One of the guest lecturers at the 2nd VATS Peru Uniportal Master course is Dr. William Guido Gerrero from Costa Rica. Dr. Guido talked about the challenges of implementing a minimally invasive thoracic surgery program in the small central american nation that boasts a total population of less than 5 million.
Despite the small population and the low surgical volumes that accompany it; Dr. Guido is one of ten thoracic surgeons in Costa Rica, who are affiliated with two thoracic surgery departments within the nation.
Dr. Guido initially performed his first two uniportal cases with some trepidation. The first cases were simple biopsies and drainage of pleural effusions. He then performed his first lobectomy but it was a slow tedious process. After that experience, he traveled to Shanghai, and the Shanghai Pulmonary Hospital to attend and train with Dr, Diego Gonzalez Rivas in the wet lab, practicing cases on live animals.
At Hospital Rafael Angel Calderon Guardia
Dr. Guido primarily operates in a 350 bed hospital in the capital city of 1.4 million habitants. The thoracic surgery unit consists of eight beds, and cases are performed three days a week with an annual case volume of around 350 cases.
Majority of cases by Uniportal VATS
The majority of surgical cases (67%, includes all types of cases) are performed using the uniportal approach. 31% of the remainder are performed via a traditional ‘open’ approach with only 2% of cases performed using traditional (multiport) VATS. This discrepancy is explaned by Dr. Guido in that there is currently only one thoracoscope in the hospital, and it is not always available. He predicts that the rate of uniportal VATS cases will soon increase, as the second thoracoscope is scheduled to arrive in just a few weeks, followed by a third thoracoscope next year. These equipment limitations are not the only challenges for Dr. Guido and his fellow thoracic surgeons.
Low volumes, suboptimal equipment and a lack of institutional support
The low volume of surgical cases and a lack of institutional support are also problems. Unfortunately, it’s harder to convince the medical community of the value of uniportal VATS (and thus boost surgical volume) than it is to order new equipment. Despite these limitations, Costa Rica also manages to maintain a struggling lung transplantation program, that performs approximately two transplants per year, with five patients with pulmonary fibrosis and pulmonary hypertension currently on the waiting list.
Excellent care, at home
Dr. Guido hopes that many of these problems can be resolved in the future. He wants Costa Rican patients to feel that they can stay in Costa Rica for their thoracic surgery without making any sacrifices in care. He’s already lost one patient to Dr. Gonzalez Rivas himself (when the patient traveled to Spain for surgery) and another to the United States (where the patient ended up getting an open thoracotomy). Losing a patient to the Master of Uniportal Surgery himself is inevitable, but losing a patient to a country where the patient received an inferior procedure at an exorbitant cost is a bit harder to swallow.
An invited report from Dr. Marcello Migliore on the recent Italian conference on VATS and lung cancer
Report from the 3rd Mediterranean Symposium in Thoracic Surgical Oncology on VATS RESECTIONS FOR LUNG CANCER: moving toward standard of care.
Speakers and moderators at the 3rd Mediterranean Symposium on Thoracic Surgical Oncology
The third mediterranean symposium on thoracic surgical oncology was successful. The symposium was held the 21st – 22nd april 2016 at the Aula Magna of the Faculty of Medicine at the University of Catania. More than 150 people attended, and among them there were thoracic surgeons, general surgeons, oncologists, chest physicians, residents and medical students. This year, we had speakers from Europe and the USA. The main topic was VATS resections for lung cancer (Photo 1). During the opening ceremony, the Rector Giacomo Pignataro awarded a medal to Professor Tom Treasure for enhancing our outstanding education and research experience (Photo 2).
Photo 2: The Rector of the University of Catania is giving the medal to Professor Tom Treasure
Although the concept of operating thru a small port was born and developed in Europe (1- 7) it has been noted that 90% of papers on uniportal VATS lobectomy come from East Asian countries (8-11). Throughout the symposium different speakers agreed that a proper definition of uniportal VATS is mandatory to speak the same language worldwide.
Awake thoracic surgery was discussed together with the need of accurate preoperative staging procedures such as endobronchial ultrasound, videomediastinoscopy or Video-assisted mediastinal lympadenectomy. It was concluded that a wide spectrum of factors must be considered when determining the appropriate tests to assess the lymph nodes in NSCLC, which includes not only the sensitivity and specificity of the test, but also the ability to perform the procedure on an individual patient.
Data from New York showed very clearly that there have been no large-scale randomized control trials to compare open and VATS lobectomy. Although most may agree with the short-term superiority of VATs lobectomy over its open counterpart, many argue that is an in adequate oncologic procedure. Hence whether the approach is equivalent in overall and cancer specific survival to its open counterpart is not known. He also reported an important recent analysis of SEER-Medicare which confirmed that VATS lobectomy appears to have similar survival to its open counterparts (12).
A magnificent video was presented to explain every step of the lobectomies performed through a small skin incision. A long discussion followed and all auditorium proposed that ‘single incision’ VATS probably define better than uniportal VATS what surgeons are doing worldwide. Certainly the length of skin incision is important and should be taken in serious consideration. We felt that a consensus conference is probably necessary consensus conference is probably necessary. The indication for a Wedge resection rather than lobectomy in initial stage lung cancer is still weak.
The Italian VATS group was formed in 2013 , and nowadays there are 65 participating centres and that 2800 VATS lobectomy have already been included. In Catania we joined the group few months ago (13)
A very interesting session for juniors and medical students from UK and Italy was carried out, and 12 abstracts have been presented as interactive posters. Two of them have been chosen for possible publication in Future Oncology.
Finally, the first data survival seems to benefit little from the various even growing “personal” modifications of the standard VATS technique. Since there is a limited variation between VATS and uniportal VATS, the likelihood is that either VATS and uniportal VATS will be operative in the near future. Its success will depend on survival advantages and decrease chest pain and not just on new technical instrumentation. To protect patient’s safety, the length of the skin incision should be chosen on the basis of several clinical factors and not in relation of modern “demand”. Although the trial VIOLET is ongoing in UK to demonstrate if VATS resection for lung cancer is better than open thoracotomy, doubts arises as standard postero-lateral thoracotomy for lung cancer seems to be an incision which is performed rarely today. A skin incision of 6-8 cm (mini-thoracotomy) with video assistance is enough for most of lung resections. The question which arises is if a mini-thoracotomy of 6 cm should be called “uniportal” or not.
Marcello Migliore, MD
Thoracic surgeon and invited commentator
Dr. Marcello Migliore
Migliore M Initial History of Uniportal Video-Assisted Thoracoscopic Surgery. Ann Thorac Surg 2016;101 (1), 412-3.
Migliore M, Calvo D, Criscione A, Borrata F. Uniportal video assisted thoracic surgery: summary of experience, mini-review and perspectives. Journal of Thoracic Disease 2015; 7 (9), E378-E380
Migliore, M., Giuliano, R., & Deodato, G. (2000). Video assisted thoracic surgery through a single port. In Thoracic Surgery and Interdisciplinary Symposium on the threshold of the Third Millennium. An International Continuing Medical Education Programme. Naples, Italy (pp. 29-30).
Migliore, M., Deodato, G. (2001). A single-trocar technique for minimally invasive surgery of the chest. Surgical Endoscopy, 8(15), 899-901.
Migliore M. Efficacy and safety of single-trocar technique for minimally invasive surgery of the chest in the treatment of noncomplex pleural disease. J Thorac Cardiovasc Surg 2003;126:1618-23.
Rocco, G., Martin-Ucar, A., & Passera, E. (2004). Uniportal VATS wedge pulmonary resections. The Annals of Thoracic Surgery, 77(2), 726-728.
Gonzalez D, Paradela M, Garcia J, et al. Single-port video-assisted thoracoscopic lobectomy. Interact Cardiovasc Thorac Surg 2011;12:514-5.
Yang HC, Noh D. Single incision thoracoscopic lobectomy through a 2.5 cm skin incision. J Thorac Dis 2015;7:E122-5.
Ocakcioglu I, Sayir F, Dinc M. A 3-cm Single-port Video-assisted Thoracoscopic Lobectomy for Lung Cancer. Surg Laparosc Endosc Percutan Tech 2015;25:351-3.
Kamiyoshihara M, Igai H, Ibe T, et al. A 3.5-cm Single-Incision VATS Anatomical Segmentectomy for Lung Ann Thorac Cardiovasc Surg 2015;21:178-82.
Zhu Y, Xu G, Zheng B, et al. Single-port video-assisted thoracoscopic surgery lung resection: experiences in Fujian Medical University Union Hospital. J Thorac Dis 2015;7:1241-51.
Paul S, Isaacs AJ, Treasure T, Altorki NK, Sedrakyan A. Long term survival with thoracoscopic versus open lobectomy: propensity matched comparative analysis using SEER-Medicare database. BMJ 2014;349:g5575
Migliore, M., Criscione, A., Calvo, D., Borrata, F., Gangemi, M., & Attinà, G. (2015). Preliminary experience with video-assisted thoracic surgery lobectomy for lung malignancies: general considerations moving toward standard practice. Future Oncology, 11(24s), 43-46.
Migliore M. Will the widespread use of uniportal surgery influence the need of surgeons ? Postgrad Med J 2016 (in press).
Updates in multi-disciplinary care from the Foundation for the Advancement of Cardiothoracic Surgery at the 2014 Cardiovascular- Thoracic Critical Care conference in Washington D.C
Washington D.C.
While the majority of the 11th annual conference by the Foundation for the Advancement of Cardiothoracic Surgery was focused on cardiac surgery topics, Dr. Namrata Patil, the Director of the Thoracic Intermediate Care Unit (and thoracic surgeon) at Brigham & Women’s Hospital in Boston, MA gave an excellent presentation on the management of critically ill thoracic surgery patients.
Attendees at the Factscare conference
Early Intervention, Rapid Response versus Failure to Rescue
Rather than an exhaustive review of the literature, Dr. Patil’s lecture gave a much-needed bedside perspective on the care of these patients. She stressed the importance of remaining hypervigilant as well as the need for early identification and early, aggressive intervention in these patients.
While the majority of the conference focused on ECMO, LVADs and transplant patients, Dr. Patil’s presentation was a crucial reminder of the pitfalls of falling into complacency when caring for our vulnerable thoracic population. While these patients do not always attract the attention that patients with artificial life support mechanisms (like Heartmate II patients), it is a mistake to think that these patients are less fragile or critically ill. By definition, these lung patients, (who frequently have underlying lung disease and other serious comorbidities) are compromised – and acutely ill.
This means that clinicians need to shift their focus from the intensive care unit to the telemetry and floor units without losing their critical care perspective. Too often, when patients are transferred to step-down units, critical care concepts are relaxed because of preconceptions based on assumptions regarding patient acuity. But as anyone with thoracic experience knows, a ‘stable’ patient can easily descend into a downward spiral if not managed aggressively.
“Is this acceptable to me?”
As Dr. Patil reminds us, clinicians need to be vigilant when caring for patients of all acuities. She’s not asking us to chase ‘zebras’ but instead gently reminding clinicians not to dismiss important clinical findings. Instead of attributing low-grade fevers and cloudy X-rays to atelectasis, intervene early to prevent the next step in deterioration; pneumonia or respiratory compromise. Remain vigilant to detect later stage complications instead of racing to discharge on marginally functional patients.
She encourages clinicians to educate patients, providers and families; to teach as part of efforts to prevent complications. She also advocates for the increased development of protocols specific to the thoracic surgery population and better communication with all members of the care team; including the patients and their families.
Ethics and Advocacy
She also spoke on the ethics of caring for these patients and advocating for the rights of patients, particularly elderly patients. In an era of increased awareness of POAs, and Advance Directives, there is often a push (from the hospital administrators, nursing staff, and other medicine specialities) to advocate for a Do Not Resuscitate (DNR) code status. Unfortunately, many of the people pushing for this designation have forgotten that this is part of a patient’s right – and automatically assume it should be a decision based solely on age. This ageism is contrary to our duty to protect, to advocate and our patient’s right to self-determination.
This ageism also ignores one of the widely held truths in our society; that for many people, “Age is just a number” and that the patient’s functional status may not reflect their actual age. We’ve all met 50 year-old patients who have been debilitated by chronic and prolonged illnesses and may have a much poorer functional status than an active, alert 80 (or even 90) year-old patient. Assigning or encouraging a DNR status in these patients based on age is not only incorrect, but unethical.
In a time of an increasing push for standardized, ‘one-size-fits-all” care and ‘Angie’s List” style medicine with emphasis on short length of stay and rapid discharges, Dr. Patil’s more personalized approach will actually engender better clinical outcomes by reducing morbidity, mortality, and re-admissions. It also helps clinicians, like myself, sleep better at night – knowing we have been as aggressive as possible to prevent complications in our patients.
Using 3rd world skills to augment diagnostic technologies
Dr. Patil’s talk also highlighted the importance of clinical judgement and clinical skills in caring for these patients. While heart patients routinely have advanced life support and hemodynamic monitoring devices such as Swan Ganz catheters, NICO and telemetry, excellent clinical skills are needed when relying on less invasive measures such as physical exam and basic radiology. Her background, of practicing medicine in India (and the related limitations in resources) has added to her skills as a clinician and diagnostician without relying on expensive or extensive use of technology. In an era of rapidly expanding concerns regarding resource management and cost-containment, this skill is crucial, just at a time when new medical school graduates are focusing more on advanced diagnostics over basic clinical assessment skills.
Dr. Namrata Patil
Dr. Namrata Patel, thoracic surgeon
Dr. Namrata Patil is a polyglot (English, Urdu, Spanish, Hindi and Marathi) with extensive surgical and intensive care experience. Originally trained as an ENT surgeon, over the years she has added to her body of knowledge with residencies in Burn/ Trauma, Psychiatry, Thoracic Surgery and Surgical Critical Care.
She is an associate surgeon at the prestigious Brigham & Women’s Hospital in Boston, MA as well as a Professor of Surgery at Harvard Medical School.
Her most recent list of publications reflect her wide range of training and experience.
I have asked Dr. Patil for a copy of her presentation for use on this site. As soon as these slides are published at facts-care.org, I will provide a link for readers.
a new film showing the life-changing efforts of one thoracic surgeon.. It’s about time!
Dr. Diego Gonzalez Rivas
I am excited beyond words to hear that my long-time hero and champion of modern-day thoracic surgery, Dr. Diego Gonzalez Rivas, is featured in a new documentary film, “This is Life”. The film follows the life of a patient undergoing a single incision thoracoscopic lobectomy. The film is being released this December.
I eagerly await the film – and am happy to see thoracic surgery (and Dr. Diego Gonzalez Rivas) get their due. For too long, our humble specialty has been overlooked for the more ‘glamorous’ cardiac surgery. This oversight has led to a dire shortage of thoracic surgeons in many parts of the world.
Hopefully, this is only part of an ongoing effort to have thoracic surgery recognized as an independent and complex surgical specialty requiring extensive knowledge, advanced skills and training. It is not an ‘add-on’ for cardiac surgeons with insufficient cardiac consultations.
Dr. Gonzalez Rivas and single-port surgery in Shanghai, China
For those of you hoping to see – and learn from the best, Dr. Gonzalez Rivas will be spending much of the month of October in Shanghai, China at the “National Uniportal VATS Training Course & Continuing Medical Education Forum on General Thoracic Surgery” which runs from October 8th to November 8th, 2014 at Tongi University.
Alas! To my eternal regret, Cirugia de Torax will not be in attendance. However, I will have sources on the ground – and hope to post more information during the conference,
Talking with Dr. Mustafa Yuksel of Marmara University Hospital (Faculty of Medicine) about chest wall repairs, pectus defomities, the Yuksel bars and the future of 3D printing.
Istanbul, Turkey
Historic Istanbul
Istanbul is famous as one of the world’s truly great cities; with its exotic Eurasian mix; filled with architecture (palaces, mosques, the grand bazaar), with extensive arrays of artifacts and objects d’ art attesting to a vibrant and rich history as a former capitol (and empire in its own right), center of international trade, learning and education.
on the Bosphorus
From the earliest years of the city (Constantinople), it has been a center of technology, cultural and societal advancement. While many people know about and visit (the cisterns) of the Valens aqueducts, a fourth century AD water delivery system which provided the city with fresh water, few people know that Istanbul along with places like Iran (Persia) provided us with the foundations of medicine.
Serefeddin Sabuncuoglu, 15th century Turkish physician and surgeon (Wiki commons)
Since ancient times, learned scholars and physicians in this part of the world advanced our understanding of human anatomy, physiology, disease and medicine. Much of this knowledge was lost/ banned in other parts of the western world due to ignorance or religious-based beliefs which resulted in countless suffering in Europe and the Americas.
*(If you aren’t much of a historical scholar, just watch any of several excellently researched movies, and even some more ‘so-so’ series such as London Hospital or the new American series, “The Knick” to see how medicine fared without the basic knowledge gained by Serefeddin Sabuncuoglu and other middle eastern physicians over the centuries.)
Tombs for Sultan II Mahmud, Sultan II Abdulhamid, Sultan Abdoulaziz and valued members of their courts.. now look closer.
tomb of court physician
With such strong ties to the history (and advancement) of medicine and nursing in Istanbul, it is no surprise that my work has brought me to the doorstep of modern civilization, to Dr. Mustafa Yüksel, pectus repair and 3-D printing.
Dr. Mustafa Yüksel
Dr. Mustafa Yuksel, cardiothoracic surgeon
Dr. Yüksel is a cardiothoracic surgeon and the Chief of Thoracic Surgery and faculty professor for the school of Medicine. He is the former president (for three consecutive years) of the Chest Wall International Group and spearheads Pektus (the pectus project) which is a program aimed at training surgeons, educating people and performing pectus repair.
He attended medical school at Ankara University and completed both his surgical residency and thoracic surgery fellowship in Ankara at the Ankara Ataturk Education and Research Hospital. He briefly worked as a thoracic surgeon at the Camlica Military Hospital before becoming the Chief of Thoracic Surgery at Heybeliada Education and Research Hospital.
Dr. Yüksel spent a year as a visiting fellow at the Royal Brompton Hospital with Dr. Peter Goldstraw in London, England before returning to join the faculty at Marmara University Hospital. In 2004, he studied with Dr. Donald Nuss, of Norfolk, Virginia. Dr. Nuss is the inventor of the minimally invasive pectus repair, the “Nuss procedure“.
In 2005, Dr. Yuksel performed his first Nuss procedure for repair of a pectus defect. Since then, he has performed this procedure over 600 times. He estimates that in the last several years, he has performed 150 pectus repair procedures annually. Dr. Yüksel and Marmara University have become the major center for chest wall surgery in Turkey. The program also attracts surgeons internationally, to learn more about the center. In the last month alone, Dr. Yüksel hosted surgeons from the United Kingdom, the Ukraine, Poland, Holland and other parts of Europe. The majority of these surgeons have come to see Dr. Yüksel’s titanium carinatum bars.
Dr. Yüksel has also written several textbooks and chapters on thoracic surgery.
Prof. Mustafa Yüksel, MD
General thoracic and cardiovascular surgery
Ministery of Health of the Republic of Turkey
Marmara University Pendik Training and Research Hospital
Thoracic Surgery Department
7th Floor, F wing
Fevzi Cakmak Mah, Mimar – Sinan Cad. No 41
34899 Ust Kaynarca/ Pendik
Istanbul, Turkey
(+90) 216-625-4545 ext. 3580
Marmara University Hospital
Marmara University Hospital in Istanbul, Turkey(Kadikoy neighborhood)
Marmara University is the second largest university in Turkey and was founded in 1883. The university serves over 60,000 students. The main campus is located in the central Istanbul neighborhood of Fatih but the School of Medicine and University Hospital are located across the Bosphorus river in Kadikoy. (A newer, larger 600 bed facility is being built in nearby Maltepe but is still under construction).
As a public hospital, Marmara University sees patients from all over Turkey and from every social class.
The university hospital has a large thoracic surgery program, with five thoracic surgeons on staff, which allows the thoracic surgeons to sub-specialize. Dr. Yüksel sub-specializes in chest wall repair and tracheal surgery.
During my visit, I also met with Dr. Dr. Bedrettin Yıldızeli, a thoracic surgeon who is currently involved in developing a pulmonary arthrectomy program for patients with chronic pulmonary emboli. (These patients will develop pulmonary hypertension and right-heart failure if untreated.) The current prognosis for this growing patient population is quite grim, so an advancements in this area will certainly be welcomed. Dr. Yildizeli is also interested in thoracic surgery applications using the Davinci robot.
Pectus excavatum versus Pectus carinatum
The easiest way to remember and differentiate between these two conditions is to remember: In or out? Pectus excavatum or “funnel chest” is a chest wall defect that causes an inward deviation of the sternum. Think ‘excavate’ as removing from the ground or bringing something upwards/ outwards.
Thus, pectus carinatum or “pigeon breast” is an outward bowing of the sternum. I don’t have any cute little sayings to remember this one.
In extreme cases, these defects can compromise the function of the heart, lungs and mediastinal organs.
The Nuss Procedure
Historically, pectus repair was performed using open surgery, but in 1987, Dr. Nuss invented a procedure using steel bars inserted via small (2 to 3 cm) incisions into the chest. The bars are placed into position and affixed with sternal wires. The bars force the sternum and chest wall to the appropriate shape.
When used for pectus excavatum, the bars force the sternum outward from inside the chest. When used to correct pectus carinatum, the bars are placed more superficially – beneath skin and muscle but outside (and over, not under) the sternum. These bars are usually visible as a thin line in most patients. (Most patients with this condition are very thin.)
These bars usually remain in place for around two years. (They may be removed earlier if complications develop).
image provided by Stepshep (who underwent a Nuss procedure). This condition is often associated with scolosis or curvature of the spine which gives the bars a crooked appearance.
However, there are several problems related to this condition and the Nuss procedure. Much of Dr. Yüksel’s work has been aimed at corrected problems related to the hardware used for this procedure.
Metal Allergies
The usual Nuss bars are made of stainless steel and require sternal wires or similar fixation to remain in place. The stainless steel material can be problematic due to the incidence of nickel and steel allergies in some patients. While Dr. Yüksel performs pre-operative allergy testing in all patients prior to surgery, and takes a complete history to determine a pre-existing allergy, up to three (3%) of patients without pre-operative metal allergies will develop one from continuous contact with the stainless steel bars. While these patients are given steroids and other medications to treat this allergy, it often persists, requiring bar removal.
a collection of Yüksel and standard bars used for the Nuss procedure
Dr. Yüksel developed titanium bars to combat the problem of metal allergies. (The majority of patients are allergic to alloys or components in the stainless steel, particularly if nickel is used). These patients readily tolerate titanium.
One of the other technical problems encountered during this procedure is the inability to affix the bars to the chest wall securely. This happens more commonly in older patients who have less flexible bones. (As patients mature, bones become more rigid). The majority of patients undergoing this procedure are children, adolescents and teens but older patients often present after becoming symptomatic due to organ compression.
Using titanium bars can actually compound this problem, since titanium is a much stronger, less flexible material than stainless steel. So, Dr. Yüksel created a new way of securing the bars into position using either clips or screws – similar to the techniques used by orthopedic surgeons to stabilize a fracture.
The Yüksel Bars
Dr. Yüksel currently has three designs, two patented, with the third patent pending. He developed the first design in 2008, and several hospitals (6 or 7) are using his design for their repairs. These designs are also being used by other surgeons across Europe.
The different designs are used for different problems and allow the bars to be more readily customized for each patient. The bars are designed to be able to be used on very small children, pectus carinatum as well as older adults. (The average age of his patients is 17. The youngest patient was 6 years old – and he recently operated on a brother and sister in their late fifties. (The is a 20% familial risk.)
Each bar has adjustable plates for clip placement.
A Yüksel titanium bar
3-D Printing?
But Dr. Yüksel isn’t content to rest on his laurels. He is always thinking, creating and innovating. His newest project involves 3-D printing.
Dr. Yüksel experiments with a 3-D printer for chest wall repairs
Dr. Yüksel is currently experimenting in creating customized implants for patients using a 3 D printer. The printing itself takes one to three hours, but the entire process takes considerably longer as patients undergo CT Scan reconstructions to allow Dr. Yüksel and his team to recreate a sternum, a thoracic vertebra or a tracheal implant.
tracheal created with 3D printing
His work is currently hampered by his materials – the plastic used for 3-D printing is too toxic for long-term human use, but he reports that new, safer materials are being developed in the United States. These non-toxic materials will allow surgeons to repair and replace damaged organs in a way that is not currently possible.
One final thought
One of thousands of hydatid cysts removed by Dr. Yüksel
During my visit, we talked about some of the specific thoracic conditions endemic to particular geographic areas. I mention hydatid cysts as an example from a previous interview. Dr. Yüksel laughs and reaches for a gallon-sized jar on a high shelf.
While Istanbul is a European city (with low rates of empyema and similar type infections), Dr. Yüksel talks about his thoracic surgery training in Ankara and many of the patients from rural areas. “I think, during my training, I removed about a thousand of these.” We talked about the epidemiology – and how it is often easily spread from seemingly innocuous sources, like cute little stray puppies.
So readers, when you see that cute stray dog during one of your travels? Don’t pet it. Or you might end up with one of these growing in your lung.
Yüksel M, Bostanci K, Evman S. (2011). Minimally invasive repair after inefficient open surgery for pectus excavatum. Eur J Cardiothorac Surg. 2011 Sep;40(3):625-9. doi: 10.1016/j.ejcts.2010.12.048. Epub 2011 Feb 20.
Yüksel M, Bostanci K, Evman S. (2011). Minimally invasive repair of pectus carinatum using a newly designed bar and stabilizer: a single-institution experience. Eur J Cardiothorac Surg. 2011 Aug;40(2):339-42. doi: 10.1016/j.ejcts.2010.11.047. Epub 2011 Jan 11.
Bostanci K, Ozalper MH, Eldem B, Ozyurtkan MO, Issaka A, Ermerak NO, Yüksel M. (2013). Quality of life of patients who have undergone the minimally invasive repair of pectus carinatum. Eur J Cardiothorac Surg. 2013 Jan;43(1):122-6. doi: 10.1093/ejcts/ezs146. Epub 2012 Apr 6.
Umuroglu T, Bostancı K, Thomas DT, Yüksel M, Gogus FY. (2013). Perioperative anesthetic and surgical complications of the Nuss procedure. J Cardiothorac Vasc Anesth. 2013 Jun;27(3):436-40. doi: 10.1053/j.jvca.2012.10.016. Epub 2013 Mar 30.
Ozyurtkan MO, Yildizeli B, Kuşçu K, Bekiroğlu N, Bostanci K, Batirel HF, Yüksel M. (2010). Postoperative psychiatric disorders in general thoracic surgery: incidence, risk factors and outcomes. Eur J Cardiothorac Surg. 2010 May;37(5):1152-7. doi: 10.1016/j.ejcts.2009.11.047. Epub 2010 Feb 8.
Yüksel M, Bostanci K, Eldem B. (2011). Stabilizing the sternum using an absorbable copolymer plate after open surgery for pectus deformities: New techniques to stabilize the anterior chest wall after open surgery for pectus excavatum. Multimed Man Cardiothorac Surg. 2011 Jan 1;2011(623):mmcts.2010.004879. doi: 10.1510/mmcts.2010.004879.
Johnson WR, Fedor D, Singhal S. (2004). Systematic review of surgical treatment techniques for adult and pediatric patients with pectus excavatum.J Cardiothorac Surg. 2014 Feb 7;9(1):25. doi: 10.1186/1749-8090-9-25. While this article is dated (back to the early days of minimally invasive pectus excavatum repair aka Nuss procedure) it gives some good general information. The biggest limitations are in the comparisons of Nuss and the Ravitch procedure.
History of Thoracic Surgery and medicine in Turkey
I have provided a very limited list of citations (free full text only).
Batirel HF1, Yüksel M. (1997). Thoracic surgery techniques of Serefeddin Sabuncuoğlu in the fifteenth century. Ann Thorac Surg. 1997 Feb;63(2):575-7. pdf provided by Dr. Yüksel
Kaya SO, Karatepe M, Tok T, Onem G, Dursunoglu N, Goksin I (2009). Were pneumothorax and its management known in 15th-century anatolia?Tex Heart Inst J. 2009;36(2):152-3. Did Turkish physicians recognize and treat this condition a full 350 years before its first mention in western writings?
Zuhal Ozaydim (2004). Some landmarks in the history of medicine in Istanbul. JISHIM. Several of these landmarks including some of the medical museums are open to the public. The Medical History Museum of Istanbul is located on Koca Mustafa Pasa in the Fatih neighborhood of Istanbul (Asia side) and is open o weekdays 8 am to 5pm, free.
*Undoubtably, some readers will take issue with these statements, but the abandonment of the teachings of many of the Moor physicians (brought to European courts), as well as the prohibition against human dissections and other religious prohibitions (from various Crusades, Inquisitions and other religious actions/ proclamations) retarded the development of modern medicine by several centuries. In reading historical medical literature, it is evident and (not infrequent) to see that important discoveries, diagnoses and treatments were made, possibly published and used in a limited circle and then forgotten, only to be “re-discovered” decades (or centuries) later.
Thank you to Dr. Cristian Anuz, cardiothoracic surgeon, of Santa Cruz de la Sierra for providing me with an introduction to Dr. Yüksel.
the Babe Ruth of thoracic surgery continues his winning streak; and Dr. Benny Weksler heads south to the University of Tennessee. Kudos to both of these fine surgeons!
It’s another home run for Dr. Gonzalez Rivas as he and his team perform a single port (uni-port) thoracoscopic lobectomy with under local anesthesia, as reported by a recent story, “Operan un tumor e pulmón con una sola incisión y anestesia local” by Raul Romar in La Voz de Galicia.
Dr. Gonzalez Rivas demonstrates uniportal VATS
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. Benny Weksler, our own American (via Brazil) superstar surgeon recently made the move to the University of Tennessee. Dr. Weksler made the move in November of 2013 and is now settling in to his new position as Chief of Thoracic Surgery for the University of Tennessee (UT) Health Science Center and UT – Methodist.
Dr. Weksler, one of the United States most prominent thoracic surgeons, particularly in the area of esophageal surgery reports that he has big plans for the UT health system and the thoracic surgery department.
Big Plans for UT and the city of Memphis
These plans include a lung cancer screening program targeting vulnerable populations in Memphis including the uninsured/ underinsured, African-Americans (who are disproportionately affected) and smokers.
Related: Dr. Weksler talks about smoking cessation
Minimally invasive techniques for esophageal surgery
He has also started a new minimally invasive esophageal surgery program for esophageal cancer and reports “that there is almost an epidemics of squamous cell carcinoma of the esophagus” which is something tha was more rare in his previous practice in Pittsburgh, Pennsylvania.
Dr. Weksler and his colleagues are putting together a multi-disciplinary treatment plan to try to get these patients to a complete evaluation with a surgeon, an oncologist, and a radiation oncologist to provide patients with comprehensive, multi-faceted and coördinated care.
“The Surgeon Speaks” – Dr. Weksler talks about robotic surgery in this 2009 Jefferson University publication.
As a former Memphis resident, I want to say, “Welcome to the mid-south.. Hope you find time in your busy schedule to enjoy Beale Street, visit the Pink Palace and tour Graceland.. On behalf of all current Memphians, we are glad you are here.”
*This article was written by the author of this post.
Dr. Chin Hao Chen revisits one of the basic procedures in thoracic surgery: Chest tube placement
Even Hippocrates placed chest tubes or the history of tube thoracostomy
Chest tube placement has been performed since ancient Greek times. Early physicians, including Hippocrates himself, performed (and wrote about) the use of tube thoracostomy for the treatment of lung abscesses and empyema. Often this procedure is performed using a ‘blind approach’ based entirely on external anatomic features (intercostal spaces) and a fundamental knowledge of internal and chest wall anatomy. Over the years, surgeons have developed guidelines to this technique using palpation/ and other tactile information but none of these techniques challenged initial insertion technique.
With any blind procedure, there is a risk of inadvertent injury due to the lack of visualization, particularly in patients with previous thoracic procedures or infections (adhesions), or when performed by less experienced staff.
Direct visualization during this procedure (akin to VATS) may lessen this risk. However, little has been published on alternatives to the traditional technique.
VGTT: video-guided tube thoracostomy
Our latest post comes directly from Dr. Chih-Hao Chen at Mackay Memorial Hospital in Taiwan.
Dr. Chen presents a video clip demonstrating video-guided tube thoracostomy (VGTT), a technique used to avoid tube-related injury during the course of tube thoracostomy (versus blind insertion). This visualization technique is helpful particularly when performed by inexperienced staff, such as residents or in emergent situations.
A complete description of this technique was recently published in the Annals of Thoracic Surgery.
This paper describes the technique as well as discussing the clinical experience of Dr. Chen and his team in applying this technique to several patients.
Dr. Chin-Hao Chen is a thoracic surgeon at Mackay Memorial Hospital in Taiwan. Dr. Chen is a frequent and valued contributor here at Cirugia de Torax. He has provided several case studies as well as articles and videos on surgical techniques.
the 2013 S.W.A.T conference, presented by Johnson & Johnson. Featured presenters Dr. Diego Gonzalez Rivas and Dr. Paula Ugalde discuss single port thoracoscopy and topics in minimally invasive surgery
Very pleased that despite the initial difficulties, we are able to provide information regarding the recent conference.
Talking about Single-port surgery in Bogotá, Colombia – 2013 S.W.A.T. Summit
Dr. Diego Gonzalez Rivas and Dr. Paula Ugalde were the headliners at the recent Johnson and Johnson thoracic surgery summit on minimally invasive surgery. Both surgeons gave multiple presentations on several topics. They were joined at the lectern by several local Colombian surgeons including Dr. Stella Martinez Jaramillo (Bogotá), Dr. Luis Fernando Rueda (Barranquilla), Dr. Jose Maineri (Venezuela) Dr. Mario Lopez (Bogotá) and Dr. Pardo (Cartagena).
Thoracic surgeons at the 2013 S.W.A.T Summit in Bogota, Colombia. Drs. Gonzalez-Rivas and Dr. Paula Ugalde are center, front-row
Target audience missing from conference
The audience was made up of thirty Latin American surgeons from Colombia, Costa Rica and Venezuela. This surgeons were hand-picked for this invitation-only event. Unfortunately, while Johnson and Johnson organized and presented a lovely event; their apparent lack of knowledge about the local (Colombian) thoracic surgery community resulted in the exclusion of several key surgeons including Dr. Mauricio Velasquez, one of Colombia’s earliest adopters of single-port thoracoscopy. Also excluded were the junior members of the community, including Dr. Castano, Dr. Carlos Carvajal, and current thoracic surgery fellows. It was an otherwise outstandingand informative event.
The Gonzalez – Rivas dissector, photo courtesy of Scanlon International
As discussed in multiple publications, previous posts as well as during the conference itself, it is these younger members who are more likely to adopt newer surgical techniques versus older, more experienced surgeons. More seasoned surgeons may be hesitant to change their practices since they are more comfortable and accustomed to open surgical procedures.
Despite their absence, it was an engaging and interesting conference which engendered lively discussion among the surgeons present.
Of course, the highlight of the conference actually occurred the day before, when Dr. Gonzalez- Rivas demonstrated his technique during two separate cases at the National Cancer Institute in Bogotá, Colombia. (Case report).
Dr. Gonzalez-Rivas and Dr. Ricardo Buitrago performing single port thoracoscopy at the National Cancer Institute
Featured presenters:
Dr. Diego Gonzalez – Rivas is a world-renown thoracic surgeon jointly credited (along with Dr. Gaetano Rocco) with the development of single-port thoracoscopic (uni-port) surgery. He and his colleagues at the Minimally Invasive Surgery Unit in La Coruna, Spain give classes and lectures on this technique internationally. Recent publications include three papers in July alone detailing the application of this surgical approach, as well as several YouTube videos demonstrating use of this technique for a wide variety of cases.
Dr. Gonzalez Rivas
Dr. Paula Ugalde, a Chilean-borne thoracic surgeon (from Brazil) who gave several presentations on minimally-invasive surgery topics. She is currently affiliated with a facility in Quebec, Canada.
Dr. Paula Ugalde
Refuting the folklore
Part of the conference focused on refuting the ‘folklore’ of minimally-invasive procedures. Some of these falsehoods have plagued minimally-invasive surgery since the beginning of VATS (in 1991), such as the belief that VATS should not be applied in oncology cases. The presenters also discussed how uniportal VATS actually provides improved visibility and spatial perception over traditional VATS (Bertolaccini et al. 2013).
However, Gonzalez-Rivas, Ugalde and the other surgeons in attendance presented a wealth of data, and publications to demonstrate:
– VATS is safe and feasible for surgical resection in patients with cancer. (Like all surgeries, oncological principles like obtaining clear margins, and performing a thorough lymph node dissection need to be maintained).
– Thorough and complete lymph node dissection is possible using minimally invasive techniques like single-port surgery. Multiple studies have demonstrated that on average, surgeons using this technique obtain more nodes than surgeons using more traditional methods.
– Large surgeries like pneumonectomies and sleeve resections are reasonable and feasible to perform with single-port thoracoscopy. Using these techniques may reduce morbidity, pain and length of stay in these patients.
– Rates of conversion to open surgery are very low (rare occurrence). In single-port surgery, “conversion” usually means adding another port – not making a larger incision.
– Learning curve fallacies: the learning curve varies with each individual surgeon – but in general, surgeons proficient in traditional VATS and younger surgeons (the “X box generation”) will readily adapt to single-port surgery.
– Bleeding, even significant bleeding can be managed using single-port thoracoscopy. Dr. Gonzalez Rivas gave a separate presentation using several operative videos to demonstrate methods of controlling bleeding during single-port surgery – since this is a common concern among surgeons hesitant to apply these advanced surgical techniques.
Additional References / Readings about Single-Port Thoracoscopy
Scanlon single-port thoracoscopy kits – informational brochure about specially designed instruments endorsed by Dr. Gonzalez Rivas.
Dr. Diego Gonzalez Rivas – YouTube channel : Dr. Gonzalez Rivas maintains an active YouTube channel with multiple videos demonstrating his surgical technique during a variety of cases. Below is a full-length video demonstrating the uniportal technique.
Additional posts at Cirugia de Torax about Dr. Diego Gonzalez- Rivas
Upcoming conference in Florida – information about registering for September conference for hands-on course in single-port thoracoscopic surgery with Dr. Gonzalez-Rivas
Youtube video for web conference on Single-port thoracoscopic surgery
Bertolaccini, L., Rocco, G., Viti, A. & Terzi, A. (2013). Surgical technique: Geometrical characteristics of uniportal VATS. J. Thorac Dis. 2013, Apr 07. Article from thoracic surgeons at the National Cancer Institute in Naples, Italy explains how the geometric advantages of uniportal VATS improves visibility and spatial perception over traditional VATS, and mimics open surgery.
Calvin, S. H. Ng (2013). Uniportal VATS in Asia.J Thorac Dis 2013 Jun 20. Article discussing the spread of uniportal techniques in Taiwan, China and other parts of Asia.
Rocco, G. (2013). VATS and uniportal VATS: a glimpse into the future.J. Thorac Dis. 2013 July 04. After coming across several articles by Dr. Gaetano Rocco, and actively pursuing several other publications by this Italian thoracic surgeon, I have become increasingly convinced that Gaetano Rocco, along with Dr. Gonzalez Rivas is one of the world’s leading innovators in thoracic surgery. Hopefully, cirugia de torax will be able to catch up to Dr. Rocco at some point for an in-depth discussion.
While I advance criticism of this event – it was a fantastic conference. My only reservations were to the exclusivity of the event. While this was certainly related to the costs of providing facilities and services for this event – hopefully, the next J & J thoracic event will be open to more interested individuals including young surgeons and nurses.
writing about Dr. Diego Gonzalez Rivas and the other living legends in thoracic surgery and connecting people to the world of thoracic surgery
Readers at Cirugia de Torax have certainly noticed that there are numerous articles regarding the work of Dr. Diego Gonzalez Rivas. This week in particular, after a recent thoracic surgery conference and an afternoon in the operating room – there is a lot to say about the Spanish surgeon.
It’s also hard to escape that fact that I regard him in considerable awe and esteem for his numerous contributions to thoracic surgery and prolific publications. I imagine that this is similar to how many people felt about Drs. Cooley, Pearson or Debakey during their prime.
Making thoracic surgery accessible
But the difference is Dr. Diego Gonzalez Rivas himself. Despite the international fame and critical surgical acclaim, he remains friendly and approachable. He has also been extremely supportive of my work, at a time when not many people in thoracic surgery see the necessity or utility of a nurse-run website.
After all, the internet is filled with other options for readers; CTSnet.org, multiple societies like the Society of Thoracic Surgeons (STS), and massive compilations like journal-based sites (Annals of Thoracic Surgery, Journal of Thoracic Disease, Interactive Journal of Cardiothoracic Surgery).
But the difference between Cirugia de Torax and those sites is like the difference between Dr. Gonzalez Rivas and many of the original masters of surgery: Approach-ability and accessibility.
This site is specifically designed for a wider range of appeal, for both professionals in thoracic surgery, and for our consumers – the patients and their families. Research, innovation, news and development matters to all of us, not just the professionals in the hallowed halls of academia. But sometimes it doesn’t feel that way.
Serving practicing surgeons
For practice-based clinicians, and international surgeons publication in an academia-based journal requires a significant effort. These surgeons usually don’t have research assistants, residents and government grants to support their efforts, collect their data and clean up their grammar. Often English is a second or third language. But that doesn’t mean that they don’t make valuable contributions to their patients and the practice of thoracic surgery. This is their platform, to bring their efforts to their peers and the world.
Heady aspirations
That may sound like a lofty goal, but we have readers from over a 110 countries, with hundreds of subscribers along with over 6,000 people with Cirugia de Torax directly on their smart phone. Each month, we attract more hits and more readers.
Every day, at least 200 people read “Blebs, Bullae and Spontanous Pneumothorax”. Why? Because it’s a concise article that explains what blebs are, how a pneumothorax occurs and how it’s treated. Another hundred people usually go on to read the accompanying case report about blebectomy, for similar reasons. There are links for more information, CT scans and intra-operative photos included, so that people can find exactly what they need with a minimum of effort.
Avoiding ‘Google overload’
With the massive volume of information available on the internet, high-quality, easily understood, applicable information has actually become even more difficult for patients to find than ever before. Patients spend hours upon hours browsing through academic jargon, commercial websites and biased materials while attempting to sift through the reams of information for pertinent and easily understandable information. There is also a lot of great material out there – so we provide links to reputable sites, recommend well-written articles and discuss related research.
Connecting patients to surgeons
We also provide patients with more information about the people they are entrusting their bodies, their hopes and their lives to. It’s important that they know about the Dr. Benny Wekslers, the Dr. Hanao Chens, and the Dr. Diego Gonzalez Rivas out there.
Update: June 2019
After multiple reader requests from this site, we have launched a service to assist readers in pursuiting minimally invasive thoracic surgery, uniportal surgery, HITHOC and other state-of-the-art thoracic surgery procedures with the modern masters of thoracic surgery. We won’t talk a lot about this on the site, but we do want readers to know that we are here to help you. If you are wondering what surgery costs like with one of the world’s experts – it’s often surprisingly affordable.
If you are interested in knowing more, please head to our sister site, www.americanphysiciansnetwork.org or send an email to kristin@americanphysiciansnetwork.org.
Keeping it ‘real’
Looking over the shoulder of Dr. Gonzalez Rivas in the operating room
As much as I may admire the work and the accomplishments of Dr. Gonzalez-Rivas – it’s important not to place him on a pedestal. He and his colleagues are real, practicing surgeons who operating on regular people, not just heads of state and celebrities. So when we interview these surgeons and head to the OR, it’s time to forget about the accolades, the published papers and the fancy titles. It’s time to focus on the operations, the techniques, the patients and the outcomes because ‘master of thoracic surgery’ or rural surgeon – the operation and patient are all that really matters.
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.
a record number of surgeons fail to pass the American thoracic surgery certification exam, in the midst of a deepening shortage of surgeons.
A new report from the (American) Board of Thoracic Surgery shows a growing number of eligible surgeons are failing the thoracic surgery certification examination.
Record Failure Rate
As stated in the article published at Family Practice News, the failure rate has doubled to 28% in just a few short years. This comes at a critical period in American medicine as shortages in specialty surgeons have emerged around the country due to an aging workforce. This shortage is not confined to the United States – and has been echoed in Canada, the UK and several other industrialized nations.
Decrease in resident hours = decreased surgical knowledge
This record failure rate comes in the wake of recent reforms to resident surgical education – including several reductions in resident training hours, and the push for a condensed 6 year residency program.
Rapidly evolving surgical technology
At the same time, rapidly evolving surgical technology and research in thoracic surgery may actually require significant curriculum changes and increased length of specialty training, according to this report at Thoracic Surgery News.
But, as previously reported, the extensive training requirements for cardiothoracic surgery have led to fewer residents and widespread vacancies in residency programs as fewer and fewer surgical residents elect to devote themselves to cardiothoracic surgery due to concerns about diminishing financial returns, reduced economic opportunities, excessive student loan burdens and concerns related to the hardships of the ‘cardiothoracic lifestyle’.
Solo Cardiac, General Thoracic tracks may trump combined “Cardiothoracic”
Alternatively, North American surgeons may need to follow the example of many of their international peers and diverge into two separate tracks: cardiac surgery and general thoracic to maintain surgical proficiency without excessive education burden in an era of rapidly evolving surgical knowledge.
a clinical case report from Bogota, Colombia – and the work of Dr. Kalyanam Shivkumar, MD, PhD, Director, UCLA Cardiac Arrhythmia Center on treating ventricular arrhythmias with cardiac sympathetic denervation, including an upcoming clinical trial.
Dr. Ricardo Buitrago, Thoracic Surgeon
Dr. Andres Franco, Thoracic Surgeon
K. Eckland, Nurse Practitioner
Clinica Shaio
Bogota, Colombia
Left cardiac sympathetic denervation for uncontrolled ventricular arrhythmias in a young child
Dr. Andres Franco (right) assists Dr. Ricardo Buitrago (left) during VATS cardiac denervation
Case History: The patient, a 9-year-old Hispanic female child had a history of congenital long QT syndrome*, and had her first AICD (automated internal cardiac defibrillator) placed at two months of age, after receiving the initial diagnosis as a neonate.
After several years and multiple medical regimens were unsuccessful in controlling frequent episodes of ventricular tachycardia, the patient had undergone several additional procedures aimed at reducing the incidence of arrhythmia. The device had been checked thoroughly, evaluated and exchanged twice as part of on-going evaluation to ensure that the device was working properly, and was set at appropriate thresholds.
At the time of the initial referral to thoracic surgery, the child suffered from intense post-traumatic stress disorder symptoms and was being treated for psychiatric disturbances that were believed to be related to the extreme fear and stress related to frequent defibrillations delivered by her device. As a final resort, the department of electrophysiology requested evaluation for Video assisted thoracoscopic (VATS) sympathectomy for cardiac denervation.
After the patient is anesthetized and intubated with a double lumen endotracheal tube, a single anterior thoracic 10 mm port incision is made in the 5th intercostal space of the left chest without rib spreading. A 10mm port is inserted, for camera access to the interior of the chest. The left lung is deflated for easy identification and access to the sympathetic nerves at the T2 – T4 level on the chest wall. After successful identification, the nerves were cauterised. The lung was reinflated, and surgical instruments removed. Chest incision was closed with several layers of suture. The patient was awakened, extubated and transferred to the PACU.
In addition to the standard intra-operative hemodynamic and telemetry monitoring, an electrophysiology cardiologist was present during the case to monitor and treat the patient, if necessary.
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Following surgery, the patient was transferred to the post-anesthesesia care unit (recovery room). Following an uneventful recovery, she was discharged home. At follow-up surgical visit, her incision was well-healed and family reported no further discharges from her AICD.
At six months, post surgery, the patient has had no further cardiac events or ventricular arrhythmias reported or recorded by her device.
Discussion
The cardiovascular effects of sympathectomy have been well-known and described in the medical literature since the early 20th century. However, limitations in surgical technique prior to the advent of thoracoscopic surgery as well as the potential side effects of sympathectomy procedures have limited the use and research into this technique for the treatment of cardiac conditions.
In recent years, researchers at the David Geffen School of Medicine at the UCLA Cardiac Arrhythmia Center (Ajijola et. al) have published several papers about their experiences treating patients with persistant ventricular arrhythmias. In their work, which is one of the largest studies to date, the authors report their experiences with both selective left-sided cardiac sympathetic denervation (LCSD) alone or bilateral cardiac sympathetic denervation (BCSD) as a last-ditch treatment for persistent ventricular arrhythmias. Many of their patients have previously undergone multiple ablation therapies and/or evaluation for cardiac transplantation.
On-going research and clinical trials
Their results have been so promising, in fact, that they have now made cardiac denervation a routine procedure at UCLA and have designed an international multi-center trial called PREVENT VT to study this procedure in a larger group of patients. Since the publication of their initial work, Aijiola et al. have continued their study, with over 40 cases under their belt. Dr. Kalyanam Shivkumar, MD, PhD, Director, UCLA Cardiac Arrhythmia Center & EP Programs reports that they will be presenting their surgical outcomes at an upcoming conference, the Heart Rhythm Meeting at Denver in May of 2013 (Vaseghi et al Cervicothoracic Sympathectomy In Patients With Refractory Vt: Intermediate And Long Term Follow Up).
Contact information for Dr. Kalyanam Shivkumar:
Kalyanam Shivkumar MD PhD
Professor of Medicine & Radiology
Director, UCLA Cardiac Arrhythmia Center & EP Programs
For both their work, and the purposes of this post, persistent ventricular arrhythmias were defined as repeated episodes of ventricular tachycardia or ventricular fibrillation despite maximal medical therapy with a beta blocker and amiodarone**. (In a related article, Ajijola et al. further define which patients are the best candidates for successful outcomes with this procedure.) In their work, the researchers at UCLA were able to show increased effectiveness with the use of bilateral sympathetomy versus left-sided only.
However, the use of left-sided versus bilateral sympathectomy is also determined by the type of arrhythmia (monomorphic versus polymorphic) as well as previous patient history and medical treatments such as catheter based ablations or extensive scar tissue formation from previous cardiac injury.
Given the high morbidity, mortality and adverse effects on the quality of life for people with uncontrolled ventricular arrhythmias as well as the relative low risk, and ease of VATS procedures to treat this condition, cardiac sympathetic denervation should remain an important clinical tool in the treatment of this life-threatening condition, particularly when other treatments have failed.
*Patients with this condition are at very high risk of sudden cardiac risk.
**In the addition to implanted or external defibrillatory devices.
Wilde AA, Bhuiyan ZA, Crotti L, Facchini M, De Ferrari GM, Paul T, Ferrandi C, Koolbergen DR, Odero A, Schwartz PJ. (2008). Left cardiac sympathetic denervation for catecholaminergic polymorphic ventricular tachycardia. N Engl J Med. 2008 May 8;358(19):2024-9. doi: 10.1056/NEJMoa0708006. Case report of a 17 year old boy. In this article, the authors also talk about the psychological trauma experienced by these patients due to frequent defibrillation from AICDs similar to the patient in Colombia.
the latest predictions on the impending shortage of surgeons in the United States
Unsurprisingly – rural area hospitals face additional challenges in attracting and retaining specialty surgeons in comparison to big cities/ metropolitan areas. However, as reported by Patrice Welding at Thoracic Surgery News in a report on the annual meeting of the Central Surgical Association, this may be viewed as a boon for the surgeons themselves as hospitals may devise new and enhanced incentives to attract surgeons to their facilities. The surgical specialties most likely to benefit from this strategy include (as previously reported), obstetrics and gynecology, orthopedic surgery, general surgery, otolaryngology, urology, neurosurgery, and thoracic surgery.
The article which quotes Dr. Thomas E. Williams, Jr. predicts that hospitals and institutions may break out into a ‘bidding war’ over surgeons.
While this is dire news for rural hospitals and the estimated 56 million patients served by these facilities, it comes as a relief for current thoracic surgery fellows and new thoracic surgeons who have faced an increasingly bleak economic landscape over the last few years.
Of course, more sanguine experts note that the impact of the impending shortage has been reported for several years – with little impact on the current job market for new graduates.
Dr. Thomas E. Williams Jr. is one of the main researchers on the impending shortage in the United States and published a book based on his findings in 2009, entitled, “The coming shortage of surgeons: why they are disappearing and what that means for our health“. (Praeger, ISBN #978-0313380709). His work has also be published in multiple journals, and presented in meetings and conferences across the country.
Interested in learning more about single port thoracoscopy, or talking to the inventors of this technique? This March – head to the 1st Asian single port surgery conference in Hong Kong.
It doesn’t look like Cirugia de Torax will be in attendance for this conference, but it’s another opportunity for practicing thoracic surgeons and thoracic surgery fellows to learn more about single port thoracoscopic surgery.
This March (7th – 8th), the Chinese University of Hong Kong, along with the Minimally Invasive Thoracic Surgery Unit (Coruna, Spain), and Duke University are presenting the 1st Asian Single Port Symposium and Live Surgery conference in Hong Kong.
This is your chance to meet the experts – and the inventors of this technique (such as Dr. Diego Gonzalez – Rivas, one of the new masters frequently featured here at Cirugia de Torax.)
what is the future of thoracic surgery education? A new American study asks the if it is time to separate the specialties of cardiac and thoracic surgery.
A new study by Cooke & Wisner performed at a large medical center in California (UC Davis) and published in the Annals of Thoracic Surgery provides additional weight to the idea that Thoracic Surgery has increasingly developed into it’s own subspecialty away from the traditional cardiothoracic surgery model (seen in the United States and several other countries.)
In an article published in Medical News Today, the authors of the study explained that the increased complexity of (noncardiac) thoracic surgery procedures for general thoracic conditions has led to increased referrals and utilization of general thoracic surgeons (versus cardiac or general surgeons). This shows a reversal in a previous trend away from specialists – with more patients now receiving “complex” thoracic surgery procedures from specialty trained, board-certified thoracic surgeons. Previously up to 75% of all thoracic surgery procedures were performed by general surgeons.
With lung cancer rates expected to climb dramatically in North America and Europe, particularly in women – along with esophageal cancer, and long waits already common, support and on-going discussion about the evolution of resident and fellow education is desperately needed.
Reference
Cooke, D. T. & Wisner, D. H. (2012). Who performs complex noncardiac thoracic Surgery in United States Academic Medical Centers? Ann Thorac Surg 2012;94:1060-1064. doi:10.1016/j.athoracsur.2012.04.018
a day in the operating room with one of Colombia’s New Masters of Thoracic Surgery
Cali, Colombia
Dr. Mauricio Velasquez is probably one of the most famous thoracic surgeons that you’ve never heard of. His thoracic surgery program at the internationally ranked Fundacion Valle del Lili in Cali, Colombia is one of just a handful of programs in the world to offer single port thoracic surgery. Dr. Velasquez has also single-handedly created a surgical registry for thoracic surgeons all over Colombia and recently gave a presentation on the registry at a national conference. This registry allows surgeons to track their surgical data and outcomes, in order to create specifically targeted programs for continued innovation and improvement in surgery (similar to the STS database for American surgeons).
Dr. Mauricio Velasquez after another successful case
Dr. Velasquez is also part of a team at Fundacion Valle del Lili which aims to add lung transplant to the repertoire of services available to the citizens of Cali and surrounding communities.
He is friendly, and enthusiastic about his work but humble and apparently unaware of his growing reputation as one of Colombia’s finest surgeons.
Education and training
After completing medical school at Universidad Pontificia Bolivariana in Medellin in 1997, he completed his general surgery residency at the Universidad del Valle in 2006, followed by his thoracic surgery fellowship at El Bosque in Bogotá.
The Colombia native has also trained with thoracic surgery greats such as Dr. Thomas D’Amico at Duke University in Durham, North Carolina, and single port surgery pioneer, Dr. Diego Gonzalez Rivas in Coruna, Spain. He is also planning to receive additional training in lung transplantation at the Cleveland Clinic, in Cleveland, Ohio this summer.
Single port surgery
Presently, Dr. Velasquez is just one of a very small handful of surgeons performing single port surgery. This surgery is an adaptation of a type of minimally invasive surgery called video-assisted thoracoscopy. This technique allows Dr. Velasquez to perform complex thoracic surgery techniques such as lobectomies and lung resections for lung cancer through a small 2 – 3 cm incision. Previously, surgeons performed these operations using either three small incisions or one large (10 to 20cm) incision called a thoracotomy.
By using a tiny single incision, much of the trauma, pain and lengthy hospitalization of a major lung surgery are avoided. Patients are able to recovery and return to their lives much sooner. The small incision size, and lack of rib spreading means less pain, less dependence on narcotics and a reduced incidence of post-operative pneumonia and other complications caused by prolonged immobilization and poor inspiratory effort.
However, this procedure is not just limited to the treatment of lung cancer, but can also be used to treat lung infections such as empyema, and large mediastinal masses or tumors like thymomas and thyroid cancers.
Dr. Velasquez in the operating room with Lina Caicedo Quintero (nurse)
Team approach
Part of his success in due in no small part to Dr. Velasquez’s surgical skill, another important asset to his surgical practice is his wife, Dr. Indira Cujiño, an anesthesiologist specializing in thoracic anesthesia. She trained for an additional year in Spain, in order to be able to provide specialized anesthesia for her husband’s patients, including in special circumstances, conscious sedation. This allows her husband to operate on critically ill patients who cannot tolerate general anesthesia. While Dr. Cujiño does not perform anesthesia for all of Dr. Velasquez’s cases, she is always available for the more complex cases or more critically ill patients.
In the operating room with Dr. Velasquez
I spent the day in the operating room with Dr. Velasquez for several cases and was immediate struck by the ease and adeptness of the single port approach. (While I’ve written quite a bit about the literature and surgeons using this technique, prior to this, I’ve had only limited exposure to the technique intra-operatively.) Visibility and maneuverability of surgical instruments was vastly superior to multi-port approaches. The technique also had the advantage that it added no time, or complexity to the procedure (unlike robotic surgery).
Dr. Velasquez performing single port thoracoscopy
Cases proceeded rapidly; with no complications.
close up view
Note to readers – some of the content, and information obtained during interviews, conversations etc. with Dr. Velasquez may be used on additional websites aimed at Colombia-based readers.
an Interview with Dr. Diego Gonzalez Rivas – and coverage of ‘Videotoracoscopia y cirugia robotica en torax: Avances y perspectivas’ in Santiago, Chile
Santiago, Chile
I was a little intimidated to actually interview Dr. Diego Gonzalez Rivas after reading his articles and pestering him with emails for the last few years. But he was just as nice and patient with my questions as he’s always been.
Dr. Santolaya, Dr. Sales dos Santos, Dr.Berrios and Dr. Diego Gonzalez Rivas
Since publishing the last few articles on his single port technique, Dr. Gonzalez has been in high demand from thoracic surgeons wanting to learn more, and to train in single port techniques. In addition to traveling the world to teach – he continues to offer training at the Minimally Invasive Thoracic Surgery Unit at the Complexo Hospitalario Universitario de A Coruna, in Coruna, Spain.
Dr. Gonzalez reports that single port thoracoscopy doesn’t just provide patients with the least invasive surgery possible, but that single port thoracoscopy is superior to traditional VATS in the vast majority of cases. Single port thoracoscopy is defined by the creation of one 2cm to 4cm incision – with no rib spreading and utilization of video-assisted thoracoscopy.
“Forward Motion”
He states that using a single port approach gives much better visibility than traditional VATS. This visibility is equal to that of open surgery – versus the 3 or 4 port approach, which is constrained by the 30 degree movement / rotation of the thoracoscope. This visibility concept; called ‘Forward Motion,’ along with the ease of using instrumentation through the same port makes single port surgery amendable to most thoracic surgery procedures.
Learning curve? What learning curve?
He reports that members of the “Playstation Generation” as he terms the newest young surgeons, adapt more readily to the use of both traditional and single port thoracoscopy. In fact, he reports that the residents (in his program) are able to learn and use this approach with minimal assistance.
With the exception of lung transplantation (requiring the traditional clamshell incision), Dr. Gonzalez reports that he is able to successfully perform a wide range of surgeries from wedge resections and lobectomies to more complicated procedures such as pneumonectomies and sleeve resections.
In today’s lecture he debunks some of the myths regarding the ‘classic contraindications’ to video-assisted thoracoscopy (VATS) such as broncheoplasty, the presence of dense adhesions or the need for complete lymph node dissection. While he reports that dense adhesions may make the procedure more painstaking and difficult – it is still possible.
LymphNode Dissection
In cases of lymph node dissection – he reports that lymphadenectomy is actually superior by single port and other VATS methods, with the average surgeon actually harvesting more nodes, more easily.
While he initially believed that right upper lobe resections would be impossible with this method – his recent experiences (included in an upcoming paper on 102 cases) show that any anatomic complexities are readily overcome by an experienced VATS surgeon. Not only that, but he has been able to successfully remove very large (8cm or greater) lung tumors using this method – by slightly enlarging the port at the time of specimen removal. He has also successfully removed Pancoast tumors and performed chest wall resections with this procedure, as well as single port thoracoscopy after previous VATS or previous thoracotomy including completion pnuemonectomies and completion sleeve lobectomies.
One of the biggest obstacles for surgeons implementing the single port method is the dreaded complication of catastrophic bleeding. This often causes inexperienced single port surgeons to hasten to convert to open surgery without attempting to control the bleeding. Dr. Gonzalez presented several cases today to demonstrate the difference between controlled bleeding that can be managed with the speedy application of surgical staples, clips or sutures versus heavy uncontrolled bleeding, which requires quick recognition and prompt conversion to open thoracotomy.
He reports that in the over 500 cases he has performed by VATS (3 port, dual port and single port), conversion to open thoracotomy remains a very rare occurence. (He presented data on his outcomes today.)
In his own practice, he reports that prior to 2007 the majority of cases were by traditional thoracotomy. He began using 3 port VATS more heavily in 2007 – 2009. After training with Dr. D’Amico at Duke University in Durham, NC – he moved to dual port thoracoscopy in 2009. Since 2010, his practice is almost exclusively single port thoracoscopy.
The future of single port thoracoscopy
Dr. Gonzalez believes the future of single port thoracoscopy will be a hybridization of current robotic thoracic surgery (which now uses three and four port techniques) to using less invasive, smaller robotic arms that will allow surgeons to enjoy the micro-precision of robotic technology through a single port.
Not just a ‘single port surgeon’
While he is famous internationally for his innovations in the field of minimally invasive surgery, he is also a transplant surgeon. In fact, along with his partners, he performed an average of 35 – 40 lung transplants a year.* This makes the transplant program in Coruna the second largest in Spain, despite the relatively small size of Coruna compared to other cities such as Barcelona or Madrid.
For patients who are interested in Dr. Gonzalez-Rivas and his program, please contact him at Info@videocirugiatoracica.com
I published an article based on this interview over at Examiner.com
5 / Video-assisted thoracic surgery lobectomy: 3-year initial experience with 200 cases. Gonzalez D, De la Torre M, Paradela M, Fernandez R, Delgado M, Garcia J,Fieira E, Mendez L. Eur J Cardiothorac Surg. 2011 40(1):e21-8.
6 / Single-port Video-Assisted Thoracoscopic Anatomical Resection: Initial Experience. Diego Gonzalez , Ricardo Fernandez, Mercedes De La Torre, Maria Delgado, Marina Paradela, Lucia Mendez. Innovations.Vol 6.Number 3. May/jun 2011. Page 165.
Books/ Book Chapters
1 / Thoracoscopic lobectomy through a single incision. Diego Gonzalez-Rivas, Ricardo Fernandez, Mercedes de la Torre, and Antonio E. Martin-Ucar. Multimedia Manual of Cardio-Thoracic Surgery. MMCTS (2012) Vol. 2012 doi:10.1093/mmcts/mms007. Includes multiple videos demonstrating single port techniques.
2 / Tumores del diafragma. M. de la Torre Bravos, D. González Rivas, R. Fernández Prado, JM Borro Maté. Tratado de Cirugía Torácica. Editores L. Fernandez Fau, J. Freixinet Gilart. SEPAR Editores médicos SA. Madrid 2010. Vol 2, Sec VIII, Capitulo 87: 1269-78.
3 / Trasplante Pulmonar. C. Damas, M. De la Torre, W. Hespanhol, J.M. Borro. Atlas de Pneumología. Editores A. Segorbe Luís y R. Sotto-Mayor 2010. Vol 2, Capítulo 54 651-8.
4 / Doble utilidad hemostática y sellante de fuga aérea de tachosil en un caso de cirugía compleja por bronquiectasias. M. De la Torre, J.M. Borro, D. González, R. Fernández, M. Delgado, M. Paradela. Anuario 2009. Casos clínicos en cirugía. Accesit en la 3ª edición de los Premios Nycomed 2008.
5 / Cirugía Torácica videoasistida avanzada. D. González Rivas. Videomed 2008. Certamen internacional de cine médico y científico.
6 / Traumatismo Torácico. M. de la Torre, M. Córdoba. En « Manual de Urgencias en Neumología». Editado por Luis M Domínguez Juncal, 1999 165-78.
7 / Neumotórax. M. Córdoba, M. de la Torre. En « Manual de Urgencias en Neumología». Editado por Luis M Domínguez Juncal, 1999 139-56.
8 / Cirugía del enfisema. P. Gámez, J.J. Rivas, M . de la Torre. En « Neumología Práctica al Día». Boehringer Ingelheim 1998 77-102.
9 / Neumotórax. J.J. Rivas, J. Torres, M. de la Torre, E. Toubes. En « Manual de Neumología y Cirugía Torácica». Editores Médicos S.A. 1998 1721-37.
In Jupiter, Florida talking about robots, lung cancer screening and solitary pulmonary nodules with Dr. K. Adam Lee, thoracic surgeon
Jupiter, Florida
Dr. K. Adam Lee, MD and Dawn Bitgood, FNP
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.
Dr. Lee, performing surgery with the DaVinci robot
Teaching others
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[1].
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.
[1] 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.
Prior to coming to Jupiter, Dr. Lee was most recently at the Kennedy Health System in New Jersey.
Dr. Lee is well-known for his expertise in thoracic robotic surgery and has trained surgeons in using the DaVinci robot, in live demonstrations, conferences and educational sessions. Currently, Dr. Lee is working with three other thoracic surgeons.
After reading about Dr. Lee, I contacted him (by email) to ask about his plans for the future.
Q & A with Dr. K. Adam Lee
CdeT: There is quite a bit of interest in robotic surgery right now. Would you please tell us more about some of the robotic surgery procedures you are performing, and why these procedures are becoming popular?
Dr. Lee: [In our program, we are currently performing several different robotic procedures including]:
Robotic lobectomy for lung cancer. Lobectomy, or the surgical removal of a cancerous lobe in the lung, is the standard treatment of early-stage non small-cell lung cancer. Until recently, this procedure required a large incision that could cause the patient significant pain and a long recovery period
Segmentectomy- especially for pulmonary compromised patients, Wedge resections
Robotic thymectomy for myasthenia gravis/ Thymomas. The removal of the thymus gland is often a recommended treatment for patients who have myasthenia gravis, which is a neuromuscular disorder that can cause muscle weakness. Traditional surgery involves a large, length-wise incision along the breastbone, similar to that used for open-heart surgery.
Mediastinal biopsies and resections
Robotic resection of mediastinal masses. The mediastinum is the portion of the chest cavity between the lungs. When tumors or other masses grow in the mediastinum—such as thymoma or lymphoma—surgeons can remove the masses robotically through small incisions instead of the large incisions required with traditional open surgery.
Esophogeal myotomy for achalasia. Achalasia is a disorder that affects the ability of the esophagus to move food toward the stomach. Left untreated, achalasia can result in the widening of the esophagus to the point at which it begins to function as a reservoir instead of a conduit. That can lead to infection, obstruction and even the development of esophageal cancer.
Surgeons can correct this condition using a procedure called myotomy, in which the esophageal muscle is cut and repositioned.
Robotic laparoscopic Belsey fundoplasty for gastroesophageal reflux disease (GERD). The most common disease in humans, GERD affects nearly 20 percent of Americans. Nearly everyone experiences GERD from time to time, but it can lead to injury of the esophagus and upper digestive track, as well as esophageal cancer, if it is experienced on an ongoing basis. Belsey fundoplasty is a minimally invasive surgical technique that can correct problems with the esophagus that lead to GERD.
Thoracic Sympathectomy: Palmar Hyperhidrosis [this is a condition for excessive sweating of the palms.]
CdeT:. Will you be performing esophagectomies?
Dr. Lee: We will be adding minimal invasive esophageal surgery via Video Assisted and Robotic assisted thoracoscopic
procedures.
CdeT: Do you currently perform any single port surgeries?
Dr. Lee: We will review which cases would benefit from the single port exposure. Most probable are the mediastinal biopsy and resection cases.
CdeT: How many years have you been operating/ performing robotic surgery?
Dr. Lee: I have been performing robotic thoracic surgery since 2003.
CdeT: What is your average annual case volume and what percentage of procedures are you performing using the robot?
Dr. Lee: We perform greater than 90% of all our thoracic surery cases utilizing the minimal invasive approach (VATS& RATS). We plan all of our pulmonary lobectomies for early stage Non Small Cell Lung cancers to be performed utilizing the four arm robotic lobectomy, a total endoscopic approach.
CdeT: Do you have a mesothelioma or any other specialty clinics are part of your program?
Dr. Lee: Yes, we cover the entire spectrum of the thoracic disease process as well as participating in research trials. One of our sub specialty clinics is the emphasis on minimal invasive thoracic surgery.
CdeT: Where do you think the future of thoracic surgery is heading?
Dr. Lee: I see the future continuing to progress in minimal invasive surgery. Currently a little over 20% across the country utilize MIS. This number will increase over the next 5 years and beyond as the result of MIS continues to show as good and better results as compared to the standard thoracotomy approach. Secondly, early detection methods will improve so as to find the cancers at earlier stages and hopefully shift the survival curves.
CdeT:What do you plan for the future of your program?
Dr. Lee: To be a comprehensive program with emphasis on early detection and minimal invasive surgery, utilizing trials and protocols for the most difficult of cases.
Dr. K. Adam Lee, MD
Thoracic Surgeon/ Medical Director of Thoracic Surgery & Lung Center
Cirugia de Torax in Mexicali, Baja California to interview Dr. Carlos Cesar Ochoa Gaxiola.
I spent a very pleasant and interesting morning talking to the enthusiastic and charming young surgeon, Dr. Carlos Cesar Ochoa Gaxiola in Mexicali, Mexico. Dr. Ochoa is my favorite type of surgeon to interview. He loves what he does despite the challenges it sometimes presents (due to limited local resources such as PET/CT modalities*). His enjoyment of surgery and caring for his patients is obvious – and he readily invites me to round with him, and see his daily practice. Unfortunately, on this occasion, I am unable to do so.
Just a year and a half since completing his thoracic surgery residency, and Dr. Ochoa has made Mexicali, (the capital of Baja California) his home. As the only full-time thoracic surgeon* in this city of almost one million residents – Dr. Ochoa stays busy operating and seeing patients at both the general hospital and the ISSSTecali hospital system.
Since much of his practice is working in public facilities, Dr. Ochoa spends much of his time caring for the poor, and the underserved patients of Mexicali – who have little access to preventative health and wellness therapies. He reports that he performs a large volume of decortications and other procedures to treat empyemas and similar endemic diseases of poverty. This includes surgical treatments for tuberculosis, which remains a serious health problem in Mexico.
During our interview, we discussed his work with tuberculosis patients many of whom have multi-drug resistant tuberculosis. (The emergence of MDR and XDR strains of tuberculosis has become a rapidly spreading health threat not just in the middle east and Asia but in the United States and Mexico, particularly in border towns.) In adjoining Calexico, the University of San Diego has a tuberculosis project to help identify and aggressively treat these resistant strains. While this program has been successful in encouraging compliance and adherence to complicated (and expensive) long-term drug regimens, it also highlights the importance of thoracic surgery in the treatment of this disease. Dr. Ochoa reports that he frequently treats pulmonary complications of this [TB], and other chronic lung infections. He performs many of these operatives to prevent constrictive complications and to restore patients functional status/ prevent disability.
He also performs the entire spectrum of other thoracic surgery procedures including other types of pulmonary resections for the treatment of cancer(s), traumatic injuries to the chest, thymectomies and other mediastinal procedures, esophagectomies and tracheal surgeries. He embraces the use of minimally invasive procedures including dual port thoracoscopic procedures, and performs the majority of his cases by VATS.
He prefers the transhiatal approach for the majority of esophageal cases since it limits the development of catastrophic complications such as mediastinitis from anastomosis leak. He reports that he does not get do as many esophageal cases as he would like since the majority of the cases performed locally are done by general surgeons.
Dr. Ochoa is certified nationally as a cardiothoracic surgeon, though he explains that similar to the United States – the majority of programs are combined – and he subspecialized in Thoracic Surgery. He states that current board certifications in Mexico make no distinction between subspecialties. He has also received additional certification by the National Counsel of Thoracic Surgery, and is a member of multiple specialty organizations including: the LatinAmerican Association of Thoracics (ALAT), Sociedad Mexicana de Neumologico y Cirugia de Torax.
Dr. Ochoa attended medical school at the Universidad Autonoma de Baja California. He completed his general surgery residency (four years) at the Hospital General del Estado; in Hermosillo, Sonora. He then performed his thoracic surgery fellowship at the Instituto Nacional de Enfermedades Respiratorias (INER). This four-year program is one of the only Thoracic Surgery specialty training programs in Mexico. He had received additional training in bronchoscopy, and video assisted thoracoscopy (VATS).
He has presented multiple case reports at national conferences.
Publications: (note: I was unable to find live links for all of his publications).
* The nearest PET/ CT scanner in Baja California is located in Tijuana.
** There are two cardiothoracic surgeons who divide their time between Tijuana and Mexicali, who primarily perform cardiac surgery. Dr. Ochoa sometimes partners with these surgeons on more complex, and complicated cardiac and thoracic cases.
New project here on Cirugia de Torax.org: to compile a list of thoracic surgeons and thoracic surgery programs that are investigating and performing HITHOC procedures, but we need your help. Includes clinical trial information.
Since I’ve had enough web traffic and emails to see that I am not the only person that is interested in more news and research in the area of HITHOC, I have started contacting thoracic surgeons and programs that are doing research and treatment using hyperthermic intrathoracic chemotherapy. (I have identified thoracic surgeons through published literature.)
I’ve already contacted several (by email) and hope to hear back soon – so I can pass it on to interested readers. If you are currently researching this treatment, or know of a thoracic surgery program, please contact me via the site with more specific details.
HITHOC programs – Cytoreductive surgery with Hyperthermic intrathoracic chemotherapy
1. University Medical Center (Department of Cardiothoracic Surgery) and at the Barmherzige Brüder Regensburg (Department of Thoracic Surgery) – Regensburg, Germany (more details pending).
1 July 2011
Running into some roadblocks on this project – having a hard time contacting (and receiving replies) from authors researching HITHOC. Hopefully, I’ll get some more leads soon.
Other Research Programs:
HITHOC (Cytoreductive surgery + hyperthermic chemotherapy
Thoracic Surgery (Cirugia de Torax. org) welcomes Dr. Dov Weissberg, noted thoracic surgeon and memoirist as our first guest commentary. Here, Dr. Weissberg comments on one of his previously published articles from 2010 on the history of lung abscess.
We at Thoracic Surgery are delighted to present Dr. Dov Weissberg, a renown thoracic surgeon with a distinguished career as a surgeon, a scholar and professor of surgery with an extensive resume and list of contributions to the field of Thoracic Surgery as our first guest commentator. Dr. Weissberg has published an exhaustive list of articles, and papers in addition to several books, including his memoirs which include his boyhood accounts of life in Poland as a hidden jew during the Holocaust, personal experiences of starvation, and his experiences as a surgeon.
He is an expert in his field, with contributions to the development of pleuroscopy and the body of knowledge surrounding a wide range of thoracic surgery topics including mediastinoscopy, thymomas, lung abscess, empyemas, traumatic thoracic injuries, tracheal disease and tracheal surgery, pleural effusions, lung cancer and lung resection.
The treatment of lung abscesses has come full circle since it was first described by Hippocrates. The treatment at that time was surgical drainage (of the accumulated pus and dead tissue matter). A small tube was placed in the chest, and the accumulated pus drained out. This remained the standard of treatment until the 195o’s when the widespread use of antibiotics became popular, replacing surgery with medications. Antibiotics remained the primary treatment for this condition through the 1960’s to the 1980’s. Surgical intervention was relegated as a treatment of last resort, after multiple medication failures. In those cases, patients were usually referred for lobectomies or lung resections. On our service, (in 1980) our experiences with several patients referred for medical treatment failure showed surgical drainage to be an effective treatment and preferable over both long-term antibiotics and lung resection, thus coming back to Hippocrates. We presented these findings at several conferences, and meetings. Now in 2011; surgical drainage is once again, the treatment of choice for lung abscess.
Note: Lung resection should be reserved only for cases of extensive tissue destruction (pulmonary gangrene).
Biography of Dr. Dov Weissberg
In this particular case, with a gifted memoirist such as Dr. Weissberg, it is not possible to tell his story as well as he does.
Links:
1. The Limits of Starvation – a personal experience : Dr. Weissberg recalls his wartime experiences as a 13 year boy.
the health care crisis hits home: prolonged waiting times for patients with lung cancer results in the deaths of several patients in Canada – and this scenario is projected to be repeated in the USA and Europe due to surgeon shortages and limited access to health care.
In disturbing news from Canada, as reported by the Vancouver Sun in April 2011, as part of an ongoing court case, an estimated 250 lung cancer patients died awaiting surgery due to prolonged wait times. In this case, the thoracic surgeon, Dr. Ciaran McNamee had previously complained to hospital administrators at Capital Health in Alberta, Canada about the prolonged waiting times patients were experiencing due to insufficient operating room facilities. For his patient advocacy efforts, Dr. McNamee was fired, and slandered as experiencing ‘mental health issues.’ Dr. NcNamee also alleges that other doctors who complained about the problem were also punished or paid off to keep silent about the problem while their patients suffered.
While in this case, the prolonged wait times were caused by insufficient operating room facilities, in the future the problem may be more directly related to the lack of thoracic surgeons themselves.
May 13, 2011
I admire Dr. McNamee for his convictions and patient advocacy in the face of serious repercussions. I wrote to him at Brigham Womens & Childrens Hospital in Boston, where he is now a professor of surgery as part of the thoracic surgery program to extend an invitation to submit a guest post. (He specializes in esophagectomies along with VATS which are two subjects we always like to hear more about here at cirugia de torax.)
October 30, 2011 – the Calgary Herald updated this story among controversy over the original comments by Dr. McNamee and his successor, Dr. Tim Winton.
March 2, 2012 – The Vancouver Sun reports that the Canadian politicians continue to argue over the issue but do very little to address these allegations and the shortage of health care services affecting Alberta residents.
Thoracic Surgery 