during the trip, Dr. Velasquez also spoke about several other aspects of his current practice including some of his recent cases, and the thoracic surgery program at Fundacion Valle de Lili.

Dr. Mauricio Velasquez after another successful case
Dr. Mauricio Velasquez after another successful case

We also talked with his wife, (and lead author), the talented Dra. Cujiño, an anesthesiologist who subspecializes in thoracic anesthesia.   Together, they have successfully performed several thoracic cases using thoracic epidural anesthesia on awake patients.

By chance, they published articles in both  Revista Colombianas de anesthesia and Neumologia y cirugía de torax in the last few weeks.

Revista Colombianas de anesthesia

Patients receiving epidural anesthesia received a small dose of midazolam prior to insertion of epidural needle at the T3 – T4 intervertebral space.  During the case, patients received bolus administration via epidural of 0.5% bupivacaine on a prn basis.

Short surgeries, single port approach

All patients, regardless of anesthesia type underwent single port thoracoscopic surgery for the talc pleurodesis procedure.  Surgery times were brief, averaging 30 to 35 minutes  for all cases (range 25 – 45 minutes) with the epidural patient cases being slightly shorter.

Dr. Mauricio Velasquez performing single port thorascopic surgery
Dr. Mauricio Velasquez performing single port thorascopic surgery

Dramatic reduction in length of stay

In their study, patients receiving awake anesthesia had an average length of stay of four days compared with ten days for the general anesthesia group.

Decreased incidence of post-operative complications

There was a marked reduction in the incidence of post-operative respiratory complications (19 in general anesthesia group) versus 3 patients in the awake anesthesia group.  Post-operative mortality was also decreased (six in general anesthesia) versus two deaths in the awake anesthesia group.  However, the mortality statistics may also be impacted by the overall poor prognosis and median survival time of patients presenting with malignant effusions.

Post-operative pain

Study patients also self-reported less post-operative pain in the awake anesthesia group – with only one patient reporting severe pain versus seven patients in the general anesthesia group.

Conclusions

Cujiño, Velasquez and their team found awake thoracic epidural anesthesia (ATEA) was a safe and effective method for intra-operative anesthesia and was associated with a decreased post-operative pain, decreased length of stay (LOS) and decreased incidence of post-operative complications.

Notes

This study was funded by the authors with no relevant disclosures or outside financial support.

References

Indira F. Cujiño,  Mauricio Velásquez,  Fredy Ariza,  Jhon Harry Loaiza (2013).    Awake epidural anesthesia for thoracoscopic pleurodesis: A prospective cohort studyRev Colomb Anestesiol. 2013;41:10-5.  A 36 month study involving 47 cancer patients comparing (standard) general anesthesia outcomes with awake epidural anesthesia.

en Espanol: Anestesia epidural para pleurodesis por toracoscopia: un estudio prospectivo de cohort.

The second article has not been posted online yet.  Look for updates in the coming weeks.

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.

Evolving thoracic surgery: from open surgery to single port thoracoscopic surgery and future robotic

the future of thoracic surgery as seen by one of the New Masters, Dr. Diego Gonzalez Rivas.

A new editorial by ‘New Master‘, Dr. Diego Gonzalez Rivas explores the evolution of thoracic surgery from traditional open surgery to minimally invasive technologies such as robotic surgery and single port surgery.  The article is available on-line and as a free pdf download over at the Chinese Journal of Cancer Research.

Dr. Gonzalez at a conference in Chile
Dr. Gonzalez at a conference in Chile

We’ve also posted it here for our readers.

Gonzalez Rivas, D. (2013).  Evolving thoracic surgery: from open surgery to single port thoracoscopic surgery and future robotic.  Chinese Journal of Cancer Research, 25 (1) 4-6.  Editorial pdf download.

Surgeon shortage to hit rural areas the hardest

the latest predictions on the impending shortage of surgeons in the United States

Unsurprisingly – rural area hospitals face additional challenges in attracting and retaining specialty surgeons in comparison to big cities/ metropolitan areas.  However, as reported by Patrice Welding at Thoracic Surgery News in a report on the annual meeting of the Central Surgical Association, this may be viewed as a boon for the surgeons themselves as hospitals may devise new and enhanced incentives to attract surgeons to their facilities.  The surgical specialties most likely to benefit from this strategy include (as previously reported), obstetrics and gynecology, or­thopedic surgery, general surgery, otolaryngology, urology, neurosurgery, and thoracic surgery.

The article which quotes Dr. Thomas E. Williams, Jr. predicts that hospitals and institutions may break out into a ‘bidding war’ over surgeons.

While this is dire news for rural hospitals  and the estimated 56 million patients served by these facilities, it comes as a relief for current thoracic surgery fellows and new thoracic surgeons who have faced an increasingly bleak economic landscape over the last few years.

Of course, more sanguine experts note that the impact of the impending shortage has been reported for several years – with little impact on the current job market for new graduates.

The United States isn’t the only nation to be suffering from a shortage of surgeons, particularly in thoracic surgery.  So, maybe this is one of the questions we should be asking.

Dr. Thomas E. Williams Jr. is one of the main researchers on the impending shortage in the United States and published a book based on his findings in 2009, entitled, “The coming shortage of surgeons: why they are disappearing and what that means for our health“. (Praeger, ISBN #978-0313380709).  His work has also be published in multiple journals, and presented in meetings and conferences across the country.

Williams, T. E & Ellison, E. C. (2008). Population analysis predicts a future critical shortage of general surgeons.   Surgery, 144 (4): 548-556, October 2008.

1st Asian Single Port Symposium & Live Surgery

Interested in learning more about single port thoracoscopy, or talking to the inventors of this technique? This March – head to the 1st Asian single port surgery conference in Hong Kong.

It doesn’t look like Cirugia de Torax will be in attendance for this conference, but it’s another opportunity for practicing thoracic surgeons and thoracic surgery fellows to learn more about single port thoracoscopic surgery.

This March (7th – 8th), the Chinese University of Hong Kong, along with the Minimally Invasive Thoracic Surgery Unit (Coruna, Spain), and Duke University are presenting the 1st Asian Single Port Symposium and Live Surgery conference in Hong Kong.

This is your chance to meet the experts – and the inventors of this technique (such as Dr. Diego Gonzalez – Rivas, one of the new masters frequently featured here at Cirugia de Torax.)

conference

“General Thoracic Surgery” is thoracic surgery

what is the future of thoracic surgery education? A new American study asks the if it is time to separate the specialties of cardiac and thoracic surgery.

A new study by Cooke & Wisner performed at a large medical center in California (UC Davis) and published in the Annals of Thoracic Surgery  provides additional weight to the idea that Thoracic Surgery has increasingly developed into it’s own subspecialty away from the traditional cardiothoracic surgery model (seen in the United States and several other countries.)

In an article published in Medical News Today, the authors of the study explained that the increased complexity of (noncardiac) thoracic surgery procedures for general thoracic conditions has led to increased referrals and utilization of general thoracic surgeons (versus cardiac or general surgeons).  This shows a reversal in a previous trend away from specialists – with more patients now receiving “complex” thoracic surgery procedures from specialty trained, board-certified thoracic surgeons.  Previously up to 75% of all thoracic surgery procedures were performed by general surgeons.

As the authors of the study discussed; this has serious implications for the curriculum of thoracic surgery fellowship programs, particularly as the specialty tries to attract more residents to stem an on-going and critical shortage.

With lung cancer rates expected to climb dramatically in North America and Europe, particularly in women – along with esophageal cancer, and   long waits already common, support and on-going discussion about the evolution of resident and fellow education is desperately needed.

Reference

Cooke, D. T. & Wisner, D. H. (2012).  Who performs complex noncardiac thoracic Surgery in United States Academic Medical Centers? Ann Thorac Surg 2012;94:1060-1064. doi:10.1016/j.athoracsur.2012.04.018

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

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

Cali, Colombia

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

Dr. Mauricio Velasquez after another successful case

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

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

Education and training

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

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

Single port surgery

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

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

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

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

Team approach

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

In the operating room with Dr. Velasquez

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

Dr. Velasquez performing single port thoracoscopy

Cases proceeded rapidly; with no complications.

close up view

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

Recent Publications

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

Single port thoracoscopy for wedge resection – does size matter?

Dr. Chen discusses single port thoracoscopy – and specimen size.

Single port thoracoscopy for wedge resection – does size matter?
Dr. Chih-Hao Chen, Thoracic Surgeon, Mackay Memorial Hospital, Taiwan
Correspondence: musclenet2003@yahoo.com.tw

Case presentation and discussion

A 77 y/o woman was found to have a neoplasm in RML during routine health exam. (Full case presentation here.)
The incision was 2.5 cm. The specimen was removed successfully; patient experienced no complications and was discharged from the hospital without incident. However, when discussing this case with surgeon colleagues a specific question arose.

preparing to remove the specimen through the port

Does size matter? How big is too big to remove through a port incision?
An important issue is the theoretically smallest (and effective) incision size.  The issue is very challenging for most surgeons. In the past, other surgeons have questioned me :
“The specimen to be removed is more than 12-15 cm. How can you remove the specimen from a 3.5 cm incision?”

BUT, the fact is “the smallest size depends mostly on the solid part of the neoplasm “.

The lung is soft in nature. In my experience, a 3.5 cm port is usually enough for any lobe.  The only problem is that if the solid part is huge, pull-out of the specimen may be difficult.
Therefore, the solid part size is probably the smallest incision size we have to make, usually in the last step when dissection completed , if needed.

successful removal of lung specimen thru small port
Port with chest tube in place

Using endo-bags to avoid larger incisions
There is an exception. I have never do this but I think it may be possible.  We usually avoid opening the tumor (or cutting tumor tissue into half ) within the pleural space in order to prevent metastasis from spillage of cancerous tissue.

What if we can protect the tumor from metastasis while we cut it into smaller pieces? For example, into much smaller portions that will easily pass through the small port incisions?
My idea is to use double-layer or even triple layers of endo-bag to contain the specimen. If it is huge, with perfect protection, we cut it into smaller parts within the bag. Then the huge specimen  can be removed through a very tiny incision. This is possible.

We still have to avoid “fragmentations” since this might interfere or confuse the pathologist for accurate cancer staging. Therefore, in theory, we can cut it into smaller parts but not into fragments. However this idea is worthy of consideration, and I welcome debate from my fellow surgeons and medical colleagues.

Thank you to Dr. Chen.

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.

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.

 

Pulmonology throws down the gauntlet..

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

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

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

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

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

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

Abstract and Introduction

Abstract

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

Introduction

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

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

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

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

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

Surgery for Diagnosis of Pleural Effusions

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

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

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

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

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

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

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

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

Surgery for Pleural Infection

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

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

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

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

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

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

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

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

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

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

Surgery for Malignant Pleural Effusions

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

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

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

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

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

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

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

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

Indwelling Pleural Catheters

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

Surgery for Malignant Pleural Mesothelioma

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

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

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

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

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

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

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

Surgery for Chylothorax

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

Surgery for Pneumothorax

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

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

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

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

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

Conclusion

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

Sidebar

Key Points

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

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    • of special interest
    •• of outstanding interest
    Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 293).

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

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

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

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.

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.)

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.

Robotic Thoracic Surgery

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

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

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

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

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

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

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

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

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

The Future of Thoracic Surgery

What is the future of thoracic surgery? Who are our brightest and best young surgeons? Who are the upcoming surgeons of tomorrow?

The future of Thoracic Surgery and the impending shortages of thoracic surgeons is something I’ve talked about before on my sister sites, but since it’s integral to any discussion on thoracic surgery – I’ve re-posted some of my thoughts here.

In discussions on the growing medical tourism phenomenon, we talked about the fact that these shortages, not cost, will soon be the driving force behind the outsourcing of American health care.

We also talked about the need to interview thoracic surgeons in other locations, tour their facilities, observe surgeries and evaluate the care – to establish our international networks now, in:
Chasing Thoracics

But, as this site grows and matures, I would also like to start profiling some of the wonderful and talented surgeons I have been interviewing and meeting during my travels. I also [and this is a big leap] would like to do MORE travelling, as part of an effort to meet more of our thoracic surgery counterparts all over the globe – and bring them here, to you, my readers.

K. Eckland ACNP

For a snapshot of Thoracic Surgeons (dated to 2002), the profession, and projections – this article gives an excellent overview.

Impending Thoracic Surgery Shortage – unable to fill residencies (2008)

Thoracic surgery education; Past, Present and Future (2005) – shortage projections, educational requirements and implications for the future