the latest trailer about the documentary film on single port surgery and information about an upcoming training course.
For everyone that’s interested in learning more about the single port surgery technique, as taught by its creator, Dr. Diego Gonzalez Rivas – here’s another opportunity which may be closer to home for some readers.
The February conference takes place in Berlin, Germany on the 19th thru 21st. While Dr. Gonzalez Rivas, Dr. Delgado and Dr. Prado are headlining the event, other prominent thoracic surgeons such as Gaetano Rocco (Italy) and Alan Sihoe (Hong Kong) will also be lecturing at this event.
The conference includes live surgery demonstrations as well as a wet-lab for hands-on practice.
Deadline for registration is February 6th. Interested surgeons should contact:
R. Mette, M. Schmitt Charité – Universitätsmedizin Berlin Tel. +49 30 450 622 132 | Fax +49 30 450 522 929 E-mail: firstname.lastname@example.org
In other news – the newest trailer for the documentary about Dr. Gonzalez Rivas and his work was recently released. I encourage all thoracic surgery personnel to see (and promote) this movie, which highlights the work of one of our own.
Reviewing “Ten years experience on 644 patients undergoing single-port (uniportal) video-assisted” by Gaetano Rocco et al. at the National Cancer Institute in Naples, Italy
In this month’s issue of the Annals of Thoracic Surgery, Dr. Gaetano Rocco and his colleagues at the National Cancer Institute, Pascale Foundation in Naples, Italy reported their findings on ten year’s worth of single-port surgery in their institution.
Who: 644 patients; (334 males, 310 females)
What: Outcomes and experiences in single port thoracic surgery over a ten-year period. All procedures performed by a single surgeon at this institution, and single-port VATS accounted for 27.7% of all surgeries performed during this time period.
When: data collected on thoracic surgery patients from January 2000 – December 2010.
Pre-operative CT scan was used for incision placement planning. Incision was up to 2.5 cm (1 inch) in length depending on indications for surgery.
Conversion rate to 2 or 3 port VATS: 2.2% (14 patients)
Conversion to mini-thoracotomy: 1.5% (10 patients)
Patients underwent conversion due to incomplete lung collapse (22 patients) and bleeding (2 patients).
There were no re-operations or “take backs”. The four patients with malignant effusions who died within the 30 day post-op period were re-admitted to the ICU.
Otherwise, all patients were admitted to either the floor or the step-down unit following surgery.
Pain management: post-operative pain was managed with a non-narcotic regimen consisting of a 24 hour IV infusion pump of ketorolac (20mg) and tramadol (100mg*). After the first 24 hours, patients were managed with oral analgesics such as paracetamol (acetaminophen).
Limitations: in this study, uni-port VATS was not used for major resections, as seen in the work of Dr. Diego Gonzalez and others. This may be due to the fact that uni-port VATS was an emerging technique at the initiation of this study.
Strengths: This is one of the largest studies examining the use of single-port thoracic surgery – and showed low morbidity and mortality. (Arguably, the 30 day mortality in this study was related to the patients’ underlying cancers, rather than the surgical procedure itself.)
*Intravenous tramadol is not available in the United States.
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.
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: email@example.com
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.
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.
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.
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.
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.
a new article published in Cancer, and summarized at Medscape talks about the importance of Lung Resection for long-term survival in Lung Cancer.
Re-posting an article on the benefits of early surgical intervention on elderly patients with early stage lung cancers from Medscape.com. This is a nice article summarizing the research study conducted by Dr. Nancy Keating at Harvard Medical School in Boston, MA. A link to the original research abstract is here, but no free full-text available.
This article that highlights the importance of surgery – even for patients that primary care physicians and others may not immediately think of as great surgical candidates (frail elderly, COPD, other illnesses.)
Unfortunately, they didn’t address WHO was doing the surgeries – was it thoracic surgeons in high resection geographic areas (on the higher risk patients) as is often the case? Were surgeries in the areas with lower resection rates more likely to be done by general surgeons who are less experienced in operating on more frail thoracic patients? [all thoracic patients are frail to some decrease given the nature of the condition – so specialty trained thoracic surgeons are usually much more experienced in caring for these patients]. It would have been nice to know.
Surgery Rates tied to Lung Cancer Outcomes in the Elderly
David Douglas (Medscape)
NEW YORK (Reuters Health) Aug 24 – People with early non-small cell lung cancer (NSCLC) live longer if they’re in regions of the U.S. where doctors perform more surgeries for that indication, according to a new study.
The link between higher surgery rates and better survival held true even for frailer patients.
“We found that areas with high rates of surgery tended to operate on older and sicker patients, yet still had better outcomes for early-stage lung cancer than areas with lower use of surgery,” said senior investigator Dr. Nancy L. Keating in an email to Reuters Health.
“These data suggest that areas with lower surgery rates may benefit from higher rates of surgery,” she said.
Dr. Keating, from Harvard Medical School in Boston, said, “Resection has by far the highest chance of cure.”
But, she noted, “It may be that fear of harm (surgeons being concerned about causing poor outcomes) may be leading to relative underuse of this effective treatment.”
“While there are some patients for whom the risks certainly outweigh the benefits,” she added, “those patients may be fewer than some physicians recognize.”
Dr. Keating and colleagues studied a population-based cohort of more than 17,000 Medicare beneficiaries at least 66 years old who were diagnosed with stage I or II NSCLC during 2001 to 2005.
Using Surveillance, Epidemiology, and End Results (SEER) data, they compared areas with high and low rates of curative surgery for early stage lung cancer.
Fewer than 63% of patients had operations in low-surgery areas, whereas more than 79% did in high-surgery areas, according to a July 28th online paper in Cancer.
The high-surgery areas saw more operations on older patients and in those with chronic obstructive pulmonary disease (COPD).
The one-year lung-cancer-specific mortality rate was 12% in the high-surgery regions and 17% in low-surgery. The adjusted odds ratio for each 10% increase in the surgery rate was 0.86. There were similar findings for all-cause mortality.
Original article reference information:
Cancer. 2011 Jul 28. doi: 10.1002/cncr.26363. [Epub ahead of print]. Improved outcomes associated with higher surgery rates for older patients with early stage nonsmall cell lung cancer. Gray SW, Landrum MB, Lamont EB, McNeil BJ, Jaklitsch MT, Keating NL.
This limited study compared combination treatment using photodynamic therapy along with a lesser lung surgery (14 patients) in comparison to extrapleural pneumonectomy alone (14 patients). 22 of the 28 patients also received chemotherapy.
Patient population: 28 patients – 12 /14 patients in either group with advanced (stage III/IV ) disease
Results: Extrapleural pneumonectomy group had a median survival of 8.9 months. The combination photodynamic/ surgery group median survival exceeded two years (when the study ended).
Take away message for readers: It’s too early, and the study groups are far too small for us to generalize these findings. However, these preliminary results are encouraging and should prompt more, larger scale studies / trials looking at photodynamic therapy as adjuvant therapy along with thoracic surgery for pleural mesothelioma.
the mesothelioma study from PA just got picked up by a major wire service, so expect to read and hear a lot more about it.
Update: 08/15/2014: Mesothelioma.net has asked that I link with their site. They offer some informational services for people facing mesothelioma. Please let me know if this site is spam-plagued or otherwise dubious and I will remove the link (the site is a bit ‘shiny’ and circular for my taste.)
How to maximize your chances before lung surgery to speed healing, post-operative recovery and reduce the incidence of complications.
As most of my patients from my native Virginia can attest; pre and post-operative surgical optimization is a critical component to a successful lung surgery. In most cases, lung surgery is performed on the very patients who are more likely to encounter pulmonary (lung) problems; either from underlying chronic diseases such as emphysema, or asthma or from the nature of the surgery itself.
Plainly speaking: the people who need lung surgery the most, are the people with bad lungs which makes surgery itself more risky.
During surgery, the surgeon has to operate using something called ‘unilung ventilation’. This means that while the surgeon is trying to get the tumor out – you, the patient, have to be able to tolerate using only one lung (so he can operate on the other.)
Pre-surgical optimization is akin to training for a marathon; it’s the process of enhancing a patient’s wellness prior to undergoing a surgical procedure. For diabetics, this means controlling blood sugars prior to surgery to prevent and reduce the risk of infection, and obtaining current vaccinations (flu and pneumonia) six weeks prior to surgery. For smokers, ideally it means stopping smoking 4 to 6 weeks prior to surgery.(1) It also means Pulmonary Rehabilitation.
Pulmonary Rehabilitation is a training program, available at most hospitals and rehabilitation centers that maximizes and builds lung capacity. Numerous studies have show the benefits of pre-surgical pulmonary rehabilitation programs for lung patients. Not only does pulmonary rehabilitation speed recovery, reduce the incidence of post-operative pneumonia,(2) and reduce the need for supplemental oxygen, it also may determine the aggressiveness of your treatment altogether.
In very simple terms, when talking about lung cancer; remember: “Better out than in.” This means patients that are able to have surgical resection (surgical removal) of their lung cancers do better, and live longer than patients who receive other forms of treatment such as chemotherapy or radiation.
If you are fortunate enough to have your lung cancer discovered at a point where it is possible to consider surgical excision – then we need you to take the next step, so you are eligible for the best surgery possible.
We need you to enhance your lung function through a supervised walking and lung exercise program so the surgeon can take as much lung as needed. In patients with marginal lung function,(3) the only option is for wedge resection of the tumor itself. This is a little pie slice taken out of the lung, with the tumor in it. This is better than chemotherapy or radiation, and is sometimes used with both – but it’s not the best cancer operation because there are often little, tiny, microscopic tumor cells left behind in the remaining lung tissue.
The best cancer operation is called a lobectomy, where the entire lobe containing the tumor is removed. (People have five lobes, so your lung function needs to be good enough for you to survive with only four.(4) This is the best chance to prevent a recurrence, because all of the surrounding tissue where tumors spread by direct extension is removed as well. Doctors also take all the surrounding lymph nodes, where cancer usually spreads to first. This is the best chance for five year survival, and by definition, cure. But since doctors are taking more lung, patients need to have better lung function , and this is where Pulmonary Rehab. comes in. In six weeks of dedicated pulmonary rehab – many patients who initially would not qualify for lobectomy, or for surgery at all – can improve their lung function to the point that surgery is possible.
Post-operatively, it is important to continue the principles of Pulmonary rehab with rapid extubation (from the ventilator), early ambulation (walking the hallways of the hospitals (5) and frequent ‘pulmonary toileting’ ie. coughing, deep breathing and incentive spirometry.
All of these things are important, where ever you have your surgery, but it’s particularly important here in Bogota due to the increased altitude.
One last thing for today:
a. Make sure to have post-pulmonary rehab Pulmonary Function Testing (PFTs, or spirometry) to measure your improvement to bring to your surgeon,
b. walk daily before surgery (training for a marathon, remember)
c. bring home (and use religiously!) the incentive spirometer provided by rehab.
ALL of the things mentioned here today, are things YOU can do to help yourself.
1. Even after a diagnosis of lung cancer, stopping smoking 4 to 6 weeks before surgery will promote healing and speed recovery. Long term, it reduces the risk of developing new cancers.
2. Which can be fatal.
3. Lung function that permits only a small portion (or wedge section) to be removed
4. A gross measure of lung function is stair climbing; if you can climb three flights of stairs without stopping, you can probably tolerate a lobectomy.
5. This is why chest tube drainage systems have handles. (so get up and walk!)
and the snowball effect of atrial fibrillation after surgery. Discussion includes beta blockers and vitamin C as methods to reduce the incidence of post-operative atrial fibrillation with discussion of the literature supporting its use.
In previous posts, we’ve talked about prevention and management of respiratory complications of lung surgery. However, one of the more common complications of lung surgery, is atrial fibrillation, or an abnormal heart rate and rhythm. Most of the time, atrial fibrillation after surgery is temporary – but that does not make it a benign problem.
Developing atrial fibrillation is problematic for patients because increases length of stay (while we attempt to treat it) and increases the risk of other problems (such as stroke – particularly if we can’t get the heart rhythm to return to normal).
‘The Cootie Factor’ Length of stay is important for more than cost and convenience. One of the things I try to explain to my patients – is that hospitals are full of sick people, and in general, my surgery patients are not sick– they’ve had surgery..
But surgery increases their chance and susceptibility to contracting infections from other patients, and visitors. I call this ‘the cootie factor’. (Everyone laughs when you say cooties – but everyone knows exactly what you mean.) So the reason I am rushing my patients out the door is more than just for patient convenience and the comforts of home – it’s to prevent infection, and other serious complications that come from being hospitalized, in close quarters, with people who have may have some very bad cooties indeed (MRSA, resistant Klebsiella, VRE, Tuberculosis and other nasties.)
But besides, length of stay – atrial fibrillation, or a very rapid quivering of the atrial of the heart (250+ times per minute) increases the chance of clots forming within the atrial of the heart, and then being ejected by the ventricles straight up into central circulation – towards the brain – causing an embolic stroke.. Now that’s pretty nasty too..
Atrial fibrillation risk reduction
But there are some easy things we can do to reduce the chance of this happening..
One of the easiest ways to prevent / reduce the incidence of post-operative atrial fibrillation – to slow down the heart rate. We KNOW that just by slowing down the heart by 10 – 15 beats per minute, we can often prevent abnormal heart rhythms.
Most of the time we do this by pre-operative beta blockade, which is a fancy term for using a certain class of drugs, beta blockers (such as metoprolol, carvedilol, atenolol) to slow the heart rate, just a little bit before, during and after surgery.
In fact, this is so important – national/ and international criteria uses heart rate (and whether patients received these medications prior to surgery) as part of the ‘grading’ criteria for rating surgery/ surgeons/ and surgery programs. It’s part of both NSQIPs and the Surgical Apgar Scale – both of which are important tools for preventing intra-operative and post-operative problems..
The good thing is, most of these drugs are cheap (on the $4 plan), very safe, and easily tolerated by patients. Also, most patients only need to be on these medications for a few days before and after surgery – not forever.
Now, if you do develop atrial fibrillation (a. fib) after surgery – we will have to give you stronger (more expensive, more side effects) drugs such as amiodarone, or even digoxin (old, but effective) to try to control or convert your heart rhythm back to normal.
If you heart rhythm does not go back to normal in a day or two – we will have to start you on a blood thinner like warfarin to prevent the blood clots we talked about previously. (Then you may have to have another procedure – cardioversion, and more medicines, if it continues, so you can start to see why it’s so important to try to prevent it in the first place).
Research has also looked at statin drugs to prevent atrial fibrillation after surgery – results haven’t been encouraging, but if you are already on cholesterol medications prior to surgery, there are plenty of other reasons for us to continue statins during and after surgery.. (Now, since the literature is mixed on whether statins help prevent a. fib – I wouldn’t start them on patients having lung surgery, but that’s a different matter.)
Now Dr. Shu S. Lin, and some of the other cardiac surgeons did some studies down at Duke looking at pre-operative vitamin C (along with quite a few others) and the results have been interesting.. That doesn’t mean patients should go crazy with the supplements.. anything, even Vitamin C can harm you, if taken willy-nilly (though the risk with vitamin C is usually minimal).
In fact, the evidence was strong enough (and risk of adverse effects was low enough) that we always prescribed it to our pre-operative patients for both heart and lung surgery. (Heart patients are at high risk of atrial fibrillation too.) We prescribed 500mg twice a day for a week before surgery, until discharge – which is similar to several studies. I’ve included some of these studies before – please note most of them focus on atrial fibrillation after heart surgery.
Contrary to popular belief, performing a VATS procedure (versus open surgery) does not eliminate the risk of post-operative atrial fibrillation.
Now Dr. Onaitis, D’Amico and Harpole published some interesting results last year (and of course, as Duke Thoracic surgeons, I am partial) – but I can’t repost here since it’s limited access articles..