thoracic surgery in China – Thoracic Surgery

Welcome to Shanghai Pulmonary Hospital

Shanghai Pulmonary Hospital – Shanghai, China

Shanghai Pulmonary Hospital is a dream come true for a thoracic surgery aficionado like myself. Twelve operating rooms, a 30 ICU beds, 30 to 40 operations per day and over 40 staff surgeons means that there is always something interesting going on down the hall.

Am case presentations is like a review of Robbins’ pathology. Bilateral nodules, ground glass opacity nodules, giant-sized tumors, mediastinal masses of all types and atypical presentations abound. By tradition, all tuberculosis cases must come to the medical complex at Shanghai Pulmonary Hospital because they have a designated tuberculosis hospital on site. Even with other facilities competing for some of the pathology, there is plenty to go around, and I am able to see a couple of lung abscesses as well as several varieties of cavitary lesions. I am sure that there is still a wealth of untapped pathology for me to explore, but I suspect that more interesting infectious cases and occupational diseases are probably confined to the more distant provinces.

I briefly talk to one of the surgeons here, who is from Kashdar region, on the far western side of China. Kashdar is located in one of the more mountainous regions of China, which was part of the famous Silk Road trade route explored by the likes of Marco Polo more than half a millennia ago. We discuss the region and compare it to its American counterpart of West Virginia. It’s not a perfect analogy but there are enough similarities to help me for a picture of life, and industry there. That is where the mines are concentrated, and that is where I might find the black lung disease, the silicosis and similar type diseases, though the surgeon I speak with reports that the rates of occupational disease for this occupation to be quite low. Given the dangerousness of underground mining, I wonder if many of the miners worry about living long enough to see a chronic disease like black lung. I don’t know enough about China to ask a lot of the other interesting questions that are swarming in my mind, but I wonder about mesotheliomas and other diseases related to all the heavy industry that forms the backbone of the booming Chinese economy. I wonder about the prevalence of empyemas given the pollution levels and the closeness in which many people are forced to live. It seems like it would be a daily surgical feast, but I don’t know a polite way to ask directions to the hospital with the pus-filled buffet.

My hosts also tell me regretfully that they also only see a limited amount of esophageal cancer because many people are misled by the name of the facility, and are unaware that esophagectomies are performed here. One of the surgeons looks so woe-begotten as he tells me this that I know he has the same love of that surgery as I do – that feeling of joy when surgical planning, pre-operative optimization, surgical skill and aggressive post-operative care come together flawlessly for an uncomplicated post-operative course in a complex case. It’s not just satisfaction with a job well-done but pure joy at seeing our patients walk out of the hospital and back to the regular lives.

I am here at part of the Uniportal VATS conference with Dr. Diego Gonzalez, but it’s also an opportunity to literally wander the operating rooms at will, listen to case discussions and interview surgeons as I encounter them. I always joke about feeling like a kid in a candy store, now I really am. If I hear a particularly interesting case during am rounds, I am welcome to come into the operating room, watch the case, listen to the discussions and talk to the surgeons.

As one of the largest general thoracic surgery departments in the world*, it would be impossible for me to know and present all staff surgeons in the few days that we are here for the Uni-portal Surgery conference. Instead I would like to highlight a just a few of the interesting and talented surgeons at this busy facility.

Dr. Jiang Gening – Chief of Thoracic Surgery

Dr. Jiang is the head of one of the world’s largest thoracic surgery services, but it doesn’t seem to faze him. Then again, he’s been here at Shanghai Pulmonary Hospital (SPH) since he came here to train in 1982. At that time, the thoracic surgery department was just a fraction of the size it is today.

As resident, staff surgeon, and then now Chief for the last ten years, Dr. Jiang has seen numerous changes, many of which have occurred in just the last few years. Volumes have dramatically increased, resulting in annual hospital construction to expand the operating rooms. A 16 bed thoracic surgery department has grown to over 250 beds.

Dr. Jiang has a strong vision of where his hospital ranks in the world, and where he would like it to be. He sees a strong future for this facility as an international leader in thoracic surgery and clinical research, and he has been working aggressively towards these aims.

Dr. Jiang has trained with Dr. Patterson (Bowman Grey, St. Louis) and other leaders in thoracic surgery in Boston and Los Angeles, and he encourages his surgeons to do the same. He strongly supports surgical development among his staff such as bringing leading surgeons like Dr. Diego Gonzalez Rivas to train staff in the most up-to-date procedures.

As a surgeon himself, he enjoys the more complex cases, the larger surgeries for the challenges they bring. When I mention, ‘chest wall resection,’ he smiles and nods before Dr. Wang can translate.

He is also very interested in expanding the lung transplant program but acknowledges that his facility has difficulties in obtaining donors now that China has discontinued the policy of using incarcerated people for organ donation. Organ procurement has been complicated by the traditionally low rates of voluntary donation in Chinese societies. As Dr. Jiang explains, Chinese culture and many Chinese families has a hard time recognizing and reconciling with the concept “brain death” in the absence of physical death. This means that Dr. Jiang and his program are focusing on donation after cardiac death and ex-vivo implantation. But this too is problematic – the scarcity of organs means that despite being in a metropolitan area of almost 30 million, surgeons may have to travel to Beijing or other locations for available organs. Often on arrival, these organs are not in suitable condition for transplantation. Another problem is the reluctance of Chinese insurance companies and third-party payers to cover the cost of ex-vivo support. Dr. Jiang acknowledges that his facility has several large hurdles to overcome if Shanghai Pulmonary Hospital is to become the transplant center for Singapore, Korea and the rest of Asia, as he envisions.

I am hoping to find my way into Dr. Jiang’s operating room. I have been advised by the Taiwanese surgeons that Dr. Jiang is widely-known and admired for his ‘nimble fingers’ so I want a chance to see him in action.

Dr. HaiFeng Wang

Dr. HaiFeng Wang is a very nice 41 year old surgeon who assisted in translating during the interview with Dr. Jiang. It was strange, as soon as I started talking to Dr. Wang, it was like we recognized each other. I immediately knew that we would see eye to eye. And so it was, as he presented his daily cases, and we discussed the findings, the planned surgeons and related research. So it seemed natural for me to spend the day with Dr. Wang in the operating room.

Like Dr. Jiang, Dr. Wang is from Shanghai. After completing a combined medical school and internship program, (with training in urology), Dr. Wang decided to switch to thoracic surgery (a decision that cirugia de torax wholeheartedly supports).

After receiving the World Health Organization fellowship, he traveled to Australia to train with Dr. Peter Clarke at Austin Hospital in Victoria. He focused his studies on the surgical control of cancer. More recently, in 2013, he received the Graham fellowship (from AATS) to study with Dr. Mathisen in Boston, Massachusetts. He also spent one month with Dr. McKenna in Los Angeles and another month with Dr. Patterson in St. Louis.

His areas of interest include minimally invasive surgery, tracheal surgery, lung transplantation and the diagnosis and treatment of ground glass opacities.

HIs first surgery of the day is an asymptomatic middle-aged patient with an incidental finding[1] of a large bronchiogenic cyst in the right middle lobe.

On the CT scan, it looks like an egg-yolk with solid material within a fluid-based cyst. The initial suspicion is a possible aspergilloma but this presumptive diagnosis is eliminated during surgery based on tumor appearance.

Frozen section is requested intra-operatively but the results of that only deepen the mystery when a diagnosis of a possible sarcoma is suggested by the pathologist. The resection is completed quickly, but the mysterious aspect of the case has me intrigued as we wait for the final pathology.

Update: Final pathology completed 3/17/2015. The report says pulmonary lymphangioma, a rare disease in the lung, and the pathologist says that the cyst itself is actually the lymphangioma, not only the small nodules we see inside the cyst wall.

The second case is a young patient with a GGO (ground glass opacity) in the right upper lobe. A needle biopsy confirms that the mass is a malignancy, an adenocarcinoma. This surgery is also smooth and uneventful.

There is a third case still scheduled, (and interesting too!) but unfortunately, it’s time for me to race back to the hotel, do some writing before I go to sleep to get ready to do this all over again.

I’ll be here in China for three weeks, so this isn’t the last you will hear about Thoracic surgery in China or Shanghai Pulmonary Hospital.

[1] In China, a CT scan is a fairly affordable diagnostic tool ($40) for most middle class Chinese citizens. Healthcare among certain classes, is also consumerized to a degree that the United States is only beginning to approach. This means that many Chinese residents have CT scans with the same gravitas that a many of us may approach a new hairstyle, or similar type purchase.

* noncardiac. There may be larger combined CTS departments.

Note: this article has been edited for corrections due to translational and other inaccuracies.

The Sweet Esophagectomy for esophageal cancer: the ZhongShan experience

Is the Sweet esophagectomy still relevant in this era?

The Sweet esophagectomy, which was first described in 1942 by surgeon Richard H. Sweet has fallen out of popular practice in many locations in the world. It has been replaced by the more extensive Ivor- Lewis approach, as well as more recent developments including minimally invasive techniques.

Now, Jua Ma et al. (2014) argue that the Sweet esophagectomy remains relevant in the minimally invasive surgery era.

The Sweet Technique

Dr. Richard Sweet was not the first surgeon to perform a successful esophagectomy for cancer. As discussed in A. P. Naef’s series on the history of thoracic surgery, that distinction belongs to Dr. Franz Torek who performed what would become the “Torek” technique back in 1913.

all photos courtesy of Dr. Qun Wang, Fudan Univeristy, Zhongshan Hospital — all intra-operative photos courtesy of Dr. Qun Wang, Fudan Univeristy, Zhongshan Hospital

However, it was Dr. Sweet’s modifications to this technique as well as numerous successes with this procedure that ushered in a new era of esophagectomies and successful esophageal surgery. In his hey-day, Dr. Sweet was also heralded for the speed of his procedure, which at under two hours was just half the time of many of his contemporaries.

What makes the Sweet esophagectomy different from the ‘modern’ techniques practiced today is the use of a sole left thoracotomy incision. (Versus the Ivor-Lewis with a right thoracotomy and midline laparotomy as well as the multiple port approaches, the Chen esophagectomy, not withstanding**).

(**In esophageal cancer, the need for extensive lymph node dissection for intra-operative staging often precludes the use of minimally invasive procedures). At present, the Ivor – Lewis approach remains the primary operation for esophageal cancer.

left posterolateral thoracotomy (illustration courtesy of Office of Military History)

As described by Jua Ma et. al, the standard incision is a posterolateral thoracotomy incision at the 5th or 6th intercostal space. After entering the chest cavity, the esophagus is dissected at least 5 cm above the lesion to allow for adequate surgical margins post-resection.

Care is taken to avoid trauma or damage to surrounding structures such as the thoracic duct, recurrent laryngeal and vagus nerves.

Once the esophagus was dissected completely from surrounding tissue, a 5 to 6cm incision was made into the diaphragm (which separates the thoracic and abdominal cavities). From here, surgeons can readily and easily enter the abdominal compartment to free the stomach for eventual anastomosis to the remaining portion of the esophagus.

Blood flow to the stomach is maintained by preserving the right gastro-epilotic arteries while the left gastric artery and vein are ligated for mobilization.

Complete abdominal lymph node dissection is completed with en-bloc dissection of distal esophagus and proximal stomach. The anastomosis itself is performed either above or below the aortic arch.

mobilizing the stomach,Sweet esophagectomy — Good visualization while mobilizing the stomach during Sweet esophagectomy

As you can see from the photos included, this incision allows easy access to both the thoracic and abdominal cavities.

The Zhongshan experience

In this retrospective study involving patients undergoing esophagectomies for middle or lower esophageal carcinomas from January 2007 to December 2010, the authors were able to include 784 patients who had surgery via the Sweet approach versus 167 patients who underwent the Ivor – Lewis esophagectomy.

Exclusions

Patients who were inoperable due to the presence of mediastinal disease at the time of diagnosis and well as patients with high level lesions (located above the carina*) were excluded from the study.

*One of the drawbacks of the Torek – Sweet type procedures is the risk of phrenic nerve injury with high level lesions.

Patients undergoing other types of esophageal surgery such as cervical approaches or minimally invasive procedures were also excluded from this study. (Table 1 of the original article gives full details regarding surgical approaches for 1,138 patients having esophageal surgery at Zhongshan Hospital during this time period.)

Extensive experience

Most notable from a technical aspect of this study is the surgical experience of the surgeons involved. Each of the surgeons in this study had performed over 100 esophagectomies before initiating this investigation. As demonstrated numerous times in the scientific literature, the surgical experience of the surgeon as well as the oncological surgical volume of individual facilities play a significant role in patient outcomes.

Results

Overall:

Patients followed for 24 to 72 months. Out of 915, complete follow-up data was collected from 618 patients. (Patient attrition due to loss of follow-up, death etc. was accounted for in this study).

21 patients found to have metastasis (celiac lymph nodes) during lymph node dissection.

There was no different in the number of nodes dissected with either approach, however, there was a higher number of positive nodes in patients undergoing Ivor-Lewis with an open laparotomy. (28.7 % versus 38.7% with Ivor Lewis). Despite this finding – there was no significant different in the total number of metastasis in either approach – Sweet 42.5% and Ivor Lewis 45.2%

No difference in overall 5 year survival rate for either procedure.

Operative mortality was similar in both groups (2.3% for Sweet, Ivor Lewis 1.8%)

Sweet versus Ivor Lewis

– Shorter surgical time with Sweet approach (181 min +/-71 minutes) versus 208 minutes for Ivor Lewis (+/- 63 minutes).

– Less blood loss (and less transfusions) with Sweet approach

– Fewer complications

Overall rate of complications: Sweet 12.3%. One fifth of all Ivor Lewis (IL) patients experienced post-operative complications (20.4%)

wound infection: Sweet 3.2% IL 7.8%

delayed gastric emptying: Sweet 1.7% IL 4.7%

Anastomotic leak: Sweet 2.1% IL 4.2%

– Shorter length of stay

Average length of stay was 13.2 days for patients undergoing the Sweet procedure compared to 17.3 days for the Ivor Lewis group.

In addition, while only 4.4% of the Sweet group remained hospitalized for more than 30 days after surgery, 12.6% of the Ivor Lewis patients had a length of stay greater than 1 month.

Discussion

More positive nodes, but Why?

The increased finding of positive lymph nodes in patients undergoing the Ivor Lewis merits further discussion and investigation as to whether this is related to the areas of lymph node dissection since the authors discuss the difficulty of assessing areas of the anterior mediastinum. There is no mention of how using a single incision technique and accessing the stomach via the diaphragm affected abdominal lymph node dissection.

While the actual numbers harvested using either technique were comparable, were the surgeons able to harvest more lymph nodes from specific sites in the patients with an open laparotomy?

If so, this supports the notion that for some cancer operations, like this one, where accurate staging is absolutely essential for determining prognosis – open surgery may remain superior to “lesser” procedures such as the Sweet or minimally invasive approaches.

More importantly, the surgeons at Zhongshan illustrate both the magnitude of a surgical procedure like the Ivor Lewis and the potential benefits of alternative approaches performed by experienced surgeons.

Fewer anastomosis leaks

In their facility, patients experienced demonstrated only half the rate of wound infection with only one primary incision versus the two incision Ivor Lewis. More importantly, the incidence of a potentially lethal complication like anastomotic leak was also half (2.1%) of that for Ivor Lewis (4.2%**). While some of the literature has cited a mortality rate as low as 3.3% due to advances in the treatment of the associated sepsis, anastomotic leak remains a devastating complication.

**This rate mirrors what is seen in the literature for Ivor Lewis esophagectomies. The cited mortality for anastomotic leaks varies widely.

Limitations

The biggest limitation of this study is the retrospective design. However, at present, researchers (Dr.Haiquan Chen) at Fudan University are conducting another ongoing clinical trial to compare these procedures. This study is a prospective, randomized design.

Implications / considerations

The work done by Jua Ma et al. warrents careful reading and consideration; Zhongshan Hospital in Shanghai, China has over 1700 beds, and serves a large patient population, in which esophageal cancer is relatively common. The elevated incidence of esophageal cancer in China has been noted as far back as 2,000 years ago by Chinese scholars and physicians.

The increased incidence and presentation of patients with surgically resectable esophageal cancers combined with a robust thoracic surgery division (with over 29 thoracic surgeons on staff) provides the authors with an opportunity to collect, analyze and present data on a scale unheard of in the majority of institutions performing single-site investigation. In 2013, for example, the thoracic surgery department performed over 1152 Lung procedures and 683 esophageal procedures.

Article:

Jua Ma, Cheng Zhan, Lin Wang, Wei Juang, Yongxing Zhang, Yu Shi & Qun Wang (2014). The Sweet approach is still worthwhile in modern esophagectomy. Annals of Thoracic Surgery, 2014 [in-press].

References

Churchill ED, Sweet RH. (1942). Transthoracic resection of tumors of the esophagus and stomach. Ann Surg. 1942 Jun;115(6):897-920. Contains pdf of original article but loads slowly.

Naef, A. P. (2004). The mid-century revolution in thoracic and cardiovascular surgery, part 3. Interactive cardiovascular and thoracic surgery 3.

Sweet R. H. (1946). Subtotal esophagectomy with high intrathoracic esophagogastric anastomosis in the treatment of extensive cicatricial obliteration of the esophagus. Surg Gynecol Obstet. 1946 Oct;83:417-27.

Thank you to Dr. Qun Wang for his assistance.

16th National Continuing Education Forum in General Thoracic Surgery

Report from the recent 16th National Forum on Thoracic Surgery in Shanghai, China.

Shanghai Pulmonary Hospital, Tongji University

Shanghai, China

October 18th – 19th, 2013

Dr. Gonzalez Rivas demonstrates the single port technique during a live surgery presentation — Dr. Gonzalez Rivas (second from the left) demonstrates the single port technique during a live surgery presentation

As readers know, we strive to feature information about thoracic surgery from around the world. This report on the 16th National Continuing Education Forum in General Thoracic Surgery comes from featured speaker, Dr. Diego Gonzalez Rivas of Coruna, Spain.

Some of the biggest names in thoracic surgery were in attendance, to present their research and surgical techniques to a crowd of over 600 Chinese thoracic surgeons. The lectures (and live surgery) were also broadcast across China.

World-renown thoracic surgeons at the 16th National Forum in Shanghai, China

Invited International Speakers included:

Dr. G. Alexander Patterson, thoracic surgeon/ lung transplant from the Washington School of Medicine in St. Louis, Mo. (USA). Dr. Patterson gave a lecture on clinical experiences and advances in Lung Transplantation. He also lectured on pancoast tumors.

Dr. Claude Deschamps, French Canadian thoracic surgeon and Chair of Surgery at the Mayo Clinic, Rochester, MN (USA). Dr. Deschamps talked about the use of anti-reflux surgery.

Dr. Gaetano Rocco, of the National Cancer Institute in Naples, Italy. Dr. Rocco talked about advances in chest wall reconstruction. He gave another lecture on uniport surgery.

Dr. Alan Sihoe from the University of Hong Kong discussed management of air leaks.

Surgeons from Taiwan and mainland China presented on a variety of topics including tracheal surgery, management of empyema, sympathectomy for hyperhidrosis and surgical treatment of tuberculosis. (The full list of speakers and topics presented is available here*.)

Conference Spotlight: Single port surgery

But the focal point of the forum was single port (uniportal) surgery. Saturday (the 19th) was devoted to lectures and demonstrations of the single port thoracoscopic technique, including live surgical demonstrations performed by Dr. Diego Gonzalez Rivas. His live surgery presentation was viewed by 500 surgeons at the conference as well as hundreds of other surgeons via a live feed.

Dr. Gonzalez Rivas demonstrates the uniport technique in Shanghai, China — Dr. Gonzalez Rivas demonstrates the single port (uniport) technique in Shanghai, China

Thank you to Dr. Gonzalez Rivas for his submission. We welcome reports, photographs and discussions on recent and upcoming thoracic surgery conferences. If you have a meeting, paper or presentation to share, please contact us at k.eckland@gmail.com

*Information is translated from Mandarin using google software with some obvious translational errors, particularly names of several of the Chinese surgeons.