VATs – Thoracic Surgery

International VATS 2018: Better than before – Extreme Fast track thoracic surgery

Some of the videos are silly, cheesy even… But ugly track suits aside…

The results are, in arguably, wonderful. Patients eating, drinking, walking, and relaxing just an hour after major lung surgery.

Dr. Joao Carlos Das Neves Pereira is a Brazilian thoracic surgeon, who has been the primary author and leader on several articles, and programs for what he is calling ‘extreme fast track thoracic surgery’. He was also one of the featured speakers at International VATS 2018. “Better than before” is his model. “Patient empowerment’ is his ideology.

His presentation was easily the best in show, so to speak.. What’s more remarkable about his results are – that this isn’t new. He’s been doing it for more than a decade. In fact, he published an article on his experience in the European Journal of cardio-thoracic surgery was back in 2009. And now he is responsible for the implementation of a multi-disciplinary program at two hospitals on two continents – one on Paris, France and the second in Sao Paulo, Brazil.

So what does he do? How does he do it? And why aren’t the rest of us doing it?

What he does: “Feed & walk”

Change the existing surgical traditions:

no prolonged fasting
no cold operating rooms
no IV opioids

He does this with a multifaceted program that starts several weeks before surgery; with a comprehensive nutrition, smoking cessation and and an exercise regimen.

The night before:

Aromatherapy with lavender / Orange to promote sleep.
Avoid benzodiazepines

On the morning of surgery

patients are able to drink liquids within two hours of surgery, preventing dehydration and eliminating the need for IV fluids (no starving!)

During surgery

Normothermia
Multi-modality approach for anxiety/ nausea/ vomiting / pain
Opioid-free

Patient analgesia and anesthetic is treated with a combination of approaches including hypnosis, pre-emptive oral medications, BIS for awake anesthesia, minimally invasive airways. Patients are only given very short acting medications such as ketamine, or propofol combined with local anesthesia. By avoiding narcotics, there is a reduction in both sedation, and GI complications post-operatively.

Patients who are able to readily wake up after surgery and who haven’t had narcotics that adversely affect bowel function) are able to eat and drink immediately after surgery.

Post-operative

Immediate extubation (once the specimen is out of the chest)
Immediate feeding
Immediate exercise
“Hands free” care: No IV lines, oral medications only, patient controlled and opioid free.

Patients are encouraged to wear their own clothing before going to the exercise room, the outside garden or walking the halls. Post-operative pain management consists of oral medications only, and is augmented by physical therapy, acupuncture, aromatherapy and massage. Friends and family are instructed in the proper massage techniques so that they are able to participate in the patients care (also shortage of massage therapists). Patient recovery is enhanced by conviviality: patients don’t spend time in the rooms, alone or in bed. Patients are welcome to spend time in open spaces, aromatherapy areas, exercise rooms, a japanese style garden, an indoor garden and a tea room. Patients are encouraged to socialize and spend time with other patients.

While some of these ideas are novel, there is no magic surgical technique, and no miracle drug to account for these results – which are arguably better the most of ours. But it’s not just aromatherapy, it’s a philosophy of care.

More importantly, what Dr. Das Neves Pereira and his colleagues have; that many of us find difficult to replicate – is patient buy-in. We can call it “Patient empowerment” but it’s the part that many of us continue to struggle with.

But Dr. Das Neves Pereira’s lecture leaves us with more questions as well as answers..

Would this work for your practice? And why aren’t the rest of us already doing it? Will the patients accept it?

For the answer to this – we have to look at our own practices, in the here and now, in late 2018. A recent issue of the thoracic journal of disease did just that, devoting an entire issue to ERAS (enhanced recovery and fast track programs) while providing blueprints for anesthesiologists, nursing and physical therapists. But for many of us, the pat and simple answer is something like this:

“While most of my patients wouldn’t mind some aromatherapy or a massage after surgery, the unfortunate truth is that few would participate in a pre-operative program stressing diet and exercise. Even fewer patients would sign on for a program that restricts narcotics. Many of us already know this about our patient populations because we try routinely to incorporate more holistic practices into our treatment in a daily basis. While holistic premises and alternative treatments make billions of dollars in the United States (under the guise of prevention) it’s still a culture that is highly dependent on fast, and immediate remedies and a strong belief that very little post-operative pain is acceptable or tolerable. For every one patient that would embrace the philosophies of extreme rehabilitation, there would be another 200 screaming at the nurses for IV dilaudid.”

Much of the research actually confirms this view:

British researchers, Rogers et al. (2018) had a similar experience, noting in their recent publication that benefits of enhanced recovery protocols were dependent on compliance (and adherence) to protocols – particularly in regards to pre-operative dietary modification, and early post-operative ambulation. Refai et al. (2018) have attempted to address these issues with a comprehensive patient education component. However, their publication does not address whether these interventions increased compliance and reduced patient stress or anxiety.

Does this mean that we are skeptical of extreme rehab – no, not at all! Interest, participation and development in fast track thoracic surgery programs continues to grow despite these obstacles.

In fact, the tightening of many federal and state restrictions on narcotics due to the American opioid crisis may make this the best time in modern American medical history to bring this ideas and approaches to our patients (Bruera & Del Fabbio, 2018, Herzid, 2018). It also means that many of us have some preliminary hurdles and preconceived notions (on all sides) to overcome to engage our patients, nurses, therapists and fellow medical professionals to get their buy-in on the idea. We might be over a decade behind – but it’s not too late to start today.

References:

Das-Neves-Pereira, et al. 2009). Fast track rehabilitation for lung cancer lobectomy: a five year experience. European Journal of Cardio-thoracic surgery, 36 (2009) 838-392. primary reference article.

Additional references:

Bruera, E. & Del Fabbio, E. (2018). Pain management in the era of the opioid crisis. Am Soc Clin Oncol Educ Book 2018 May 23 (38): 807-812.

D’Andrilli, A. & Rendina, E. (2018). Enhanced recovery after surgery and fast-track in video-assisted thoracic surgery lobectomy: preoperative optimisation and care-plans. Journal of visualized surgery, 2018:4 (4).

Herzid, S. (2018). Annals for hospitalists Inpatient Notes: Managing acute pain in the hospital in the face of the opioid crisis. Annals of internal medicine 169(6): H02-H03.

Rogers, et. al (2018). The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. Journal of thoracic and cardiovascular surgery. 155(4) April 2018: 1843 -1852.

European Society of Anaesthesiology. “Hypnosis/local anesthesia combination during surgery helps patients, reduces hospital stays, study finds.” ScienceDaily. ScienceDaily, 21 June 2011.

From the Journal of thoracic disease – special issue: Supplemental issue #4 2018

Ardo et. al. (2018). Enhanced recovery pathways in thoracic surgery.

Bertani et al. (2018). A comprehensive protocol for physiokinesis therapy and enhanced recovery after surgery in patients undergoing video assisted thoracoscopic surgery: lobectomy.

Picconi, et. al. (2018). Enhanced recovery pathways in thoracic surgery from Italian VATS group: perioperative analgesic protocols.

Refai et. al. (2018). Enhanced recovery after thoracic surgery: patient information and care-plans.

the 4th VATS International

The fourth VATS International Symposium is this October 20th – 21st, 2017. As readers know, this course has been highly recommended in the past by Thoracics.org.

The preliminary program has been released, and it looks like audience favorite and straight shooter, Eric Lim will be opening the conference.

Italian thoracic surgeon, and the inventor of the first uniportal VATS procedure, Dr. Gaetano Rocco, along with the prominent American surgeon, Dr. Robert Cerfolio will also be presenting. There will be several presentations comparing uniportal VATS with robotic assisted surgical techniques (RATS). But this is more than an academic discussion – in addition to notable speakers, the conference includes live cases, practical tips and hands-on training.

Representatives from Storz will be speaking to thoracic surgeons on caring, repairing and maintaining thoracoscopic equipment. There are still spaces available for attendees, including the state-of-the-art wet lab. This wet lab offers surgeons the opportunity to try new techniques using 3-D models, while proctored by leaders in the field.

To register for this event – visit VATS International 2017

Thoracics.org will be there, reporting on this event – as well as conducting live interviews with CTSnet.org for overseas real-time broadcast.

Why you should have your thoracic surgery at the university affiliated hospital

While working on a recent interview with one of the New Masters of Thoracic Surgery, I talked about one of his biggest contributions to his local community, which was establishing the first dedicated thoracic surgery program in that city. Then I realized that maybe readers wouldn’t know what that was important.. This article came from that interview

Big hospitals, little hospitals. Major health systems and community facilities battle it out of our insurance dollars. Private wings, VIP suites, catered meals and fancy robots all try and lure patients in the doors. As a writer of several books based on the business of medical tourism – I’ve seen that the appeal of glistening marble floors, free fancy coffees and an aura of exclusivity can trump the principles of safe and effective patient care when it comes to attracting paying patients. This is acutely evident in the surgery wars; the wars to attract referrals between private practice and academic medicine (which usually, but not always – has less glamorous facilities**). But for a person facing a large, and possibly life-saving thoracic surgery, we need to explore the differences that are more than just skin-deep.

Subspecialty interest and skill

The difference between a true thoracic surgery program and a cardiothoracic surgery private practice group is often marked by the degree of continuing competence, subspecialty interest and skill in minimally invasive techniques. (For more about the overall differences between general thoracic and cardiothoracic surgery, read here.) This post is discussing the pitfalls of the private practice medical group and surgical referral patterns. Surgical partners in a lucrative practice don’t have continuing education requirements, but residencies do. In order to teach surgical residents, the attendings themselves need to be well-versed in the latest operating techniques and surgical outcomes research.

Where the patients come from

Private practice groups get their patients thru an ‘old boy network’ particularly in cities with few strong ties to university medical centers. Patients don’t just walk thru the door to see a thoracic surgeon – they are referred to one. Most people have never even heard of a thoracic surgeon before they or a loved one needs one.

As we talked about in one of our very first posts, “Who is performing your thoracic surgery?” – just because you need thoracic surgery, that doesn’t guarantee that a patient will see an actual board certified thoracic surgeon.

In a referral based system, patients are often not referred based on the skills or merits of the surgeon in the operating room, his rates of post-operative infection or even the health system affiliations – but by his charm, wit or connections on the social scene. In a city like Memphis, which is awash in old money, southern tradition and the Junior League, this means that patients are referred to the surgeon based on the friendships amongst wives, college fraternity friendships or 6 am tee-off times.

Cardiothoracic versus general thoracic

Often times, the surgeon is not particularly gifted or even interested in modern lung or esophageal surgery techniques, meaning that the surgeon is most likely to revert to large thoracotomies or median sternotomies because that’s where his comfort lies. There is no standard or requirement to master minimally invasive techniques, so often these surgeons don’t. It’s not a criticism of cardiothoracic surgery, but a basic reality. A heart surgeon wants to be a heart surgeon. He doesn’t necessarily want to do lung or esophageal surgery, but he might not turn away these cases either, because everyone likes to make a living.

In comparison, a dedicated thoracic surgery program, particularly in an academic setting; is made up exclusively of thoracic surgeons who live and breathe general (noncardiac) thoracic surgery. This is what they do, this what they want to do, this is what they have always wanted to do. Academic settings also have more stringent requirements (in general) regarding maintaining clinical and educational competencies. These surgeons are learning or teaching the newer techniques, reading and writing the literature and actively pursuing advances in the field. This dedication is important for more than the most obvious reason – sure, you want your surgeon to be competent in the operating room – but you also want him to be knowledgeable and skilled outside of it.

Academic centers with general thoracic surgery programs are more likely to have a protocol based, formalized multidisciplinary approach to thoracic disease. This means that patients are treated by a team of specialists in a cooperative fashion. There are no conflicts between what the oncologist wants to do and what the surgeon wants. If the patient needs pre-operative radiation or chemotherapy, it’s coordinated in conjunction with surgery, so that the patient receives care in a timely and organized fashion based on the current treatment recommendations and clinical research**.

But American medical care is the best in the world, right?

Multidisciplinary approach, evidence-based practice, ongoing academic research and continuing surgical education: All of these themes don’t sound extraordinarily unusual to readers because I have been discussing and presenting surgeons who work within these types of programs for years here at Thoracics.org.

Not the norm

But it’s actually not the norm in the United States, which means that many American patients get woefully inadequate, outdated or just plain uncoordinated care. These patients have more pain, more suffering, longer lengths of stay, more complications and less quality of life than any of the patients who have been cared for by just about any surgeon ever mentioned on this site. Patients at the University of Pittsburgh, Duke, University of Virginia or John Hopkins were getting great care, but patients here in Memphis, Las Vegas or any of the other cities or regions without these types of specialized programs, weren’t and often still aren’t.

When added to the growing shortages in this specialty area, an appointment with a trained thoracic surgeon may become an elusive endeavor. Especially if patients don’t know to ask.

* A thoracic surgery program that focuses on diseases and conditions of the lungs, esophagus and mediastinum.

** There are several academic medicine facilities that have managed to boast their own celebrity style perks, like the VIP wings at John Hopkins.

Guest post: Report from the 3rd Mediterranean Symposium in Thoracic Surgical Oncology – VATS

An invited report from Dr. Marcello Migliore on the recent Italian conference on VATS and lung cancer

Report from the 3^rd 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 21^st – 22^nd 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

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).

An Ordinary Afternoon

An Ordinary Afternoon at Shanghai Pulmonary Hospital

The Uniportal VATS course continues for much of the rest of the week (March 9 – 20th).

Dr. Gonzalez Rivas performs uniportal lobectomy

After Dr. Gonzalez completed his second case today, we had a short break before the start of his next case. I took the opportunity to peek into the operating rooms to give everyone a better idea of what surgery at Shanghai Pulmonary Hospital is like. There were 32 surgeries scheduled for today. I couldn’t watch them all, of course, but at 2:30 pm – the operating rooms looked something like this:

In OR #10 – surgeons were completing a right-sided thoracotomy (bilobectomy with pulmonary artery resection secondary to tumor invasion).

OR #9 – was in the midst of a subxyphoid resection of a mediastinal mass

OR# 2 was finishing up a “traditional” three port-VATS case for lung resection

OR #7 was finishing ligating the last branches of the pulmonary artery for a giant-sized left upper lobe tumor requiring open thoracotomy

OR #8 was performing a 3 segmentectomy of the left upper and lower lobe by dual port thoracoscopy using a 3-D monitor

Dr. Jiang Gening performs dual port thoracoscopy using a 3D monitor

OR # 5 sternotomy with resection of a large thymoma

OR # 4 subxyphoid approach for mediastinal tumor resection in a patient s/p previous right upper lobectomy

OR # 1 uniportal lung resection (left lower lobectomy)

OR #11 uniportal lung resection – right lower lobectomy

OR # 12 just wheeled in a patient for a right sided pluerodesis after spontaneous pneumothorax.

I also passed a patient being wheeled to the post-operative recovery room, when 4 more patients were recuperating.

I’ll be writing a couple case studies to publish over the next few days, so check back soon.

Single port surgery conference in Berlin

the latest trailer about the documentary film on single port surgery and information about an upcoming training course.

For everyone that’s interested in learning more about the single port surgery technique, as taught by its creator, Dr. Diego Gonzalez Rivas – here’s another opportunity which may be closer to home for some readers.

The February conference takes place in Berlin, Germany on the 19th thru 21st. While Dr. Gonzalez Rivas, Dr. Delgado and Dr. Prado are headlining the event, other prominent thoracic surgeons such as Gaetano Rocco (Italy) and Alan Sihoe (Hong Kong) will also be lecturing at this event.

The conference includes live surgery demonstrations as well as a wet-lab for hands-on practice.

Deadline for registration is February 6th. Interested surgeons should contact:

R. Mette, M. Schmitt
Charité – Universitätsmedizin Berlin
Tel. +49 30 450 622 132 | Fax +49 30 450 522 929
E-mail: thoraxchiurgie@charite.de

To download the event brochure, click: VATS_Course_2015 brochure

In other news – the newest trailer for the documentary about Dr. Gonzalez Rivas and his work was recently released. I encourage all thoracic surgery personnel to see (and promote) this movie, which highlights the work of one of our own.

Highlights from Shanghai – Uniportal Surgery conference

Uniportal surgery in Shanghai

While Cirugia de Torax was unable to be in attendance and provide on location reporting and news, I would like to present some highlights from the recent event for our readers..

Maybe next year, I’ll see you there.

NHS thoracic offering: Cambridge International VATS symposium

information about the upcoming VATS symposium in Cambridge, UK – with featured speakers Dr. Diego Gonzalez Rivas and Ian Hunt.

Another conference/ educational announcement for all residents, fellows and interested thoracic surgeons. This course is sponsored by the United Kingdom’s National Health Service and is being held in Cambridge, UK at Papworth Hospital this November. There is parallel content for nurses and other thoracic surgery personnel.

Internationally known Spanish surgeon Dr. Diego Gonzalez Rivas as well as native surgeon Mr. (Dr.) Ian Hunt of St. George’s Hospital in London, will be part of the faculty teaching this course.

Dr. Gonzalez Rivas will be discussing single port surgery in addition to performing a live case on the second day of the symposium.

Mr. Hunt will be discussing how to perform a total lymphadenectomy, as well as lymphadenectomies on more complicated cases.

Additional speakers will be discussing topics including issues in thoracic anesthesia, management of bleeding (in VATS and other minimally invasive surgery), and managing other operative complications.

Interested persons can register here.

ALAT : The Grand Trifecta

Talking about the roles of traditional VATS, single port surgery and robots in modern thoracic surgery.

The Ethicon (Johnson & Johnson) sponsored session was by far, the best of the conference – and an excellent overview of modern technologies in thoracic surgery.

Dr. Diego Gonzalez Rivas

“Is uni-port surgery feasible for advanced cancers?” Short answer: Yes.

The first speaker, was Dr. Diego Gonzalez Rivas of Coruna, Spain. He is a world-renown thoracic surgeon and innovator of uni-port thoracoscopic surgery. He discussed the evolution of single port surgery as well as the most recent developments with this technique, including more advanced and technically challenging cases such as chest wall resections (2013), sleeve resections/ reconstructions (2013), pulmonary artery reconstructions (2013) and surgery on non-intubated, awake patients (2014).

Experience and Management of bleeding

The biggest challenges to surgeons learning this technique is management of bleeding. But as he explained in previous lectures, this can be overcome with a direct approach. (these lectures and YouTube videos, Dr. Gonzalez explains the best ways to manage intra-operative bleeding.) In the vast majority of cases – this did not require deviation or conversion from the uni-port technique.)

As surgeons gain proficiency with this technique which mirrors open surgery, the only contra-indications for surgical resection of cancerous tissue (by single port) are tumors of great size, and surgeon discomfort with the technique.

Dr. Mario Ghefter

My favorite lecture of the series was given by Dr. Mario Ghefter of Sao Paolo, Brazil. While his lecture was ostensibly about video-assisted thoracoscopy (VATS), it was more of a retrospective vision and discussion of the modern history of thoracic surgery as seen through the eyes of a 22 year veteran surgeon.

He talked about the beginnings of VATS surgery and the contributions from such legends as Cefolio and D’Amico, including the 2005 paper – and modern-day thoracic bible, “Troubleshooting video-assisted thoracoscopic lobectomy (Demmy, James, Swanson, McKenna and D’Amico).

Dr. Ghefter also talked about how improved imaging and diagnostic procedures such as PET-CT and EBUS have been able to provide additional diagnostic information pre-operatively that helps surgeons to plan their procedures and treatment strategies more effectively.

As a counterpoint to both Dr. Gonzalez and Dr. Buitrago, Dr. Ghefter acquitted himself admirably. He reminded audience members that even the newer technologies have some drawbacks – both as procedures and for the surgeons themselves.

He also successfully argued (in my opinion) that while the popularity of procedures such as multiple port VATS and even open thoracotomies have dropped drastically as thoracic surgeons embrace newer technologies, there will always be a place and time for these more traditional procedures.

Dr. Mario Ghefter is the Director of Thoracic Surgery at Hospital do Servidor Público Estadual – Sāo Paulo and on staff at the Hospital Alemão Oswaldo Cruz.

Dr. Ricardo Buitrago

Native Colombian (and my former professor), Dr. Ricardo Buitrago is acknowledged as one of the foremost experts in robotic thoracic surgery in Latin America.

During his presentation, he discussed the principles and basics of use of robotic techniques in thoracic surgery. He reviewed the existing literature surrounding the use of robotic surgery, and comparisons of outcomes between thoracic surgery and traditional lobectomy.

He reviewed several recent robotic surgery cases and the use of robotics as a training tool for residents and fellows.

While he mentioned some of previously discussed limitations of robotic surgery (namely cost of equipment) he cited recent studies demonstrating significant cost savings due to decreased length of stay and a reduced incidence of surgical complications.

He also discussed recent studies (by pioneering surgeons such as Dr. Dylewski) demonstrated short operating times of around 90 minutes.

Case Report: Hilar mass resection using single port thoracoscopy with Dr. Diego Gonzalez – Rivas

in the operating room with Dr. Diego Gonzalez Rivas for single port thoracoscopic (uniportal) surgery.

Hilar mass resection using single port thoracoscopy with Dr. Diego Gonzalez – Rivas

K. Eckland & Andres M. Neira, MD

Instituto Nacional de Cancerlogia

Bogota, Colombia

Surgeon(s): Dr. Diego Gonzalez Rivas and Dr. Ricardo Buitrago

Dr. Diego Gonzalez Rivas demonstrates single port thoracoscopy

Case History:

59-year-old female with past medical history significant for recurrent mediastinal mass previously resectioned via right VATS. Additional past medical history included prior right-sided nephrectomy.

Pre-operative labs:

CBC: WBC 7230 Neu 73% Hgb:14.1 Hct 37 platelets 365000

Pt 12.1 / INR1.1 PTT: 28.3

Diagnostics:

Pre-operative CT scan: chest

Procedure: Single port thoracoscopy with resection of mediastinal mass and lymph node sampling

After review of relevant patient history including radiographs, patient was positioned for a right-sided procedure. After being prepped, and draped, surgery procedure in sterile fashion. A linear incision was made in the anterior chest – mid clavicular line at approximately the fifth intercostal space. A 10mm port was briefly inserted and the chest cavity inspected. The port was then removed, and the incision was expanded by an additional centimeter to allow for the passage of multiple instruments; including camera, grasper and suction catheter.

Dr. Gonzalez Rivas and Dr. Ricardo Buitrago at National Cancer Institute

The chest cavity, pleura and lung were inspected. The medial mediastinal mass was then identified.

As previously indicated on pre-operative CT scan, the mass was located adjacent and adherent to the vessels of the hilum. This area was carefully dissected free, in a painstaking fashion. After freeing the mediastinal mass from the hilum, the remaining surfaces of the mass were resected. The mass was fixed to the artery pulmonary and infiltrating it) . The mass was removed en-bloc. Care was then taken to identify, and sample the adjacent lymph nodes which were located at stations (4, 7 and 10).

Following removal of the tumor and lymph nodes, the area was re-inspected, and the lung was re-inflated. A 28 french chest tube was inserted in the original incision, with suturing of the fascia, subcutaneous and skin layers.

Hemostasis was maintained during the procedure with minimal blood loss.

Patient was hemodynamically stable throughout the case, and maintained appropriate oxygen saturations. Following surgery, the patient was awakened, extubated and transferred to the surgical intensive care unit.

Post-operative: Post-operative chest x-ray confirmed appropriate chest tube placement and no significant bleeding or pneumothorax.

Immediate post-operative film (chest tube visible)

Patient did well post-operatively. Chest tube was discontinued on POD#2 and discharged home.

Discussion: Since the initial published reports of single-port thoracoscopy, this procedure has been applied to an increasing range of cases. Dr. Gonzalez and his team have published reports demonstrating the safety and utility of the single-port technique for multiple procedures including lobectomies, sleeve resections, segmentectomies, pneumonectomies and mediastinal mass resections. Dr. Hanao Chen (Taiwan) has reported several successful esophagectomies using this technical, as well as bilateral pleural drainage using a unilateral single-port approach.

Contrary to popular perception, the use of a single-port versus traditional VATS procedures (three or more) is actually associated with better visibility and accessibility for surgeons. Surgeons using this technical have also reported better ergonomics with less operating fatigue related to awkward body positioning while operating.

The learn curve for this surgical approach is less than anticipated due to the reasons cited above, and has been cited at 5 to 20 cases by Dr. Gonzalez, the creator of this approach.

The main limitations for surgeons using this technique is often related to anticipated (but potentially unrealized) fears regarding the need for urgent conversion to open thoracotomy. In reality, many of the complications that may lead to urgent conversion, such as major bleeding, are manageable thoracoscopically once surgeons are experienced and comfortable with this approach.

Dr. Gonzalez and his colleagues have reported a conversion rate of less than 1% in their practice. Subsequent reports by Dr. Gonzalez and his colleagues have documented these findings.

Other barriers to adoption of this technique are surgeon-based, and may be related to the individual surgeon’s willingness or reluctance to adopt new techniques and technology. Many of these surgeons would be surprised by how this technique mimics open surgery.

The successful adoption of this technique by numerous thoracic surgery fellows shows the feasibility and ease of learning single-port thoracoscopy by surgeons interested in adopting and advancing their surgical proficiency in minimally invasive surgery.

The benefits for utilizing this technique include decreased length of stay, decreased patient discomfort and greater patient satisfaction.

References/ Additional Readings

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.

Chen, Chin-Hao, Lin, Wei-Sha, Chang, Ho, Lee, Shih-Yi, Tzu-Ti, Hung & Tai, Chih-Yin (2013). Treatment of bilateral empyema thoracis using unilateral single-port thoracoscopic approach. Ann Thorac Cardiovasc Surg 2013.

Gonzalez Rivas, D., Fieira, E., Delgado, M., Mendez, L., Fernandez, R. & De la Torre, M. (2013). Surgical technique: Uniportal video-assisted thoracoscopic lobectomy. J. Thorac Dis. 2013 July 4.

Gonzalez Rivas, D., Delgado, M., Fieira, E., Mendez, L. Fernandez, R. & De la Torre, M. (2013). Surgical technique: Uniportal video-assisted thoracoscopic pneumonectomy. J. Thorac Dis. 2013 July 4.

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.

Rocco, G., Martucci, N., La Manna, C., Jones, D. R., De Luca, G., La Rocca, A., Cuomo, A. & Accardo, R. (2013). Ten years experience on 644 patients undergoing single-port (uniportal) video-assisted surgery. Annals of Thoracic Surgery, 2013, Aug, 96(2): 434-438.

Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg. 2004;77:726–728.

Rocco G. Single port video-assisted thoracic surgery (uniportal) in the routine general thoracic surgical practice. Op Tech (Society of Thoracic and Cardiovascular Surgeons). 2009;14:326–335.

Rocco G, Khalil M, Jutley R. Uniportal video-assisted thoracoscopic surgery wedge lung biopsy in the diagnosis of interstitial lung diseases. J Thorac Cardiovasc Surg. 2005;129:947–948.

Rocco G, Brunelli A, Jutley R, et al. Uniportal VATS for mediastinal nodal diagnosis and staging. Interact Cardiovasc Thorac Surg. 2006;5:430–432

Rocco G, La Rocca A, La Manna C, et al. Uniportal video-assisted thoracoscopic surgery pericardial window. J Thorac Cardiovasc Surg. 2006;131:921–922.

Jutley RS, Khalil MW, Rocco G . Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia. Eur J Cardiothorac Surg 2005;28:43-46.

Salati M, Brunelli A, Rocco G. Uniportal video-assisted thoracic surgery for diagnosis and treatment of intrathoracic conditions. Thorac Surg Clin. 2008;18:305–310.

Rocco G, Cicalese M, La Manna C, La Rocca A, Martucci N, Salvi R. Ultrasonographic identification of peripheral pulmonary nodules through uniportal video-assisted thoracic surgery. Ann Thorac Surg. 2011;92:1099–1101.

Rocco G, La Rocca A, Martucci N, Accardo R. Awake single-access (uniportal) video-assisted thoracoscopic surgery for spontaneous pneumothorax. J Thorac Cardiovasc Surg. 2011;142:944–945.

Rocco G, Romano V, Accardo R, et al. Awake single-access (uniportal) video-assisted thoracoscopic surgery for peripheral pulmonary nodules in a complete ambulatory setting. Ann Thorac Surg. 2010;89:1625–1627.

Rocco G. (2012). One-port (uniportal) video assisted thoracic surgical resections – a clear advance. J Thorac Cardiovasc Surg.2012;144:S27–S31.

Additional publications on single-port thoracoscopy (Dr. Gonzalez Rivas)

1 / Single-port video-assisted thoracoscopic anatomic segmentectomy and right upper lobectomy. Gonzalez-Rivas D, Fieira E, Mendez L, Garcia J. Eur J Cardiothorac Surg. 2012 Aug 24

2 / Single-incision video-assisted thoracoscopic lobectomy: Initial results. Gonzalez-Rivas D, Paradela M, Fieira E, Velasco C.J Thorac Cardiovasc Surg. 2012;143(3):745-7

3 / Single-incision video-assisted thoracoscopic right pneumonectomy. Gonzalez Rivas D, De la Torre M, Fernandez R, Garcia J. Surgical Endoscopy. Jan 11. 2012 (Epub ahead of print)

4 / Single-port video-assisted thoracoscopic left upper lobectomy. Gonzalez-Rivas D, de la Torre M, Fernandez R, Mosquera VX. Interact Cardiovasc Thorac Surg. 2011 Nov;13(5):539-41

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.

Dr. Gonzalez Rivas, Johnson & Johnson and Single-port thoracic surgery

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.

However, this oversight represents a lost-opportunity for the parent company of Scanlon surgical instruments, the makers of specialized single port thoracoscopic instrumentation endorsed and designed by Dr. Gonzalez-Rivas himself, including the Gonzalez-Rivas dissector.

The Gonzalez - Rivas dissector, photo courtesy of Scanlon International — 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. 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.

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

2012 interview in Santiago, Chile –

Dr. Gonzalez-Rivas “TedTalk” –

SITS lobectomy – discussion on previous publication/ case report.

Dr. Gonzalez Rivas and the future of thoracic surgery

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.

Gonzalez Rivas, D., Fieira, E., Delgado, M., Mendez, L., Fernandez, R. & De la Torre, M. (2013). Surgical technique: Uniportal video-assisted thoracoscopic lobectomy. J. Thorac Dis. 2013 July 4.

Gonzalez Rivas, D., Delgado, M., Fieira, E., Mendez, L. Fernandez, R. & De la Torre, M. (2013). Surgical technique: Uniportal video-assisted thoracoscopic pneumonectomy. J. Thorac Dis. 2013 July 4.

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.

Living legends and Cirugia de Torax

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.

Patient-focused information

That’s important for the other half of our mission – connecting our patients with the world of thoracic surgery. Discussing research findings, describing procedures and presenting information to the people who are actually undergoing the procedures we are writing about. Letting them know what’s new, what’s changed – and what to expect.

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.

K. Eckland

Rocco et al. “Ten year experience on 644 patients undergoing single-port (uniportal) video-assisted surgery

Reviewing “Ten years experience on 644 patients undergoing single-port (uniportal) video-assisted” by Gaetano Rocco et al. at the National Cancer Institute in Naples, Italy

In this month’s issue of the Annals of Thoracic Surgery, Dr. Gaetano Rocco and his colleagues at the National Cancer Institute, Pascale Foundation in Naples, Italy reported their findings on ten year’s worth of single-port surgery in their institution.

Who: 644 patients; (334 males, 310 females)

Indications:

Annals of thoracic surgery - Rocco et. al (2013) — Annals of thoracic surgery – Rocco et. al (2013)

What: Outcomes and experiences in single port thoracic surgery over a ten-year period. All procedures performed by a single surgeon at this institution, and single-port VATS accounted for 27.7% of all surgeries performed during this time period.

When: data collected on thoracic surgery patients from January 2000 – December 2010.

Technical Notes:

Pre-operative CT scan was used for incision placement planning. Incision was up to 2.5 cm (1 inch) in length depending on indications for surgery.

Since manual palpation of non-visible nodules is not possible using this technique, an ultrasound probe was used to identify these lesions.

Mean operating time was 18 minutes (diagnostic VATS) and 22 minutes for wedge resections.

Outcomes:

30 day Mortality: 0.6% (4 patients – all who presented with malignant effusions).

Major Morbidity: 2.8%

Persistent drainage requiring re-do talc pleurodesis: 13 patients

Prolonged airleak (more than 5 days): 13 patients

Atrial fibrillation: 4 patients

Pancreatitis: 1 patient

Conversion rate: 3.7% (overall)

Conversion rate to 2 or 3 port VATS: 2.2% (14 patients)

Conversion to mini-thoracotomy: 1.5% (10 patients)

Patients underwent conversion due to incomplete lung collapse (22 patients) and bleeding (2 patients).

There were no re-operations or “take backs”. The four patients with malignant effusions who died within the 30 day post-op period were re-admitted to the ICU.

Post-operatively:

Otherwise, all patients were admitted to either the floor or the step-down unit following surgery.

Pain management: post-operative pain was managed with a non-narcotic regimen consisting of a 24 hour IV infusion pump of ketorolac (20mg) and tramadol (100mg*). After the first 24 hours, patients were managed with oral analgesics such as paracetamol (acetaminophen).

Limitations: in this study, uni-port VATS was not used for major resections, as seen in the work of Dr. Diego Gonzalez and others. This may be due to the fact that uni-port VATS was an emerging technique at the initiation of this study.

Strengths: This is one of the largest studies examining the use of single-port thoracic surgery – and showed low morbidity and mortality. (Arguably, the 30 day mortality in this study was related to the patients’ underlying cancers, rather than the surgical procedure itself.)

*Intravenous tramadol is not available in the United States.

Reference article

Additional work by these authors on uni-port VATS: (many of these articles require subscription).

Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg. 2004;77:726–728.

Rocco G. Single port video-assisted thoracic surgery (uniportal) in the routine general thoracic surgical practice. Op Tech (Society of Thoracic and Cardiovascular Surgeons). 2009;14:326–335.

Rocco G, Khalil M, Jutley R. Uniportal video-assisted thoracoscopic surgery wedge lung biopsy in the diagnosis of interstitial lung diseases. J Thorac Cardiovasc Surg. 2005;129:947–948.

Rocco G, Brunelli A, Jutley R, et al. Uniportal VATS for mediastinal nodal diagnosis and staging. Interact Cardiovasc Thorac Surg. 2006;5:430–432

Rocco G, La Rocca A, La Manna C, et al. Uniportal video-assisted thoracoscopic surgery pericardial window. J Thorac Cardiovasc Surg. 2006;131:921–922.

Salati M, Brunelli A, Rocco G. Uniportal video-assisted thoracic surgery for diagnosis and treatment of intrathoracic conditions. Thorac Surg Clin. 2008;18:305–310.

Rocco G, La Rocca A, Martucci N, Accardo R. Awake single-access (uniportal) video-assisted thoracoscopic surgery for spontaneous pneumothorax. J Thorac Cardiovasc Surg. 2011;142:944–945.

Recommended reading: Rocco G. (2012). One-port (uniportal) video assisted thoracic surgical resections – a clear advance. J Thorac Cardiovasc Surg.2012;144:S27–S31.

Additional articles on single-port surgery can be found in the new single-port surgery section, under “Surgical Procedures“

Awake Epidural Anesthesia for thoracoscopic pleurodesis

Awake epidural anesthesia for thoracoscopic pleurodesis: A prospective cohort study. a new publication from Dr. Mauricio Velasquez and his surgical team reviewing results from their 36 month study

On the heels of a recent announcement on CTSnet.org soliciting surgeon input on their experiences with non-general anesthesia for thoracic surgery procedures, Cirugia de torax is revisiting one of the surgeons we interviewed last year, Dr. Mauricio Velasquez at Fundacion Valle de Lili in Cali, Colombia.

Dr. Velasquez in the operating room with Lina Caicedo Quintero (nurse) Valle de Lili, Cali, Colombia

The trip to Cali was primarily to discuss Dr. Velasquez’s Thoracic Surgery Registry, and to observe him performing several single port surgery cases. However, during the trip, Dr. Velasquez also spoke about several other aspects of his current practice including some of his recent cases, and the thoracic surgery program at Fundacion Valle de Lili.

Dr. Mauricio Velasquez after another successful case

We also talked with his wife, (and lead author), the talented Dra. Cujiño, an anesthesiologist who subspecializes in thoracic anesthesia. Together, they have successfully performed several thoracic cases using thoracic epidural anesthesia on awake patients.

By chance, they published articles in both Revista Colombianas de anesthesia and Neumologia y cirugía de torax in the last few weeks.

Revista Colombianas de anesthesia

Patients receiving epidural anesthesia received a small dose of midazolam prior to insertion of epidural needle at the T3 – T4 intervertebral space. During the case, patients received bolus administration via epidural of 0.5% bupivacaine on a prn basis.

Short surgeries, single port approach

All patients, regardless of anesthesia type underwent single port thoracoscopic surgery for the talc pleurodesis procedure. Surgery times were brief, averaging 30 to 35 minutes for all cases (range 25 – 45 minutes) with the epidural patient cases being slightly shorter.

Dr. Mauricio Velasquez performing single port thorascopic surgery

Dramatic reduction in length of stay

In their study, patients receiving awake anesthesia had an average length of stay of four days compared with ten days for the general anesthesia group.

Decreased incidence of post-operative complications

There was a marked reduction in the incidence of post-operative respiratory complications (19 in general anesthesia group) versus 3 patients in the awake anesthesia group. Post-operative mortality was also decreased (six in general anesthesia) versus two deaths in the awake anesthesia group. However, the mortality statistics may also be impacted by the overall poor prognosis and median survival time of patients presenting with malignant effusions.

Post-operative pain

Study patients also self-reported less post-operative pain in the awake anesthesia group – with only one patient reporting severe pain versus seven patients in the general anesthesia group.

Conclusions

Cujiño, Velasquez and their team found awake thoracic epidural anesthesia (ATEA) was a safe and effective method for intra-operative anesthesia and was associated with a decreased post-operative pain, decreased length of stay (LOS) and decreased incidence of post-operative complications.

Notes

This study was funded by the authors with no relevant disclosures or outside financial support.

References

Indira F. Cujiño, Mauricio Velásquez, Fredy Ariza, Jhon Harry Loaiza (2013). Awake epidural anesthesia for thoracoscopic pleurodesis: A prospective cohort study. Rev Colomb Anestesiol. 2013;41:10-5. A 36 month study involving 47 cancer patients comparing (standard) general anesthesia outcomes with awake epidural anesthesia.

en Espanol: Anestesia epidural para pleurodesis por toracoscopia: un estudio prospectivo de cohort.

The second article has not been posted online yet. Look for updates in the coming weeks.

1st Asian Single Port Symposium & Live Surgery

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.)

Single port thoracoscopy for wedge resection – does size matter?

Dr. Chen discusses single port thoracoscopy – and specimen size.

Single port thoracoscopy for wedge resection – does size matter?
Dr. Chih-Hao Chen, Thoracic Surgeon, Mackay Memorial Hospital, Taiwan
Correspondence: musclenet2003@yahoo.com.tw

Case presentation and discussion

A 77 y/o woman was found to have a neoplasm in RML during routine health exam. (Full case presentation here.)
The incision was 2.5 cm. The specimen was removed successfully; patient experienced no complications and was discharged from the hospital without incident. However, when discussing this case with surgeon colleagues a specific question arose.

single port thoracoscopy — preparing to remove the specimen through the port

Does size matter? How big is too big to remove through a port incision?
An important issue is the theoretically smallest (and effective) incision size. The issue is very challenging for most surgeons. In the past, other surgeons have questioned me :
“The specimen to be removed is more than 12-15 cm. How can you remove the specimen from a 3.5 cm incision?”

BUT, the fact is “the smallest size depends mostly on the solid part of the neoplasm “.

The lung is soft in nature. In my experience, a 3.5 cm port is usually enough for any lobe. The only problem is that if the solid part is huge, pull-out of the specimen may be difficult.
Therefore, the solid part size is probably the smallest incision size we have to make, usually in the last step when dissection completed , if needed.

does size matter? — successful removal of lung specimen thru small port

single port — Port with chest tube in place

Using endo-bags to avoid larger incisions
There is an exception. I have never do this but I think it may be possible. We usually avoid opening the tumor (or cutting tumor tissue into half ) within the pleural space in order to prevent metastasis from spillage of cancerous tissue.

What if we can protect the tumor from metastasis while we cut it into smaller pieces? For example, into much smaller portions that will easily pass through the small port incisions?
My idea is to use double-layer or even triple layers of endo-bag to contain the specimen. If it is huge, with perfect protection, we cut it into smaller parts within the bag. Then the huge specimen can be removed through a very tiny incision. This is possible.

We still have to avoid “fragmentations” since this might interfere or confuse the pathologist for accurate cancer staging. Therefore, in theory, we can cut it into smaller parts but not into fragments. However this idea is worthy of consideration, and I welcome debate from my fellow surgeons and medical colleagues.

Thank you to Dr. Chen.

Dual port VATS for recurrent spontaneous pneumothorax: Foroulis et. al

A newly published study comparing dual port thoracoscopy with mini-thoracotomy for the treatment of recurrent spontaneous pneumothorax

Here at cirugia de torax, we take a keen interest in the development of increasingly minimally invasive technologies from dual (and single-port) thoracoscopy for a variety of conditions to RATS (robot- assisted thoracic surgery). It is our belief that by embracing these emerging technologies, we help to advance the thoracic surgery specialty.

This spring, we have had the pleasure of publishing case reports on dual port thoracoscopy for decortication of parapneumonic effusions and empyema and catching up with one of the leaders in single incision thoracic surgery, Dr. Diego Gonzalez Rivas.

This month, another entry, “A modified two-port thoracoscopic technique versus axillary minithoracotomy for the treatment of recurrent spontaneous pneumothorax: a prospective randomized study,” by Dr. Christophoros N. Foroulis at the Aristotle Medical School in Thessaloniki, Greece was published in Surgical Endoscopy. As noted in a previous post, there have been few (if any) published papers on dual port thoracoscopy, and no comparison studies of these two techniques.

This study, which was conducted during 2006 to 2009 followed 66 patients who were randomly assigned to receive either mini-thoracotomy or dual-port VATS for surgical pleurodesis/ bullectomy / blebectomy.

In this study, despite random assignment, each group of 33 patients were well matched in all characteristics such as age, operative side and BMI. After surgical treatment, patients were followed for a median of 30 months (range 3 – 53 months) for development of late complications or recurrent pneumothorax.

Each treatment group – VATS versus open surgical was overseen by one surgeon with Dr. Foroulis performing all of the dual port surgeries, and Dr. Papakonstantinou performing all of the open procedures. Outcomes were independently reviewed / evaluated by the remaining authors.

Study Findings

– No conversions to open thoracotomy from the VATS group.

– Similar rate of recurrence between open (2.7%) and VATS (3%) group (but timing of recurrence differed.) Both recurrent pneumothoraces in the VATS group occurred early post-operatively (POD#5) compared to the open surgical group – 13 months post-op.

– Rate of complications the same between groups but the type of complications differed. 2 patients in each group required reoperation:

VATS – reoperation for prolonged airleak

Minithoracotomy group – hematomas/ evacuation of clots

Length of stay (LOS) and post-operative pain

Surprisingly, length of stay and post-operative pain – two of the outcomes that are usually cited in favor of minimally invasive procedures – were not significantly different between the groups.

Differences

Patient satisfaction

However, patient satisfaction was significantly higher in the dual port group. This was related to an earlier return to normal activities, and earlier full mobilization of the affected arm.

Longer procedures

VATS procedures were longer than open procedures – by a mean of 21 minutes (87.1 minutes for VATS versus 66.7 minutes for minithoracotomy) with associated increases in uni-lung ventilation time.

Discussion/ Conclusions

While previous studies had reported a recurrence rate that was significantly higher in the VATS group – that was not seen here. The ability to detect blebs/ bullae (and thus treat) with VATS remains limited in comparison to a mini-thoracotomy, but does not appear to change outcomes after a successful pleurodesis procedure. Dual port thoracoscopy does take more time but both procedures appear equally effective.

Reference:

Foroulis, C. N., Anastasiadis, K., Charokopos, N., Antonitisis, P., Halvatzoulis, H. V., Karapanagiotidis, G. T., Grosomanidis, V. & Papakonstantinou, C. (2012). A modified two-port thoracoscopic technique versus axillary minithoracotomy for the treatment of recurrent spontaneous pneumothorax: a prospective randomized study. Surg Endosc 2012 May 12. Includes color photographs of procedures.

Thank you to Dr. Foroulis for your assistance.

For more on related topics:

Case study: spontaneous pneumothorax

About spontaneous pneumothorax

Minimally invasive surgery: SITS

mystery diagnosis: pleural plaques

Discovery of extensive pleural plaques during VATS

Usually with pleural plaques, you think of two possible diagnoses: metastatic cancer and tuberculosis.

But which is the more likely culprit?* That kind of depends on both your patient and your geographic location.

If this had been in my native Virginia – I’d “assume/ guess” metastatic cancer (since my patient population is usually older, high rate of smoking, other risk factors for cancer).

But luckily (who ever thought I’d be saying luckily) in my current location (Northern Mexico) in this patient (with multiple risk factors for infectious disease but no asbestos exposure) – tuberculosis is the more likely diagnosis.

* Prior to formal tissue pathology results, which confirmed tuberculosis in this patient.

** I apologize for the lack of formal references, but I was unable to find any comprehensive literature (available as free articles).

Radiology Reference on-line article

Case Report: Dual port VATS decortication of empyema

case report of dual port thoracoscopy for decortication of empyema in a thirty-eight year old woman.

Note: This case report was written with the assistance of Dr. Carlos Cesar Ochoa Gaxiola.

Case Report: Dual port thoracoscopic decortication of empyema

Presentation: A 38-year-old woman presented to the local hospital with fever, pneumonia, chest pain and an elevated leukocyte count of 25,000. Initial chest x-ray showed a large left-sided effusion.

Risk factors: Patient had several traditional risk factors for the development of empyema including heavy ETOH, and malnutrition, poor access to healthcare. Patient HIV, and Hep C negative.

Initial Hospital Course: She was admitted, and started on dual therapy antibiotics (ceftriaxone & levofloxacin). A chest tube was placed with return of frank purulent material. After several days of draining minimal amounts of pus, patient remained febrile.

Subsequent CT scan showed a left-sided empyema with large loculated areas. At that time, thoracic surgery was consulted for additional evaluation and treatment. Surgery was scheduled.

At the time of surgery, patient remained on dual antibiotics with WBC of 19,000. Albumin 1.5 , Hgb 10.2, Hct 33, other labs within normal limits.

Surgical procedure: dual-port VATS with decortication

The initial chest tube was removed, patient was prepped and draped in the traditional sterile fashion. The previous chest tube site was carefully cleaned with a betadine solution, and debrided of purulent material to prevent abscess tract formation, with instrumentation traded out after debridement.

A single additional ten mm thoracoscopy port was created, with visual interior inspection performed. Initial inspection confirmed the presence of a stage IV empyema with large loculations, moderate pleural thickening and the presence of frankly purulent material adhering to the pleural/ chest wall and lung tissue. The pleura was noted to be thickened but malleable, loosely adherent to the pleural and lung surfaces.

A formal decortication was undertaken with separation of the lung from the diaphragm and adhesions to obliterate the empyema cavity. Decortication of visceral pleura was performed until the lung was completely free and able to re-expand. Lavage was performed with evacuation and drainage of copious amounts of purulent materials.

After decortication was complete, two chest tubes were placed*; anteriorly and posteriorly, under thoracoscopic guidance, and the lung was re-inflated.

*Due to the location, and presence of infection/ purulent material in the initial chest tube site, an additional chest tube site (5mm) was created at the time of chest tube insertion to prevent additional infectious complications.

At the conclusion of the case, patient was awakened and extubated prior to being transferred to the PACU as per post-operative protocols.

EBL during the case was minimal.

Post-operative course: Patient’s post-operative course was uncomplicated. On post-operative day #5, anterior chest tube was removed. On post-operative day #7, the posterior chest tube was removed. Patient was discharged post-operative day #8.

Discussion: While convention medical wisdom dictates a trial and error treatment approach with initial trial of antibiotic therapy followed by chest tube placement (Light, 1995), surgeons have long argued that this delay in definitive treatment places the patient at increased risk of significant morbidity and mortality (Richardson, 1891). Indeed, as discussed by Dr. Dov Weissburg (on a previous discussion of empyema and lung abscess) multiple recent reviews of the literature and research comparisons continue to demonstrate optimal outcomes with surgery based approaches versus antibiotics alone, TPA and tube thoracostomy. The ability to perform these procedures in the least invasive fashion (VATS versus thoracotomy approaches) defies the arguments against surgical intervention as advanced by interventionalists (radiologists and pulmonologists.) Successful decortication with the use of dual port thoracoscopy is another example of how technology is advancing to better serve the patient and provide optimal outcomes.

Earlier, not late surgical referral would have been of greater benefit to this patient.

I apologize but I was unable to take films / photographs of this procedure during this case.

References (with historical perspectives)

Andrade – Alegre, R., Garisto, J. D. & Zebede, S. (2008). Open thoracotomy and decortication for chronic empyema. Clinics, 2008; 63 (6), 789 – 93. Color photographs. Panamanian paper discussing the effectiveness of traditional open thoracotomy and decortication for stage III / chronic empyemas in an era of increased reliance on VATS. Observations and recommendations for open thoracotomy approach for chronic empyema based on 33 cases spanning from March 1992 – June 2006, showing safe and effective results with open surgery for more advanced/ chronic empyemas.

Light, R. W. (1995). A new classification of parapneumonic effusions and empyema. Chest (108) 299 – 301.

Marks, D. J., Fisk, M. D., Koo, C. Y., et. al. (2012). Thoracic empyema: a 12-year study from a UK tertiary cardiothoracic referral centre. PLoS One. 2012;7(1):e30074. Epub 2012 Jan 20. Treatment with VATS was shown to reduce the length of stay versus open surgery with a 15% conversion rate.

Nwiloh, J., Freeman, H. & McCord, C. Malnutrition: an important determinant of fatal outcome in surgically treated pulmonary suppurative disease. Journal of National Medical Association, 81(5) 525-529.

Richardson, M. H. (1891). Surgical treatment of acute and chronic empyemas. While surgical techniques have greatly changed in the 100+ years since this paper was initially published (and no one suffers from carbolic acid poisoning anymore), many of the observations of Drs. Richardson and Loomis remain clinically relevant and valid today. (As previously noted by Dr. Weissburg, this was a pre-antibiotic era.)

Balance, H. A. (1904). Seven cases of thoracoplasty performed for the relief of chronic empyema. British medical journal, 10 Dec 1904, 1561 – 1566. Dr. Balance discusses the development of Delnorme’s operation as an alternative to thoracoplasty while presenting several cases from his career. Photographs.

Tuffier, T. (1922). The treatment of chronic empyema. Discussion of 91 cases, with radiographs.

Blebs, Bullae and Spontaneous Pneumothorax

Overview of spontaneus pneumothorax and treatment modalities.

There are multiple classifications of pneumothoraces – primary, secondary, iatrogenic, traumatic, tension etc. This article is a limited overview of the most common type(s) of pneumothorax, and methods of treatment.

What are blebs?

The lung is made up of lung tissue itself (consisting of alveoli, bronchi and bronchioles) and a thin, membranous covering called the pleura. This covering serves to prevent inhaled air from travelling from the lung to the area inside the thoracic cavity. ‘Blebs’ are blister-like air pockets that form on the surface of the lung. Bulla (or Bullae for pleural) is the term used for air-filled cavities within the lung tissue.

Who gets/ who has blebs and/or bullae?

Blebs and bullae may be related to an underlying disease process such as emphysema / chronic obstructive pulmonary disease, but they (blebs in particular) may also be found in young, healthy people with no other medical issues. Indeed, the ‘classic’ scenario for a primary spontaneous pneumothorax is a young adult male (18 – 20’s), tall and thin in appearance and no other known medical history who presents with complaints of shortness of breath or dyspnea.

Smoking, and smoking cannabis have been implicated in the development of spontaneous pneumothorax in young (otherwise healthy) patients.

Bullae, or air pockets within the lung tissue are more commonly associated with chronic disease processes such as chronic obstructive pulmonary disease (emphysema). It can be also part of the clinical picture in cystic fibrosis and other lung diseases.

How do blebs cause a pneumothorax?

When these blebs rupture or ‘pop’ inhaled air is able to travel from the airways to the thoracic cavity, creating a pneumothorax or lung collapse.

The symptoms of a pneumothorax depend on the amount of lung collapse and the baseline respiratory status of the patient. In young, otherwise healthy patients, the symptoms may be more subtle even with a large pneumothorax. In patients with limited reserve (chronic smokers, COPD, pulmonary fibrosis, sarcoidosis) patients may experience shortness of breath, dyspnea/ difficulty breathing, chest and chest wall pain. With large pneumothoraces or complete collapse of a lung, patients may become cyanotic, or develop respiratory distress.

In cases of pneumothorax caused by external puncture of the lung, or other traumatic circumstances, a patient may develop a life-threatening condition from a tension pneumothorax. This can happen with a simple, primary lung collapse from bleb rupture, but it is uncommon.

How is this treated?

Simple (or first-time) pneumothorax

Oxygen therapy – traditional treatment for small pneumothorax in asymptomatic or minimally symptomatic patients was oxygen via a face mask or non-rebreather. Much of the more recent literature has discredited this as an effective treatment.

Tube thoracostomy (aka chest tube placement) – a chest tube is placed to evacuate air from the thoracic cavity, to allow the lung to re-expand. The chest tube is initially placed to suction until the lung surface heals, and the lung is fully expanded. After a waterseal trial, the chest tube is removed.

Recurrent pneumothorax / other circumstances;

Blebectomy via:

VATS (video-assisted thoracoscopy)
Open thoracotomy or mini-thoracotomy

As we have discussed previously, the VATS procedure / open thoracotomy and mini-thoracotomy are not really stand alone procedures but are the surgical approaches or techniques used to gain entry into the chest. Using a VATS technique involves the creation of one or more ‘ports’ or opening for the use of thoracoscopic surgical tools, and a thoracoscope (or camera.) There are rigid and flexible scopes available; but most thoracic surgeons prefer the rigid scopes for better visibility and control of tissue during the operation[1].

VATS photo — blebs seen during VATS procedure

Open thoracotomy or mini-thoracotomy incisions may be used to gain access to the lung, particularly for resection of bullae (lung volume reduction) surgeries for the treatment of chronic disease.

During this procedure, fibrin sealants may be used. Investigational use of both radio-frequency and other ablative therapies have also been used (Linchevskyy, Makarov & Getman, 2010, Funai, Suzuki, Shimizu & Shiiya 2011**).

Treatment Guidelines

British Thoracic Surgeons 2010 treatment guidelines

American College of Chest Physicians – a bit dated (2001)

Linchevskyy, Makarov & Getman, 2010. Lung sealing using the tissue-welding technology in spontaneous pneumothorax. Eur J Cardiothorac Surg (2010) 37(5): 1126-1128.

Funai, Suzuki, Shimizu & Shiiya (2011). Ablation of weak emphysematous visceral pleura by an ultrasonically activated device for spontaneous pneumothorax. Interact CardioVasc Thorac Surg (2011) 12(6): 908-911.

Pleurodesis may also be used – in combination with either tube thoracostomy or surgical resection. Pleurodesis can be performed either mechanically, chemically or both. Mechanical pleurodesis is accomplished by irritated the pleura by physical means (such as scratching or rubbing the pleura with the bovie scratch pad or surgical brushes. A chest tube also produces a small amount of mechanical pleurodesis as the tube rubs on the chest wall during patient movement.

Chemical pleurodesis is the instillation of either sterile talc or erythromycin to produce irritation or inflammation of the pleura. With bedside pleurodesis or tube thoracostomy pleurodesis, sterile talc is mixed with lidocaine and sterile water to create a talc slurry. (If you like your patient, carry it in your pocket for 10 – 20 minutes to allow the solution to warm to at least room temperature. This will help reduce the discomfort during instillation.) The mixture should be in a 60cc syringe or similar delivery device – shake briskly before use. The mixture is then instilled via the existing thoracostomy tube. The chest tube is clamped for 30 – 60 minutes (dwell time) and the patient is re-positioned every 10 to 20 minutes. Despite the lidocaine, the talc will produce a burning sensation, so pre-medication is desirable. This procedure has largely fallen out of fashion in many facilities. Post-pleurodesis, pleural inflammation may cause a brief temperature elevation. This is best treated with incentive spirometry, and pulmonary toileting.

Chemical pleurodesis can also be performed in the operating room. Loose sterile talc can be insufflated, or instilled using multiple delivery devices including aerosolized talc. As discussed in previous articles, pleurodesis can also be used for the treatment of pleural effusions.

Sepehripour, Nasir and Shah (2011). Does mechanical pleurodesis result in better outcomes than chemical pleurodesis for recurrent primary spontaneous pneumothorax? Interact CardioVasc Thorac Surg ivr094 first published online December 18, 2011 doi:10.1093/icvts/ivr094

Alayouty, Hasan, Alhadad Omar Barabba (2011). Mechanical versus chemical pleurodesis for management of primary spontaneous pneumothorax evaluated with thoracic echography. Interact CardioVasc Thorac Surg (2011) 13(5): 475-479

Special conditions and circumstances related to Pneumothorax:

Catamenial pneumothorax – this a pneumothorax that occurs in menstruating women. It usually occurs on the right-side and is associated with endometriosis, and defects in the diaphragm. A related case study can be viewed here. Several recent studies suggest catamenial pneumothorax may be more common that previously believed and should be suspected in all women presenting with right-sided pneumothorax, particularly if pneumothorax occurs within 48 – 72 hours of menstrual cycle. This may be the first indication of underlying endometrial disease.

Additional References

For more reference citations and articles about the less common causes – see More Blebs, Bullae and Spontaneous Pneumothorax

Pneumothorax: an update – gives a nice overview of the different types of pneumothorax, and causes of each.

Medscape overview of pneumothorax – this is a good article with radiographs with basic information about pneumothoraces.

More on the difference between blebs and bullae – from learning radiology.com

Lung resection for bullous emphysema

Japanese study suggesting Fibulin-5 protein deficiency in young people with pneumothoraces.

VATS versus tube thoracostomy for spontaneous pneumothorax

What’s worse than a spontaneous pneumothorax? Bilateral pneumothoraces – a case report.

Early article suggesting VATS for treatment of spontaneous pneumothorax (1997)

Blebs, Pneumothorax and chest drains

[1] Flexible scopes are usually preferred for GI procedures such as colonoscopy, where the camera is inserted into a soft tissue orifice. By comparison, the thoracic cavity with the bony rib cage is more easily navigated with the use of a firm instrument.

** I have contacted the primary authors on both of these papers for more information.

Like all materials presented on this site, this paper is presented for information only. It should not be considered medical advice or treatment. Also, all information provided is generalized information and (outside of clinical case presentations) is not intended to treat of diagnose any disease or condition. If you have questions about the content, please contact us. If you have medical questions, please consult your thoracic surgeon or pulmonologist.

Case report: Blebectomy with talc pleurodesis after spontaneous pneumothorax

Case report of spontaneous pneumothorax followed by bleb resection and talc pleurodesis.

During my various travels and interviews, I have had the opportunity to meet and talk with thoracic patients from around the world. During a recent trip, I encountered a very nice young woman (in her early 20’s**). This is her story below:

The patient, the aforementioned young woman had no significant past medical history. She initially presented to a small tertiary facility with chest pain. She was evaluated for acute coronary syndrome and discharged from the emergency department. She subsequently miscarried an early pregnancy.

Several days later, her symptoms intensified, and she became short-of-breath so she returned to the emergency department. On chest radiograph, she was found to have a large left-sided pneumothorax. A chest tube was placed but subsequent radiographs showed a persistent pneumothorax. The nearest trauma facility was notified and the patient was transferred for further evaluation and treatment.

On arrival, the patient who was experiencing significant chest and LUQ pain, and breathlessness received a second chest tube. Following chest tube placement in the emergency room, chest radiograph showed the pneumothorax to be unchanged. The patient was admitted to the hospital for further testing.

A CT scan (TAC) of the chest showing chest tubes in good position and several large blebs. Following the CT scan, thoracic surgery was consulted for further treatment and management.

After discussing the risks, benefits and alternatives with the patient and family, the patient elected to proceed with a left-sided VATS (video-assisted thoracoscopic surgery) with blebectomy and talc pleurodesis.

Patient received pre-operative low dose beta blockade for sinus tachycardia. Patient was intubated with a double lumen ETT for uni-lung ventilation. The patient was hemodynamically stable intra-operatively, and the case proceed without incidence.

Intra-operative thoracoscopy confirmed the presence of several blebs including a large bleb in the left lower lobe. These were resected surgically with noncoated endoGIA staples. (Coated coviden staples have been implicated in several injuries and fatalities previously.)

12 grams of sterile talc was insufflated using an aerosolized technique. A new chest tube was placed at the conclusion of the case. There was minimal to no operative blood loss.

During VATS — surgeon performing video-assisted thoracoscopy

The patient was awakened, extubated and transferred to the post-operative recovery unit. Chest radiograph in recovery showed the lung to be well expanded on -20cm of suction.

Post-operatively the patient had a small airleak. She was maintained on suction for 48 hours and watersealed. Waterseal trials were successful, and on post-operative day #4, chest tube was removed. Subsequent chest x-ray was negative for pneumothorax. Patient was discharged home with a follow-up appointment and a referral to OB-GYN for additional follow-up.

Discussion: Due to patient’s history of miscarriage in close proximity to first reports of chest pain, special consideration was given to the possibility of catamenial pneumothorax (though this was first instance, and on the left whereas 90% of reported cases occur on the right.) While the literature reports previous episodes of pneumothorax during pregnancy, these reports occurred in later gestation (37 and 40 weeks, respectively.) On further evaluation, patient had no history of abnormal vaginal bleeding, pelvic infections, pelvic inflammatory disease or a previous diagnosis of endometriosis. Thoracoscopic evaluation was negative for the presence of endometrial tissue, and there were no diaphragmatic defects.

Final pathology: no abnormal results, confirming intra-operative findings.

**Note: Since this is a blog, available for public viewing, patient permission was obtained prior to posting. All efforts are made to protect patient privacy, and thus details regarding patient demographics have been changed/ omitted. Also, our gracious thanks to the patient and family for allowing this discussion of the case. If you have an interesting, educational or informative case, contact Cirugia de Torax for publication.

For additional information and discussion on blebs and bullae, see our related post here.

Additional information and articles on catamenial pneumothorax:

Majak P, Langebrekke A, Hagen OM, Qvigstad E. Catamenial pneumothorax, clinical manifestations–a multidisciplinary challenge. Pneumonol Alergol Pol. 2011;79(5):347-50.

Ciriaco P, Negri G, Libretti L, Carretta A, Melloni G, Casiraghi M, Bandiera A, Zannini P. Surgical treatment of catamenial pneumothorax: a single centre experience. Interact Cardiovasc Thorac Surg. 2009 Mar;8(3):349-52. Epub 2008 Dec 16.

Sánchez-Lorente D, Gómez-Caro A, García Reina S, Maria Gimferrer J. Treatment of catamenial pneumothorax with diaphragmatic defects. Arch Bronconeumol. 2009 Aug;45(8):414-5; author reply 415-6. Epub 2009 Apr 29. Spanish.

Alifano M, Jablonski C, Kadiri H, Falcoz P, Gompel A, Camilleri-Broet S, Regnard JF. Catamenial and noncatamenial, endometriosis-related or nonendometriosis-related pneumothorax referred for surgery. Am J Respir Crit Care Med. 2007 Nov 15;176(10):1048-53. Epub 2007 Jul 12

Kronauer CM. Images in clinical medicine. Catamenial pneumothorax. N Engl J Med. 2006 Sep 7;355(10):e9

Marshall MB, Ahmed Z, Kucharczuk JC, Kaiser LR, Shrager JB. Catamenial pneumothorax: optimal hormonal and surgical management. Eur J Cardiothorac Surg. 2005 Apr;27(4):662-6

VATS decortication: Empyema

an in-depth look at video-assisted thoracoscopy for decortication of advanced empyema.

In a previous series of posts discussing a recent paper presented by a group of Australian pulmonologists, we debated the use of VATS for decortication of advanced empyemas versus medical treatments. Today, I would like to talk more about the VATS decortication procedure itself. This procedure is performed to remove infected material (pus) from the thoracic cavity so the lung can re-expand.

In advanced empyema, a tough, fibrous layer (or peel) forms around the lung and prevents full re-expansion. (This peel has the appearance and texture of rubbery chicken skin.)

pleural peel — thick pleural removed during decortication

In these cases, decortication (or peel removal) is necessary for full recovery.

renteria 007 — VATS decortication of a loculated empyema

If the peel isn’t removed, the lung will remain compressed and infection can easily recur. In VATS surgery, several ports are used (small 2cm incisions) versus a larger thoracotomy incision. This isn’t always possible; if the infection is severe, or surgeons are unable to free the lung through the smaller incisions. Sometimes surgeons have to convert to open surgery intra-operatively. However, VATS is preferable for patients, (if possible). Smaller incisions mean less injury, less pain leading to fasting healing, and a shorter hospital stay.

empyema, advanced with extensive purulence — advanced empyema requiring open thoracotomy for decortication

Click here to see a video showing a standard thoracotomy incision (with retractors holding it open).

As we mentioned in a previous post – empyema is a serious, potentially fatal infection* – in fact – one out of three patients with this condition will die from it.

What’s the difference between empyema and a parapneumonic effusion? Answer: Pus.

*while this case report features a patient from Uganda, similar cases have been encountered in my practice here in the USA.

References:

Prilozi. 2010 Dec;31(2):61-70. Indications for VATS or open decortication in the surgical treatment of fibrino-purulent stage of parapneumonic pleural empyema. Colanceski R, Spirovski Z, Kondov G, Jovev S, Antevski B, Cvetanovski M V. Article linked in text above, recommending early surgical treatment for better patient outcomes. However, this study did not compare surgical treatments to medical therapies.

Asian Cardiovasc Thorac Ann 2010;18:337–43. Thoracic empyema in high-risk patients: conservative management or surgery? Bar I, Stav D, Fink G, Peer A, Lazarovitch T, Papiashvilli M. Limited study of 119 patients showing benefit in both groups of patients with surgery used as primary management strategy in clinically unstable patients. (Increased mortality in this limited study of surgical interventions versus medical management can be attributed to the fact that surgery was used as a last resort in the sicker, more debilitated patients by the authors descriptions).

Metin M, Yeginsu A, Sayar A, Alzafer S, Solak O, Ozgul A, Erkorkmaz U, Gürses A. Treatment of multiloculated empyema thoracis. Singapore Med J. 2010, Mar 51(3): 242-6. Comparison of VATS, open surgery and conventional treatment for empyema. Authors recommend VATS for first line treatment.

older references on VATS decortication:

J Thorac Cardiovasc Surg 1999;117:234-8. Video-assisted thoracoscopy in the treatment of pleural empyema: stage-based management and outcome. Cassina PC et al. Authors discuss the results of VATS decortication in 45 patients after failed medical treatment and attempted thoracostomy drainage. Several patients required open thoracotomy due to late organized infectious process.

Ann Thorac Surg 2006;81:309-313. Video-Assisted Thoracic Surgery for Pleural Empyema. Wurnig, S. S.,Wittmer, V., Pridun, N., & Hollaus, P. H. (2006). Linked in text above. Austrian study of 130 patients

Ann Thorac Surg 2003;76:225-30. Minimally invasive surgery in the treatment of empyema: intraoperative decision-making. Roberts, J. R

Dual port thoracoscopy for diaphragmatic plication with Dr. Edgard Gutierrez Puente

Talking with the energetic and innovative Colombian surgeon, Dr. Edgard Gutierrez Puentes.

Dr. Edgard Gutierrez Puente is a Colombian thoracic surgeon that I had the pleasure of interviewing in February of 2010. He is a professor of Thoracic Surgery at the University of Cartagena. As the only board certified thoracic surgeon in that city (of over 1 million people) – he currently operates in several facilities including: Hospital Naval de Cartagena, Clinica Universitaria San Juan de Dios, Hospital universitario del Caribe, Clinica Medihelp.

As part of a previous project on surgeons in Cartagena, I spent a considerable amount of time with Dr. Gutierrez, seeing patients in all of these facilities. As a result, I have a deep and profound respect for his dedication to his patients and his work. (As a matter of fact – I saw my first true* uni-port thoracoscopic surgery in Dr. Gutierrez’s operating room at Medi-help.)

I recently contacted Dr. Gutierrez on a return visit to Cartagena, and he was happy to tell me about some of his recent cases including a Diaphragmatic plication utilizing dual port thoracoscopy. He is currently writing up the case for publication in surgery journals. (This is more impressive than it may sound to many of us – traditionally Diaphragmatic plication requires open surgery or traditional VATS (with five ports). This is a big development in thoracic surgery, and I will be bringing you more information as soon as possible. (I don’t want to jeopardize his upcoming article – but still wanted to bring it to you first, here at Cirugia de Torax.)

* Often surgeons call a procedure with a small but 3 -5cm surgery a uni-port surgery, but this is actually more akin to a mini-thoracotomy. A true uniport VATS procedure, is as the name implies – using an incision that is only large enough to accommodate a single port – and is then used with thoracoscopy equipment (not open surgery instrumentation). This distinction is important because the amount of post-operative pain depends on the size of the incision and trauma to surrounding tissues and nerves. (A small incision that is heavily stretched from the use of open surgery instrumentation may actually be more painful post-operatively that a sightly larger incision that is under less stress.)

More about Dr. Edgard Gutierrez Puente

Contact details:

Centro Medico Bocagrande
Consultorio 606
Bocagrande Calle 5 #6 -19
Telefonos: 6658300
Celular: 3114115130

Dr. Gutierrez is a specialty trained thoracic surgeon. After completing medical school at the University of Cartagena, he completed his general surgery residency at the University of Costa Rica. He returned to Colombia for his thoracic surgery fellowship at Universidad El Bosque. He has been operating as a thoracic surgeon for over twenty years.

While his English is limited, his surgical skills aren’t. In reviewing cases and spending time in the operating room with Dr. Gutierrez, I was very impressed by his extensive use of thoracoscopy for many of the cases that often remain in the realm of open surgery. Having said that – I would like to clarify that Dr. Gutierrez is no ‘showboat’ – the decision to perform VATS in each of these cases was based on his skills, the patient’s anatomy and the ability to complete the surgery under safe and appropriate conditions via thoracoscopy Had Dr. Gutierrez been unable to visualize the anatomy easily, or access structures during surgery (or encountered any other problems during the cases) he would have immediately converted to open thoracotomy (as is appropriate.)

Pulmonary Metastasectomy: Cherry Pickin’

A brief description of pulmonary metastasectomy (lung resection for metastatic disease) with a limited review of recent literature.

Pulmonary metastasectomy is a medical term used to indicate surgical resection or removal of a metastatic lung lesion. This terminology reflects the presence of an underlying non-lung primary cancer. This terminology can sometimes be confusing for patients; particularly as the surgical procedure itself is unchanged (from lung procedures for other lung lesions.)

In lay person’s terms; this is also sometimes called “cherry-picking[1]”.

The Procedure: Lung Resection

Usually, patients undergo the standard VATs or open wedge resection used for other primary lung lesions, to remove the cancerous tissue. The amount and type of surgery depends on the location and size of the lung lesion, so in some cases patients have bigger procedures such as lobectomies or pneumonectomies for this condition.

The reason for delineating a difference in terminology is related to long-term outcomes and adjuvant treatment strategies. This means that the accompanying treatments such as chemotherapy or radiation are different for different underlying diseases (ie. primary lung tumor versus metastatic disease from different area.)

For example:

Patient A has a wedge resection for a primary lung tumor, which turns out to be a bronchiogenic adenocarcinoma during intra-operative pathologic reporting (the lesion is sent to the pathologist during surgery & we wait for his report before completing the rest of the surgery.) The best treatment for this is a lobectomy, which is completed while the patient is still in the operating room.

Patient X has a history of colon cancer which was previously treated with surgical resection of the colon, and chemotherapy. X has been doing well but a recent CT scan shows a lesion in the right lower lobe of his lung, with no other lesions seen. Since Mr. X has a history of colon cancer – this lesion may be a metastatic colon lesion – and the adjuvant treatment, as well as the post-operative prognosis is very different.

How do we know who would benefit from pulmonary metastasectomy? (A brief look at the published literature)

1. The International Registry of Lung Metastases (IRLM): (the link is to a nice article explaining more about the history of registry and initial results). The registry was first started in 1990, and as the name suggests, this is an international registry that was created to track the outcomes of patients with lung metastases. By tracking this data, we are able to better understand which treatment therapies are useful/ life-saving and which treatments aren’t, according to patient disease characteristics (i.e patient with breast cancer and a lung lesion may fare differently than a patient X from our example above.)

The initial data from the registry actually came from fifty years of chart reviews, starting from 1945 to 1995. This study, by Pastorino, is considered the Hallmark for pulmonary metastases. All other studies build on this body of work, to either confirm, refute or expand on their findings.

Other researchers have looked at this as well: (this is just a small sample of recent research findings)

2. Zabaleta et. al (April 2011) published an article in Cirugia Espanola, “Review and update of prognostic factors in lung metastasis surgery” which nicely explains their findings. Zabaleta and his team compiled data on ten years worth of patients (146 total) and determined that the most important factors for predicting outcomes were: age of patient, disease free interval (after initial disease treated), the number of lung nodules and the size of these nodules. This study confirms the original findings.

Unsurprisingly, the patients that did the best (lived the longest and least or re-operations for more lesions) were the patients aged 41 – 79 who had long periods before the lesion appeared, with a solitary nodule less than one centimeter in size. Clear surgical margins were not determined to be statistically significant (due to low-frequency of positive margins in study population) but all of the patients with positive surgical margins failed to survive the study period (only nine cases with + margins).

Patient Population: The majority of the patients in this study (54.8%) had colo-rectal primaries, but there was a sizable sarcoma primary population
(12.3%) as well as several other primary types which adds to the generalizability of the study.

Patient outcomes: 38 patients (26%) developed recurrent lung lesions after lung surgery – with a mean time to recurrence of 18 months (range of 3 to 60 months). I would have liked to have known which primaries were responsible in the recurrence group, since certain cancers are more aggressive than others. Overall mean survival was 67 months, with a five-year survival rate of 52.4% While the authors mention the poor prognosis of sarcoma, it would have been nice if they could have broken down the survival statistics better by primary cancer type – as the authors attribute survivability by cancer factors rather than type (i.e. sarcoma usually has multiple mets).

3. A Japanese study published this winter in the Annals of Thoracic Surgery looking at colorectal patients with metastatic liver metastasis who underwent pulmonary metastasectomy (lung resection). Study population was small (19 patients) despite a long study period (1992 – 2006) but findings were interesting with a five-year survival rate of 60%.

4. This is a nice retrospective case review by Sardenberg, et. al (2010) in San Paulo, Brazil looking at pulmonary metastases and surgical lung resection in patients with soft tissue sarcomas.

Patient population: 77 patients who had 122 surgeries involving 273 nodules – this gives you a bit more of an idea how sarcoma can differ from other cancers (more lung mets – multiple nodules). Study period was a chart review of patients referred to thoracic surgery from 1990 to 2006.

Findings: number of metastatic lesions less important than resectability, meaning “Were they able to get it all?” This; [complete resectability] was the greatest predictor of survival – and 34.7 % of patients in this study survived 90 months (then investigators stopped looking). Mean survival was 36 months.

This is just a fraction of the literature out there, but all of these studies were well-written, and freely available without subscriptions. There are a couple of interesting studies that are awaiting journal publication – so I will try to update this article once they are published.

[1] The term cherry picking referred to the patients that are selected to undergo surgery for their metastatic lesions. Usually the patient has only one or two metastatic lesions – which can essentially be surgically removed or ‘plucked out’. This procedure is less feasible / successful in patients with multiple, bilateral lesions.

SITS: That’s Single Incision Thoracoscopic Surgery

the development and application of single-port thoracoscopic surgery, (or the lack there of.)

Right now, single incision scopic surgery (laparoscopic, generally*) is in all the literature. This is a minimally invasinve technique using only one port (or incision) for access to the surgical area (usually the abdomen).

I’ve seen it performed by several general surgeons as part of my travels for BogotaSurgery.org and read the literature surrounding it, but hadn’t heard much about it’s close kin, single port thoracoscopic surgery, though I’d seen it performed during a trip to Cartagena early last year. At the time, I immediately noticed the difference in technique in the operating room (it’s not something you miss) but the surgeon performing the procedure just sort of shrugged, and went back to work, a “Yeah, well.. I do this all the time sort of thing.”

Since that trip, I’ve talked to several thoracic surgeons about this technique, and they all agreed; that due to limited visibility and maneverability, it was a procedure with “limited applications”. But it didn’t sound like any of them had attempted it, or knew much on the subject.
Since ‘limited applications’ describes many surgical techniques, I decided to go to the literature, and see what has been published on the topic.

Hmm.. Not much.

An article from two Spanish surgeons dating to 2009. It’s a well written article with a decent amount of subjects (24) for the treatment of spontaneous pneumothorax. They mention one of the adaptations required is use of the Coviden multi-station system to hold instruments – this is a silly piece of equipment that costs about a thousand dollars. I know that in general surgery, several surgeons have adapted a sterile surgical glove for the same purpose. Since use of this costly but specialized piece of rubber also requires an even bigger incision – I hope these surgeons have since moved on to the sterile glove technique. In this study, length of stay and amount of post-operative pain were not greatly reduced, which was a little surprising.

Jutley, Khalil and Rocco published a paper in 2005 in the European Journaol of Cardiothoracic Surgery on the same technique for spontaneous pneumothorax with 16 patients having uniport surgery (versus 19 in the standard three port group) with positive findings of reduced pain, and less residual neuralgias.

An Italian group reported similar positive findings (compared to Jutley, et. al) in 2008 on a similar sized group/ population (28 patients uniport versus 23 ‘traditional’ 3 port). They also reported a minimum of problems with the uniport technique.

So, three published studies (there are probably more, but this is what I could find over at Pubmed) with minimum of fuss or problems… So, why isn’t there more single incision thoracoscopic surgery? Where are the surgeons performing this technique? Maybe I’m just not talking to enough thoracic surgeons, or the right thoracic surgeons..

I’ll get back to you on this.

* This laparoscopic technique goes by the anacronym: SILS for single-incision laparoscopic surgery. It is also called uni-port (uniportal) laparoscopy and it has both it’s champions and detractors.

Preventing Atrial Fibrillation after Lung Surgery

and the snowball effect of atrial fibrillation after surgery. Discussion includes beta blockers and vitamin C as methods to reduce the incidence of post-operative atrial fibrillation with discussion of the literature supporting its use.

In previous posts, we’ve talked about prevention and management of respiratory complications of lung surgery. However, one of the more common complications of lung surgery, is atrial fibrillation, or an abnormal heart rate and rhythm. Most of the time, atrial fibrillation after surgery is temporary – but that does not make it a benign problem.

Developing atrial fibrillation is problematic for patients because increases length of stay (while we attempt to treat it) and increases the risk of other problems (such as stroke – particularly if we can’t get the heart rhythm to return to normal).

‘The Cootie Factor’
Length of stay is important for more than cost and convenience. One of the things I try to explain to my patients – is that hospitals are full of sick people, and in general, my surgery patients are not sick– they’ve had surgery..
But surgery increases their chance and susceptibility to contracting infections from other patients, and visitors. I call this ‘the cootie factor’. (Everyone laughs when you say cooties – but everyone knows exactly what you mean.) So the reason I am rushing my patients out the door is more than just for patient convenience and the comforts of home – it’s to prevent infection, and other serious complications that come from being hospitalized, in close quarters, with people who have may have some very bad cooties indeed (MRSA, resistant Klebsiella, VRE, Tuberculosis and other nasties.)

But besides, length of stay – atrial fibrillation, or a very rapid quivering of the atrial of the heart (250+ times per minute) increases the chance of clots forming within the atrial of the heart, and then being ejected by the ventricles straight up into central circulation – towards the brain – causing an embolic stroke.. Now that’s pretty nasty too..

Atrial fibrillation risk reduction

But there are some easy things we can do to reduce the chance of this happening..
One of the easiest ways to prevent / reduce the incidence of post-operative atrial fibrillation – to slow down the heart rate. We KNOW that just by slowing down the heart by 10 – 15 beats per minute, we can often prevent abnormal heart rhythms.

Most of the time we do this by pre-operative beta blockade, which is a fancy term for using a certain class of drugs, beta blockers (such as metoprolol, carvedilol, atenolol) to slow the heart rate, just a little bit before, during and after surgery.

In fact, this is so important – national/ and international criteria uses heart rate (and whether patients received these medications prior to surgery) as part of the ‘grading’ criteria for rating surgery/ surgeons/ and surgery programs. It’s part of both NSQIPs and the Surgical Apgar Scale – both of which are important tools for preventing intra-operative and post-operative problems..

The good thing is, most of these drugs are cheap (on the $4 plan), very safe, and easily tolerated by patients. Also, most patients only need to be on these medications for a few days before and after surgery – not forever.

Now, if you do develop atrial fibrillation (a. fib) after surgery – we will have to give you stronger (more expensive, more side effects) drugs such as amiodarone, or even digoxin (old, but effective) to try to control or convert your heart rhythm back to normal.

If you heart rhythm does not go back to normal in a day or two – we will have to start you on a blood thinner like warfarin to prevent the blood clots we talked about previously. (Then you may have to have another procedure – cardioversion, and more medicines, if it continues, so you can start to see why it’s so important to try to prevent it in the first place).

Research has also looked at statin drugs to prevent atrial fibrillation after surgery – results haven’t been encouraging, but if you are already on cholesterol medications prior to surgery, there are plenty of other reasons for us to continue statins during and after surgery.. (Now, since the literature is mixed on whether statins help prevent a. fib – I wouldn’t start them on patients having lung surgery, but that’s a different matter.)

Now Dr. Shu S. Lin, and some of the other cardiac surgeons did some studies down at Duke looking at pre-operative vitamin C (along with quite a few others) and the results have been interesting.. That doesn’t mean patients should go crazy with the supplements.. anything, even Vitamin C can harm you, if taken willy-nilly (though the risk with vitamin C is usually minimal).

In fact, the evidence was strong enough (and risk of adverse effects was low enough) that we always prescribed it to our pre-operative patients for both heart and lung surgery. (Heart patients are at high risk of atrial fibrillation too.) We prescribed 500mg twice a day for a week before surgery, until discharge – which is similar to several studies. I’ve included some of these studies before – please note most of them focus on atrial fibrillation after heart surgery.

Vitamin C
Vitamin C with beta blockers to prevent A. Fib. This is probably my favorite free text about Vitamin C and Atrial fib – it’s my sort of writing style..

Contrary to popular belief, performing a VATS procedure (versus open surgery) does not eliminate the risk of post-operative atrial fibrillation.

Now Dr. Onaitis, D’Amico and Harpole published some interesting results last year (and of course, as Duke Thoracic surgeons, I am partial) – but I can’t repost here since it’s limited access articles..

Outpatient Treatment for Malignant Effusions

Discussion of treatment goals, and patient centered care for Malignant pleural effusions. This is the first in a series of articles on lung cancer, and lung surgery topics. Originally posted at our sister site.

Not all conditions are curable, and not all treatments are curative. Some treatments are based on improving quality of life, and alleviating symptoms. This is a hallmark of patient centered care – doing what we can to make the patient feel better even when we can’t ‘fix’ or cure the underlying disease. No where is this more evident than in the treatment of malignant effusions.

By definition, a Malignant Effusion is the development of fluid in the fluids related to an underlying (and sometimes previously undiagnosed) malignancy. Malignant effusions can be seen with several different kinds of cancers, most commonly lung and breast cancers. The development of a malignant effusion is a poor prognostic sign as it is an indicator of metastasis to the pleural tissue/ space.

The development of a malignant effusion usually presents with symptoms of shortness of breath, and difficulty breathing. While the treatment of the underlying cancer may vary, the primary goal of treatment of an effusion is palliative (or symptom relief). The best way to relieve symptoms is by removing the fluid.

This can be done several ways – but each has its own drawbacks.

Thoracentesis:
The fluid can be drawn out with a needle (thoracentesis) either bedside or under fluroscopy. This procedure is quick, and can be performed on an out-patient basis, in a doctor’s office, or in radiology.

The potential drawbacks with this treatment strategy are two-fold:

1. There is a chance that during the procedure, the needle will ‘poke’ or ‘pop’ the lung, causing a pneumothorax (or collapse of the lung). This then requires a chest tube to be placed so the lung can re-expand while it heals. However, if the procedure is performed uneventfully, (like it usually does) the patient can go home the same day.

2. The other complication – is rapid re – accumulation – since you haven’t treated the underlying cause, but have only removed the fluid. This also happens when the cause of the effusion (nonmalignant) is from congestive heart failure. This means the fluid (and symptoms of shortness of breath) may return quickly, requiring the patient to return to the hospital – which is hard of the patient and their family.

Video- Assisted Thoracoscopy: (VATs)
Malignant effusions can also be treated by VATS – this is a good option if we are uncertain of the etiology (or the reason) for the effusion. While all fluid removed is routinely sent for cytopathology (when removed during surgery, thoracentesis or chest tube placement) – but cytopathology can be notoriously inaccurate with false negative reports, because the diagnosis is dependent on the pathologist actually seeing cancer cells in the fluid. However, during the VATs procedure – the surgeon can take tissue samples, and photos along with fluid for diagnostic testing. This is important because I have had cases in the operating room (VATS) where the surgeon actually sees the tumor(s)** with the camera but the fluid comes back as negative.

** in these cases, we send biopsies of the tumor tissue – which is much more accurate and definitive.

But a VATS procedure requires an operation, chest tube placement and several days in the hospital.

Chest tube placement:
Another option is chest tube placement – which also requires several days in the hospital..

During both chest tube placement and VATS, a procedure called pleurodesis can be performed to try to prevent the fluid from re-accumulating.

But what if we know it’s a malignant effusion? What are the other options for treatment?

Catheter based treatments: (aka PleurX style catheter, or Heimlich valve)
(note: catheter means a small tube – a foley catheter is the type used to drain urine, but other types are used for many things – even an IV is a catheter.)
One of the options used in our practice was pleur X (brand) catheter placement. This catheter was a small flexible tube that could be placed under local anesthesia – either in the office or the operating room – as an ambulatory procedure. After some patient teaching, including a short video, most family members felt comfortable emptying the catheter every two or three days at home, to prevent fluid re -accumulation (and allowing the patient to continue normal activities, at home.)

PleurX catheter placement is preferred in many cases due to ease of use, and patient convenience. The Heimlich valve is messier – as it tends to leak, and harder for patients to hide under clothing.

Sometimes a visiting nurse would go out and empty the catheter, and in several cases, patients would come to the office, where I would do the same thing – it was a nice way to relieve the patient’s symptoms without requiring hospitalization, and several studies have shown that repeated drainage often caused spontaneous pleurodesis (fluid no longer accumulated.) We would then take the catheter out in the office.. Now, like any procedure, there is a chance for problems with this therapy as well, infection, catheter can clog, etc..

But here’s another study, showing that even frail patients benefit from home-based therapy – which is important when we go back and consider our original treatment goals:
-Improving quality of life
-Relieving symptoms

In the article, the authors used talc with the catheters and then applied a Heimlich valve, which is another technique very similar to pleurX catheter placement. (Sterile talc is used for the pleurodesis procedure – which we will talk about in more detail in the future.)

Another article, this one by Heffner & Klein (2009) published in the Mayo Clinic Proceedings discusses the diagnosis and treatment of malignant effusions.