Dr. Ross Bremner, and the state of thoracic surgery in Arizona

Talking with Dr. Ross Bremner, Chief of Thoracic Surgery and Chair of Thoracic Disease & Transplant at St. Joseph’s Hospital in Phoenix, Arizona.

Dr. Ross Bremner

St. Joseph’s Hospital

After talking to Dr. Bremner of the phone, I felt compelled to come down to Phoenix and meet him in person.  I am glad I did.  While St. Joseph’s is a large 607 bed hospital – it’s just one of many large healthcare facilities in the Phoenix area.  The same can not be said of their robust thoracic surgery program.  They have a surprising range of thoracic surgery subspecialties, and sub-specialty programs including transplant, anti-reflux surgery, minimally invasive surgery, esophageal surgery program and robotic surgery.  As you can imagine, I felt a bit like a kid in a candy store – so overwhelmed by the array of services, that my mind was just bursting with questions.  (I rounded with the group and got to see the full spectrum of patients – including four recent post-transplant patients.)  They also have a pediatric thoracic surgery program and plan to start a pediatric transplant program soon.

Dr. Ross Bremner & Dr. Mike Smith, Heart & Lung Institute

The head of the program, Dr. Ross Bremner is one of five thoracic surgeons at the Heart & Lung Institute of St. Joseph’s Hospital in Phoenix, Arizona which is currently the state’s largest thoracic surgery program.  A native of Johannesburg, Dr. Bremner maintains international ties to his home country by staying active in the South African Cardiothoracic Surgery Society.  He began his thoracic surgery career at University of Southern California (USC) where he met and recruited both Dr. Michael Smith, MD and Sandra Ogawa, ACNP.

As Arizona has grown, so has thoracic surgery.  Despite the relatively small population of Arizona overall, both the esophageal surgery program and the lung transplant program maintain volumes that are competitive with the big-name east coast institutions.

With over 45 lung transplants last year – and the University of Arizona currently out of the running, Dr. Bremner* and his team are set to boost those numbers this year.  They have already done ten transplants here in the first quarter of 2012, and anticipate doing fifty to sixty this year.  (If you remember from our previous posts about lung transplantation – even very large institutions are not doing huge numbers of transplants.  In fact, you can check the numbers at the Organ Procurement and Transplant Network if you’re interested*.)

St. Joseph’s also has an esophageal surgery program which maintains the high volumes of esophagectomies needed for optimal outcomes.  Dr. Bremner reports that they perform on average 50 – 60 esophagectomies for esophageal cancer ever year in addition to their benign esophageal surgery program.  (As we discussed with Dr. Molena, ‘benign’ is a bit of a misnomer for esophageal conditions since achalasia, esophageal strictures and other non-cancerous conditions of the esophagus may have a huge negative impact on the individual’s quality of life.)

The Heart & Lung Institute also offers training courses for surgeons and residents in minimally invasive surgery – in fact, they are teaching a course the weekend of my visit.

As a practicing surgeon in Phoenix, Arizona, Dr. Bremner also sees numerous cases of Coccidoidomycosis** (or Valley Fever) which is endemic to this area of the country.  In fact, Maricopa county, which encompasses the city of Phoenix sees more cases annually than the California valley the disease was originally named for.

* At the site, you can create data reports by organ, region, outcome, waiting period, etc..  For example – using this data table – we can see that there were a total 1,516 isolated lung transplants in the United States in 2011 which is actually a decrease from 2010 and 2009.

** Readers can anticipate a future article on this topic

More about Dr. Ross Bremner, MD, PhD

Dr. Bremner is a genial gentleman and a ready conversationalist.  Our interview was relaxed, but informative.  He welcomed my questions on a variety of topics and was generous with his time.  In fact, I had ready access to multiple members of his team, and spent the entire afternoon with the department of thoracic surgery.  It was an engaging afternoon, and highlighted one of the reasons I pursue interviews and opportunities to speak to my colleagues within thoracics; it was an opportunity to learn more about the specialty, and the care of thoracic surgery patients.

Dr. Bremner is a board-certified thoracic surgeon.  After obtaining his baccalaureate degree and medical school training at Witwatersrand University in South Africa, he continued his education in the United States.

He completed his general surgery residency, PhD research and thoracic surgery residency at the University of Southern California. He was the Director of the Hastings Thoracic Oncology Research Laboratory on the USC campus.  At this lab, surgeons along with researchers from multiple disciplines conduct research on the diagnosis and treatment of lung cancer including research in gene therapies prior to coming to Arizona.

He has several YouTube videos talking about his current research projects at St. Joseph’s.

He also has an informational series for patients about Lung Transplant over at EmpowHer.com

Dr. Ross M. Bremner, MD, PhD

Chief of Thoracic Surgery

Chair of the Center for Thoracic Disease & Transplantation

Heart & Lung Institute – St. Joseph’s Hospital and Medical Center

500 W. Thomas Road, Suite 500

Phoenix, Arizona 85013

Tele: (602) 406 4000

Fax: (602) 406 3090

Selected publications (not a full listing)

Jacobs JV, Hodges TN, Bremner RM, Walia R, Huang J, Smith MA. (2011). Hardware preservation after sternal wound infection in a lung transplant recipient. Ann Thorac Surg. 2011 Aug;92(2):718-20. [no free text available].

Felton VM, Inge LJ, Willis BC, Bremner RM, Smith MA. (2011). Immunosuppression-induced bronchial epithelial-mesenchymal transition: a potential contributor to obliterative bronchiolitis.  J Thorac Cardiovasc Surg. 2011 Feb;141(2):523-30.  [no free text available].

Gotway MB, Conomos PJ, Bremner RM. (2011)  Pleural metastatic disease from glioblastoma multiforme.  J Thorac Imaging. 2011 May;26(2):W54-8. [no free text available].

Coon KD, Inge LJ, Swetel K, Felton V, Stafford P, Bremner RM.  (2010).  Genomic characterization of the inflammatory response initiated by surgical intervention and the effect of perioperative cyclooxygenase 2 blockade.  J Thorac Cardiovasc Surg. 2010 May;139(5):1253-60, 1260.e1-2.  [no free text available].

Wu C, Hao H, Li L, Zhou X, Guo Z, Zhang L, Zhang X, Zhong W, Guo H, Bremner RM, Lin P. (2009).  Preliminary investigation of the clinical significance of detecting circulating tumor cells enriched from lung cancer patients.  J Thorac Oncol. 2009 Jan;4(1):30-6. [no free full-text available].

Backhus LM, Bremner RM. (2006).  Images in clinical medicine. Intrathoracic splenosis after remote trauma.  N Engl J Med. 2006 Oct 26;355(17):1811.

Backhus LM, Sievers E, Lin GY, Castanos R, Bart RD, Starnes VA, Bremner RM.  (2006).  Perioperative cyclooxygenase 2 inhibition to reduce tumor cell adhesion and metastatic potential of circulating tumor cells in non-small cell lung cancer.  J Thorac Cardiovasc Surg. 2006 Aug;132(2):297-303. [no free full-text available].

Backhus LM, Sievers EM, Schenkel FA, Barr ML, Cohen RG, Smith MA, Starnes VA, Bremner RM.  (2005).  Pleural space problems after living lobar transplantation.  J Heart Lung Transplant. 2005 Dec;24(12):2086-90.  [no free text available].

Backhus LM, Petasis NA, Uddin J, Schönthal AH, Bart RD, Lin Y, Starnes VA, Bremner RM. (2005).  Dimethyl celecoxib as a novel non-cyclooxygenase 2 therapy in the treatment of non-small cell lung cancer.  J Thorac Cardiovasc Surg. 2005 Nov;130(5):1406-12.  [no free full-text available].

Sievers EM, Bart RD, Backhus LM, Lin Y, Starnes M, Castanos R, Starnes VA, Bremner RM.  (2005).  Evaluation of cyclooxygenase-2 inhibition in an orthotopic murine model of lung cancer for dose-dependent effect.  J Thorac Cardiovasc Surg. 2005 Jun;129(6):1242-9.  [no free full-text available].

Bowdish ME, Barr ML, Schenkel FA, Woo MS, Bremner RM, Horn MV, Baker CJ, Barbers RG, Wells WJ, Starnes VA.  (2004).  A decade of living lobar lung transplantation: perioperative complications after 253 donor lobectomies.  Am J Transplant. 2004 Aug;4(8):1283-8.  [no free full-text available].

Starnes VA, Bowdish ME, Woo MS, Barbers RG, Schenkel FA, Horn MV, Pessotto R, Sievers EM, Baker CJ, Cohen RG, Bremner RM, Wells WJ, Barr ML.  (2004).  A decade of living lobar lung transplantation: recipient outcomes.  J Thorac Cardiovasc Surg. 2004 Jan;127(1):114-22.   [no free full-text available].

Haddy SM, Bremner RM, Moore-Jefferies EW, Thangathurai D, Schenkel FA, Barr ML, Starnes VA.  (2002).  Hyperinflation resulting in hemodynamic collapse following living donor lobar transplantation.  Anesthesiology. 2002 Nov;97(5):1315-7.

DiPerna CA, Bowdish ME, Weaver FA, Bremner RM, Jabbour N, Skinner D, Menendez LR, Hood DB, Rowe VL, Katz S, Kohl R.  (2002).  Concomitant vascular procedures for malignancies with vascular invasion.  Arch Surg. 2002 Aug;137(8):901-6; discussion 906-7.

Bremner RM, Hoeft SF, Costantini M, Crookes PF, Bremner CG, DeMeester TR. (1993).  Pharyngeal swallowing. The major factor in clearance of esophageal reflux episodesAnn Surg. 1993 Sep;218(3):364-9; discussion 369-70.

Robotics and Thoracic surgery : Dr. Weksler

a brief snapshot of a Dr. Benny Weksler, a thoracic surgeon using robotic technology at the University of Pittsburgh in Pittsburgh, Pennslyvania. Also, UPMC as a high volume esophagectomy center.

One of the prominent thoracic surgeons performing robotic procedures is Dr. Benny Weksler, a Brazilian native who is currently the Director of Robotic Thoracic Surgery at the University of Pittsburgh Medical Center in Pittsburgh, Pennslyvania*.

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.)

He also reports that the thoracic surgery department at UPMC is the largest esophageal center in the world, and does over 120 esophagectomies a year – and that 95% of these surgeries are done with minimally invasive techniques (via laparoscopic and thoracoscopic techniques).

Dr. Benny Weksler, MD, FACS
Associate Professor of Cardiothoracic Surgery
Director, Robotic Thoracic Surgery
University of Pittsburgh Medical Center
Pittsburgh Pa.

Office Addresses:

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.

Dr. Thomas D’Amico: Duke Thoracic Surgery

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.

Esophageal surgery and esophageal surgery centers

Discussion of article by Bilimoria and the importance of high volume esophageal surgery programs for successful post-operative outcomes.

Here’s another study highlighting the importance of having esophagectomies (esophageal surgery) at high volume centers.  It’s a topic we’ve talked about before, and as it’s something I feel very strongly about – something readers will probably see mentioned   again.  It also helps answer the question – “Do I need to travel to X for surgery or can I have it at the local hospital?”  This was the main questions the researchers were looking at for this study in terms of costs, logistics and burdens on patient and family.

This article by Bilimoria et. al (2010), published in the Annals of Surgery,  was actually comparing outcomes for multiple surgery types at small community hospital versus large specialty center, not just thoracic surgeries but the research findings are similar to what we have reported previously.  The irony of this study is that the researchers were expressly trying to prove the opposite, that small hospitals are safe for high complexity, high morbidity/ mortality operations – as a way to cut costs, and save money by preventing additional patient shifting to larger institutions that may be at a considerable distance for patients.  They demonstrated limited success in their results for other surgeries – but the need for high volume esophagectomy programs for successful surgical outcomes remains unchanged. (Some of this may be due to the fact that many of these esophagectomies at smaller hospitals are performed by general, not thoracic surgeons.)

The answer for patients with esophageal cancer is: Yes – you do need to go to the esophageal cancer center (not your local community hospital).  This is regardless of classification of low or high risk (which is based on age, and a Charlson score – which is a score used to add up other risk factors).  This is something I have had to address with patients in my own personal practice as both a referring provider (at a smaller facility) and as a receiving provider (when I was at a larger esophageal surgery center.)

I’ve reposted the abstract below, so you can read for yourself. (The article itself is several pages long).  [Italics are mine..]

Bilimoria, et. al. (2010). Risk-based Selective Referral for Cancer Surgery: A Potential Strategy to Improve Perioperative Outcomes    Annals of Surgery. 2010;251(4):708-716.

Abstract

Background: Studies have demonstrated volume-outcome relationships for numerous operations, providing an impetus for regionalization; however, volume-based regionalization may not be feasible or necessary. Our objective was to determine if low-risk patients undergoing surgery at Community Hospitals have perioperative mortality rates comparable with Specialized Centers.

Methods: From the National Cancer Data Base, 940,718 patients from ~1430 hospitals were identified who underwent resection for 1 of 15 cancers (2003–2005). Patients were stratified by preoperative risk according to age and comorbidities. Separately for each cancer, regression modeling stratified by high- and low-risk groups was used to compare 60-day mortality at Specialized Centers (National Cancer Institute-designated and/or highest-volume quintile institutions), Other Academic Institutions (lower-volume, non-National Cancer Institute), and Community Hospitals.

Results: Low-risk patients had statistically similar perioperative mortality rates at Specialized Centers and Community Hospitals for 13 of 15 operations. High-risk patients had significantly lower perioperative mortality rates at Specialized Centers compared with Community Hospitals for 9 of 15 cancers. Regardless of risk group, perioperative mortality rates were significantly lower for pancreatectomy and esophagectomy at Specialized Centers. Risk-based referral compared with volume-based regionalization of most patients would require fewer patients to change to Specialized Centers.

Conclusions: Perioperative mortality for low-risk patients was comparable at Specialized Centers and Community Hospitals for all cancers except esophageal and pancreatic, thus questioning volume-based regionalization of all patients. Rather, only high-risk patients may need to change hospitals. Mortality rates could be reduced if factors at Specialized Centers resulting in better outcomes for high-risk patients can be identified and transferred to other hospitals.