The fourth VATS International Symposium is this October 20th – 21st, 2017. As readers know, this course has been highly recommended in the past by Thoracics.org.
The preliminary program has been released, and it looks like audience favorite and straight shooter, Eric Lim will be opening the conference.
Italian thoracic surgeon, and the inventor of the first uniportal VATS procedure, Dr. Gaetano Rocco, along with the prominent American surgeon, Dr. Robert Cerfolio will also be presenting. There will be several presentations comparing uniportal VATS with robotic assisted surgical techniques (RATS). But this is more than an academic discussion – in addition to notable speakers, the conference includes live cases, practical tips and hands-on training.
Representatives from Storz will be speaking to thoracic surgeons on caring, repairing and maintaining thoracoscopic equipment. There are still spaces available for attendees, including the state-of-the-art wet lab. This wet lab offers surgeons the opportunity to try new techniques using 3-D models, while proctored by leaders in the field.
Talking to Dr. Benny Weksler about Minimally invasive esophagectomies, robotic surgery, lung cancer screening and life in the mid-south.
Memphis, Tennessee USA
Recently, I had the great pleasure and privilege to have a sit down interview with one of the thoracic surgeons whose work I have long admired. Loyal readers will certainly recognize the name, Dr. Benny Weksler, one of the modern masters of esophageal surgery.
Minimally invasive esophagectomies (MIE)
He is best known for his minimally invasive esophagectomies which take much of the pain (literally) out of the traditional surgical resection for esophageal cancer. The minimally invasive esophagectomy is the VATS approach to esophagectomy, using smaller 2 to 3cm ‘ports’ instead of large incisions.
In classic thoracic surgery, large open incisions such as the Ivor Lewis esophagectomy were the best way to optimize survival for patients with this aggressive cancer. However, the traditional open surgery itself is particularly arduous and has been likened to the “open heart surgery” of the thoracic specialty. The Ivor Lewis in particular is two full-sized surgeries; a full thoracotomy combined with a transverse laparotomy. While it has been utilized for decades for excellent visualization, staging and resection, the recovery is a long, painful process.
Dr. Weksler in the mid-south
It’s been just over three years since Dr. Benny Weksler was recruited to start a new thoracic surgery program at The University of Tennessee – West Cancer Clinic – Methodist Hospital System here in Memphis, Tennessee. It’s been a big change, and a bit of an eye-opening experience for the Brazilian native and famed thoracic surgeon who has spent much of this career in the northeast. Prior to this, he was part of the renowned University of Pittsburgh Medical Center under the famed Dr. James Luketich. Since Dr. Weksler’s move, he’s still adjusting to the warmer weather here, which is one of the things he likes best about the area along with the traditional Memphis music scene, which the city is famous for.
It’s also been a time of great changes and innovations for Memphis and the University of Tennessee, as well. Dr. Weksler started the first thoracic surgery service line for the UT – Methodist Hospital system, which is actually the first real dedicated thoracic surgery service line in the Memphis area – which extends across a tri-state area that also covers parts of northern Mississippi and western Arkansas.
Why is this important and what does it mean for Memphis?
Prior to Dr. Weksler’s arrival, patients were either referred to private cardiothoracic surgery practices in Memphis, they went to larger cities with bigger academic centers or they unwittingly trusted their health to a non-specialty surgeon. Neither of those options were ideal, but now patients in the northern Mississippi delta – metro Memphis area can receive state-of-the-art, surgical excellence close to home. For some patients, this is a matter of life or death.
Now the program is growing; so much so, that Dr. Weksler has two full-time thoracic surgeons and is actively looking for a third. With the addition of the third surgeon, Dr. Weksler hopes to expand the UT program to serve local veterans at the Memphis VA.
While Dr. Weksler doesn’t embrace the principles of uniportal surgery, his work on esophagectomies more than makes up for it. In fact, Dr. Weksler is one of the leading surgeons in the United States for minimally invasive esophagectomies. As discussed in previous posts, an experienced esophageal surgeon is critical for patient survival. (Bare Minimum competency for any esophageal surgeon is 25 cases a year – it’s not a surgery for your ‘average’ thoracic surgeon or any general surgeon).
Memphis’ newest secret weapon against cancer (too bad no one knows that he’s here)
In fact, his presence here in Memphis, among otherwise limited surgical services, is like finding a diamond while scavenging for supper in a metal dumpster in a hundred degree heat. In addition to being one of the foremost surgeons for esophageal disease (cancer and benign esophageal disease like achalasia), Dr. Weksler is also an experienced robotic surgeon.
As a newcomer to town, Dr. Weksler is having to re-build his practice volumes. As he explains, “We do about 30 esophagectomies a year, and I also see approximately 60 patients with esophageal cancer that cannot be operated on. 100% of our esophagectomies since I have been here were done minimally invasive”.
I can only speculate as a knowledgeable outsider that these surgical volumes reflect the lack of the general public and referring physicians knowledge about Dr. Weksler’s presence in the mid-south. Dr. Weksler is the type of surgeon that patients will travel across the country to see. My guess is that many of these potential patients are still traveling to Pittsburgh.
New ideas, new programs and new service lines
Dr. Weksler brings with him new ideas and new programs aimed at treating all Memphians. This includes community programs aimed at underserved and at-risk communities. One of these programs focuses on the diagnosis and treatment of lung cancer in African -American communities, which are disproportionately affected by advanced lung cancer, particularly in middle-aged males. By creating and implementing screening programs in these communities, Dr Weksler and his team are able to diagnose and treat lung cancers at earlier stages and improve patient survival. Despite being in its infancy, the program (which does not have a formal name) has screened over 100 patients and diagnosed eight cancers.
If you are a Memphis resident and would like information on this screening program or lung cancer screening: Contact the Lung Cancer Screening Navigator at Dr. Weksler’s office at 901-448- 2918.
Changing the art of Medicine & Surgery in Memphis
Dr. Weksler has been instrumental in creating at atmosphere of multidisciplinary collaboration. For example, programs have been streamlined and designed with patients in mind, to be the most effective, informative and efficient. This means that patients receive a “one stop shopping” experience as Dr. Weksler describes it. Patients are able to see their medical oncologist, thoracic surgeon and radiation oncologist on the same visit. All patients and their cases are presented at tumor board, to determine that treatment is individualized to the patient’s condition, functional status and tumor type which adhering to the clinical guidelines and evidence-based practice to optimize patient outcomes and long-term survival.
Q & A with Dr. Weksler – What patients should expect
Dr. Weksler talked to me at length about this multidisciplinary team approach as well as what patients should expect when they come to Methodist/ West Cancer center for care.
Question: What is the general process/ timeline for patient who has been referred to your clinic for evaluation?
Dr. Weksler: When patients come into the multidisciplinary clinic, patients / families with esophageal cancer will leave the office with a pretty good idea of what is going to happen. Depending on the work up done before they see me [which includes identification of tumor/ cancer staging], we will do the radiation therapy simulation the following
week, and start chemotherapy and/or radiation therapy the next week.
Question: What diagnostics/ medical records should they bring with them?
Dr. Weksler: We would like to see all available records, including previous surgeries, all scans, PET/ CT scans, barium esophagram, endoscopy report and all biopsy reports.
Question: What should patients anticipate? (will they get feeding tubes prior to surgery, etc)?
Dr Weksler: Most patients will get a port for chemotherapy*. We place feeding tubes in patients that loss more than 10% of their weight, or if they suffer from severe dysphagia. Patients can expect a 5 week course of chemotherapy and/or radiation therapy, followed by an interval of 6 to 8 weeks, followed by surgery.
*Editor’s note: A port is a long-term but temporary and completely removable central intravenous access for chemotherapy administration. It is placed underneath the skin with no cords, or lines visible externally. Feeding tubes are also temporary tubes that are easily removed/ reversible but help the patient to maintain adequate nutrition necessary for healing.
He has multiple offices including the West Cancer Center. For an appointment, please contact 901-448-2918.
Unfortunately, while Dr. Weksler and his thoracic surgery program are state-of-the-art, the Methodist website is not.
Additional references and resources (this is a selective list)
1. Oncologic efficacy is not compromised, and may be improved with minimally invasive esophagectomy.
Berger AC, Bloomenthal A, Weksler B, Evans N, Chojnacki KA, Yeo CJ, Rosato EL. J Am Coll Surg. 2011 Apr;212(4):5606; discussion 5668. doi: 10.1016/j.jamcollsurg.2010.12.042. PMID: 21463789
2. Outcomes after minimally invasive esophagectomy: review of over 1000 patients.
Luketich JD, Pennathur A, Awais O, Levy RM, Keeley S, Shende M, Christie NA, Weksler B, Landreneau RJ, Abbas G, Schuchert MJ, Nason KS. Ann Surg. 2012 Jul;256(1):95103.
doi: 10.1097/SLA.0b013e3182590603. PMID: 22668811 Free PMC Article – attached. Recommended reading. If you are only going to read one article on MIE, this is a nice project looking at a large number of patients.
3. Major perioperative morbidity does not affect long-term survival in patients undergoing esophagectomy for cancer of the esophagus or gastroesophageal junction.
Xia BT, Rosato EL, Chojnacki KA, Crawford AG, Weksler B, Berger AC. World J Surg. 2013 Feb;37(2):40815. doi: 10.1007/s0026801218236.
4. The revised American Joint Committee on Cancer staging system (7th edition) improves prognostic stratification after minimally invasive esophagectomy for esophagogastric adenocarcinoma.
Zahoor H, Luketich JD, Weksler B, Winger DG, Christie NA, Levy RM, Gibson MK, Davison JM, Nason KS. Am J Surg. 2015 Oct;210(4):6107.
doi: 10.1016/j.amjsurg.2015.05.010. Epub 2015 Jun 26. PMID: 26188709
5. Minimally invasive esophagectomy in a 6 year-old girl for the sequelae of corrosive esophagitis.
Majors J, Zhuge Y, Eubanks JW 3rd, Weksler B. J Thorac Cardiovasc Surg. 2016 Jun 22. pii: S00225223(
16)305657. doi: 10.1016/j.jtcvs.2016.06.011. [Epub ahead of print] No abstract available.
Details about the upcoming Robotic thoracic surgery course at NYU this June.
New York University School of Medicine has an upcoming CME course on Robotic Thoracic Surgery this June (10th & 11th). The day and a half course will be held at NYU Langone Medical Center in New York City.
The conference covers robotic surgery basics as well as lectures on robotic esophagectomies and mediastinal surgery. Robotic master surgeon, Dr. Robert Cerfolio will be giving two presentations.
The STS Task force takes on credentiallng in minimally invasive surgery but shouldn’t they be looking at advanced specialty certification instead?
The term “minimally invasive surgery” gets tossed around a lot these days; it’s on advertisements for surgery clinics, hospital billboards and countless CVs. But what does that term really mean? And who has earned the right to claim this skill set? It’s an issue that is becoming more relevant in thoracic surgery as many surgeons become trained in increasingly complex procedures. It’s also part of a shift in referral patterns, as patients increasingly seek and even self-refer to surgeons who advertise expertise in less invasive procedures. But right now, there is no way to designate or delineate between surgeons trained in these procedures and other general thoracic (and general surgeons). So I was excited to see that the STS was finally going to address this area. Or at least, I thought they were, when I saw the recent draft, entitled, “STS Expert Consensus Statement: A tool-kit to assist thoracic surgeons seeking credentialing for new technology and advanced procedures in general thoracic surgeon.”
Sharp eyed readers probably already see some of the problems with this draft. But first, a little background.
Currently, the primary certification in the United States for the thoracic surgery specialty is the American Board of Thoracic Surgery examination (ABTS) which is the entry-level requirement for thoracic surgeons after completing their surgical fellowship in thoracic surgery. While, the ABTS certification requires a biannual re-certification to maintain credentials, this certification only covers the minimum requirements for thoracic surgery. It doesn’t address the newest technological advances in this specialty. This is problematic for consumers seeking surgeons specially trained and experienced in performing techniques such an uniportal surgery. It also creates difficulties for surgeons seeking this skill set since there is no clearly defined coursework required to obtain these skills.
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 valuabletool 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.
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.
Minimally invasive surgery course in Naples at Hospital Monaldi (April 23 – 24th, 2015)
Munich airport, Germany
I am on the last leg of a long journey to the beautiful southern Italian coastal city of Naples. Best known for its claim as the home of pizza and the nearby ruins of Pompeii, for the next few days, the department of thoracic surgery at Hospital Monaldi will be hosting surgeons (and one wee writer) from around the world for a two day course on minimally invasive and robotic surgery.
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.
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.
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.
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.
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).
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.
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.
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.
Talking with Dr. Mark Dylewski, one of the new masters of thoracic surgery in the area of robotic surgery
Most of us never had the opportunity to meet or talk to some of the ‘masters’ of thoracic surgery like Dr. Hermes Grillo (1923 -2006), the ‘Father of Tracheal Surgery’ but as we have discussed before, thoracic surgery is not static. New technologies and new techniques are emerging all the time, and with these developments – new masters of thoracic surgery.
Dr. Mark Dylewski, may look too young to be the father of anything, but he is certain to be remembered in thoracic surgery history as one its new masters, and as one of the ‘fathers of robotic-assisted thoracic surgery’. While he is not the only surgeon doing robotic surgery, he is certainly one of the most prolific robotic / thoracic surgeons and has trained a large number of his peers.
Talking to Dr. Dylewski about robotic surgery
At the recent conference, Advances in Lung Cancer and Mesothelioma, we had the opportunity to sit and talk with Dr. Dylewski about the state of robotics in thoracic surgery. Dr. Dylewski is one of the foremost experts on the topic and teaches robotic surgery techniques at the South Miami Hospital Center for Robotic Surgery. Since he started performing robotic surgery in 2006, he estimates that he has taught over 200 thoracic surgeons how to perform surgery utilizing the DaVinci robot.
In comparison to other minimally invasive techniques (specifically VATS), Dr. Dylewski believes that robotic surgery has greater potential for use in thoracic surgery, due to its easy adoptability. He reports that unlike VATS, robotic surgery techniques utilize traditional surgical skills so that surgeons are usually proficient at robotic surgery after performing 30 – 40 cases. There are no counter-intuitive movements or altered visibility/surgical perspectives which are two of the things inherent in video-assisted thoracoscopy. He attributes both of these issues with the failure of more wide-spread adoption of VATS despite the availability of this technology for over twenty years. According to Dr. Dylewski, less than 30% of all thoracic procedures in North America are currently done using VATS.
Simply put, even some of the best thoracic surgeons may have trouble adapting to VATS techniques and as many as 20% will never fully adjust to video-assisted surgical techniques.
However, in his experience, robotic-assisted thoracic surgery such as complete portal robotic lobectomy ( aka CRPL-3 or CRPL-4, depending on the number of arms used) has a greater potential for widespread use. He explains that despite the initial hefty price tag, the robotic technology easily justifies its equipment costs, in terms of subsequent savings and benefits from decreasing the length of stay, less patient discomfort and greater patient satisfaction. He reports that these benefits have led to the adoption of robotic surgery as the standard of care in other specialties such as gynaecology despite the relative newness of this technology.
Dr. Dykewski also presented data regarding surgical outcomes from 355 cases, which includes a wide variety of thoracic procedures such as lobectomies, esophagectomies and mediastinal surgeries. Surgical outcomes were comparable to VATS procedures with a markedly shorter length of stay.
Dylewski MR, Ohaeto AC, Pereira JF. (2011). Pulmonary resection using a total endoscopic robotic video-assisted approach. Semin Thorac Cardiovasc Surg. 2011 Spring;23(1):36-42.
Ninan M, Dylewski MR. (2010). Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy. Eur J Cardiothorac Surg. 2010 Aug;38(2):231-2. Epub 2010 Mar
Additional References and Resources
Meyer M, Gharagozloo F, Tempesta B, Margolis M, Strother E, Christenson D. (2012). The learning curve of robotic lobectomy. Int J MId Robot. 2012 Sep 18. doi: 10.1002/rcs.1455. The authors of this publication report that it takes 18 – 20 complete portal robotic lobectomies to obtain competency.
Highlights from the recent conference on Advances in Lung Cancer and Mesothelioma
Instituto Nacional de Cancero
This one day conference put on by the National Cancer Institute in Bogotá, Colombia highlighted the latest research and techniques of treating lung cancer and mesothelioma.
It was headlined by a trio of invited lecturers, Dr. Carlos Jimenez, MD, Pulmonologist (MD Anderson, Houston, TX), Dr. Garrett Walsh, MD, Thoracic surgeon (MD Anderson, Houston, TX) and Dr. Mark Dylewski, MD, Thoracic surgeon (Baptist Health/ South Miami Hospital – Center for Robotic Surgery).
Dr. Ricardo Buitrago (who readers will be hearing more about in the coming months) and Dr. Rafael Beltran were the moderators for the conference.
Dr. Jimenez spoke on the topics of endobranchial ultrasound and fine needle (Wang) aspiration for lymph node biopsy as an adjuvant of mediastinoscopy for cancer staging, as well as ‘medical thoracoscopy’ or pleuroscopy. (While I will never share his views of pleuroscopy being part of the role/ scope of pulmonology – it was an interesting presentation.)
The presentations of Dr. Walsh and Dr. Dylewski served as beautiful counter-balance to each other and demonstrated the spectrum and breadth of thoracic surgery in the treatment of thoracic diseases.
While Dr. Dylewski presented the latest data from his experiences performing over 355 cases by robotic approach, Dr. Walsh spoke about performing large open cases with an interdisciplinary team to treat later stage cancers (T3, T4 respectively) and the ability to resect cases that are often referred for medical treatment due to local metastasis to adjacent organs.
Other notable speakers included Dr. Stella Martinez who debated the advisability of surgical treatment of Malignant Pleural Mesothelioma (MPM) in response to another presentation by Dr. Walsh, as well as a discussion by Dr. Humberto Varela of the utility of specific diagnostic modalities for the detection and staging of malignant pleural mesothelioma.
In Jupiter, Florida talking about robots, lung cancer screening and solitary pulmonary nodules with Dr. K. Adam Lee, thoracic surgeon
All my prepared questions fly out of my mind as I greet Dr. Lee and his team. It’s been several months since I first contacted Dr. Lee to ask about his new thoracic surgery program at Jupiter Medical Center in coastal Florida, but it has taken this long for me to find a way to Florida. After nine months here, Dr. Lee is well-settled into his new position as medical director of the thoracic surgery and lung center.
Detecting and treating lung cancer
We talk about the regional differences in thoracic surgery, with Dr. Lee confirming that the majority of his practice is surgical oncology; including diagnosed lung cancer and solitary pulmonary nodules. In fact, since coming to Jupiter, Dr. Lee has started a lung cancer screening program based on the newly released CT scan guidelines for the early detection of lung cancer, as well as a lung nodule clinic for the evaluation of lung nodules.
Minimally invasive surgery
With Dr. Lee, “minimally-invasive’ is the theme. “I want patients to ask, ‘do I have to have a thoracotomy?” he states. “I want patients to know that there are minimally invasive options,” he continues as he talks about the advantages of minimally invasive techniques such as robotic-assisted thoracic surgery (RATS) and video-assisted thoracoscopic surgery (VATS). “Why should patients have all the pain [associated with large surgical incisions] if there is no reason not to do minimally invasive surgery?”
Dr. Lee should know; he’s been performing robotic surgery since 2003.
As part of his commitment to advancing technologies, he has recently paired with Ethicon Endo-surgery to be able to provide training in minimally invasive surgery to thoracic surgery colleagues all over the world. Twice a month, he travels to other facilities to demonstrate these techniques for other surgeons. The operating rooms at the hospital here have recently been outfitted for web-based broadcasting for the remainder of the time, so that surgeons, regardless of location are able to watch these demonstrations.
He reports that learning to perform robotic surgery is easier for surgeons to learn than video-assisted thoracoscopic surgery, explaining that while the instrumentation is different (using robotic arms to perform surgery), the tissue manipulation and techniques are closer to open surgery [compared to VATS], and thus more familiar to conventionally trained surgeons.
I didn’t get to see Dr. Lee in the operating room – but soon, everyone will be able to.
 Surgeons interested in learning more can contact either Ethicon Endo-surgery or Dr. Lee directly.
* I was surprised to find out that the lung cancer screening program (CT scan, radiology interpretation/ consultation and a consultation with a thoracic surgeon) is under 300.00 USD. In an age of exorbitant medical fees, this is an affordable option for early detection of lung cancer.
a selection of full text references talking about robotics and thoracic surgery.
Continuing on our theme of robotic assisted thoracic surgery, here’s a selection of full-text case reports and published reports on thoracic surgery. Some of these stories discuss the more technical aspects of this approach, such as optimal patient positioning, and equipment placement.
Robotic assisted lung resection – an interesting italian/ american study looking at 38 cases (single surgeon experience) from 2001 – 2009. Nicely illustrated. It’s a fascinating study, so I’ve written to the lead author (and surgeon) for more information.
Dr. Weksler does a wide range of thoracic procedures using the daVinci robot including pulmonary lobectomies for cancer, esophagectomies for cancer, thymectomies for myasthenia gravis and thymoma, Heller myotomies for achalasia, Nissen fundoplications for GERD, repair of hiatal hernias, removal of mediastinal masses, correction of esophageal diverticula. He reports an overall annual surgical volume of approximately 450 cases, (with about 180 of these procedures using robotic technology.)
Dr. Benny Weksler, MD, FACS Associate Professor of Cardiothoracic Surgery Director, Robotic Thoracic Surgery University of Pittsburgh Medical Center Pittsburgh Pa.
Hillman Cancer Center
5115 Centre Avenue
Pittsburgh, PA 15232
Phone: (412) 648-6271
VA Medical Center
University Drive C
Pittsburgh, PA 15240
Phone: (412) 688-6000
Publications (an abbreviated selection of recently published works.)
Weksler B, Sharma P, Moudgill N, Chojnacki KA, Rosato EL. (2011). Robot-assisted minimally invasive esophagectomy is equivalent to thoracoscopic minimally invasive esophagectomy. Dis Esophagus. 2011 Sep 7. [no free full text available.]
Weksler B, Nason KS, Mackey D, Gallagher A, Pennathur A. (2011). Thymomas and Extrathymic Cancers. Ann Thorac Surg. 2011 Sep 30. [no free full text available].
Weksler B, Tavares J, Newhook TE, Greenleaf CE, Diehl JT (2011). Robot-assisted thymectomy is superior to transsternal thymectomy. Surg Endosc. 2011 Sep 5. [no free full text].
Berger AC, Bloomenthal A, Weksler B, Evans N, Chojnacki KA, Yeo CJ, Rosato EL. (2011). Oncologic efficacy is not compromised, and may be improved with minimally invasive esophagectomy. J Am Coll Surg. 2011 Apr;212(4):560-6; discussion 566-8. [no free full available]. Included since topic germaine to discussion.
Sivarajah M, Weksler B. (2010). Robotic-assisted resection of a thymoma after two previous sternotomies. Ann Thorac Surg. 2010 Aug;90(2):668-70. [no free full-text available].
* Dr. Weksler was kind enough to answer my questions in a series of emails. I did not have the opportunity to visit Dr. Weksler or his program on site.
A brief interview with Dr. Thomas D’Amico, Chief of Thoracic Surgery at Duke University Medical Center.
Dr. Thomas D’Amico is one of the first American thoracic surgeons I’ve had the privilege of interviewing for the website, after he was recommended to me by several other surgeons in Colombia. (Dr. D’Amico went to Medellin as an invited guest a few years ago and apparently made quite an impression.)
The irony in this scenario is unmistakable, since I worked for Duke (at another facility) for over three years – and knew of Dr. D’Amico, but had never met or spoken to him before.
Today, Dr. D’Amico took some time out of his busy schedule so we could talk about minimally invasive surgery, esophageal surgery programs and robots.
Dr. D’Amico is the Chief of Thoracic Surgery at Duke University Medical Center in Durham, North Carolina. Together with several other physicians that make up the thoracic surgery program; the surgeons at Duke perform 1600 – 1800 cases per year. This includes the entire spectrum of thoracic surgery procedures (thoracoscopic surgeries including lobectomies, wedge resections, mediastinal tumors, etc).
Last December, Duke started a minimally invasive esophageal surgery program, as well as a robotic thoracic surgery program. (Both of these concepts should be familiar to readers since we published articles on these very topics earlier this month, talking about the TIME trial in Europe, comparing outcomes between traditional and minimally invasive esophageal surgery, as well as previous post exploring the dearth of published literature on Robotic Thoracic Surgery. )
Since its inception six months ago, the program has done 80 -100 cases of minimally invasive esophageal surgery. Notably, Duke has an established esophageal cancer program – which performs about 70 – 80 esophagectomies a year. This doesn’t sound like a lot, but it actually distinguishes this program as a high volume center, which is important for reducing morbidity and mortality. Multiple studies have confirmed that esophageal surgery patients do better (less deaths, less complications) when they have surgery with thoracic surgeons at high volume centers.
The Robotics program, headed by Dr. Mark Onaitis is performing about 8 to 10 cases per month. The program is currently limited due to access to the Divinci robot. (Currently, thoracic surgery has use of the robot one day per week.) Dr. D’Amico reports that surgical case times have been increased on the robotic cases but states that much of this is robot maneuvering time as the robot is brought into position for surgery.
I’ve asked to observe a robotic case so I can bring you first hand observations (a la Bogotá Surgery style), as well as have a chance to look around the dedicated thoracic surgery unit at Duke hospital.
Pleural mesothelioma and related conditions are less well-defined within the Duke Thoracic surgery program. They only see about 20 or 25 cases per year, and don’t really have an established program for these patients. Dr. D’Amico reports they are not actively pursuing brachiotherapy or HITHOC (intrathoracic hyperthermic chemotherapy) options. The main focus of the program remains minimally invasive procedures, which is where Dr. D’Amico sees the future of thoracic surgery.
As for the surgeon himself, he is surprisingly closed lipped about his personal and professional life, and declined to answer any questions on the subject. He has a reputation around Duke as a shy, quiet and gentle man but my time with him was extremely limited, so I have no insights, or impressions to pass along to readers. Hopefully, I’ll get another chance to speak with him in the future, so I am able to give more details about these programs, and the surgeon behind it all.