THORACIC SURGERY

Surgical Treatment of Lung Cancer

Lung cancer is among most fatal cancers. Undoubtedly, the most important cause is smoking.

EARLY DIAGNOSIS is very critical. It is VERY CRUCIAL to stop smoking immediately and even avoid smoke-free environments.

It is necessary establish DIAGNOSIS and determine STAGE of the disease correctly before treatment of LUNG CANCER is started. Complaints should be addressed and noted in detail.

Diagnostic Tests & Procedures

• Chest X-ray
• CT (CT of Lung)
• PET/CT (Positron Emission Tomography)
• Cranial MRI
• Bone scan, if required, etc.
• Pulmonary Function Tests
• Bronchoscopy, FNAB (Fine Needle Aspiration Biopsy), Mediastinoscopy, etc.

Stages of Disease

• Stage 1A, B – Early Stage
• Stage 2A,B – Minimal growth of tumor (surgery is still an option)
• Stage 3A – Further growth of tumor + involvement of lymph nodes (chemotherapy and/or radiotherapy can be considered, if necessary, before the surgery)
• Stage 3B – Further growth of tumor, involvement of lymph nodes and peripheral and/or nearby organs (target of surgery can be evaluated only after chemoradiotherapy)
• Stage IV – advanced stage tumor; distant organ involvement is present (only chemoradiotherapy and/or Immunotherapy)

Surgical Options for Lung Cancer

According to location and size of lung cancer and histopathological type of tumor cell;

• A part of lung
• Wedge resection,
• Segmentectomy,
• Lobectomy or removal of entire lung
• Pneumonectomy

Duration of Surgery:

• Limited surgeries (wedge resection and segmentectomy) usually take shorter time (2-3 hours)
• Major surgeries (lobectomy and pneumonectomy) take longer time (4-5 hours) *These durations show interpatient variations!

Details of Surgery:

Surgery is performed under general anesthesia and the patient is placed flank position such that the lung to be operated on is upside. For endoscopic – closed surgery (minimally invasive VATS – video-assisted thoracic surgery), a surgical incision that measures approximately 4 to 5 cm in length is made and most surgeries are carried out through this incision. This is called “uniportal” VATS (closed surgery).

The blood vessels of the lung segment that will be surgically removed are divided with staples (a special metallic stapler) and finally, the bronchus of the target lung segment is divided again with a special metallic stapler.

After these procedures are completed, the cancerous tissue is removed and the surgery is terminated. Comparing to the open surgery technique, the postoperative convalescence is

• Shorter,
• Less painful and
• More comfortable
• The patient is mobilized on the same day or the next day.
• Liquid and soft foods are allowed
• Patients are discharged within one week.

Postoperative period:

• The most important postoperative issue is the pain at the surgical site. Pain can be easily managed with effective pain killers.
• Patients are recommended to take both pain killer and antibiotic agent for 1 week to 10 days after the operation.
• Patients can usually engage in routine activities of daily life within 2 weeks.
• Moderate-intensity walk for 30 to 45 minutes per day is very important in the postoperative period.
• Pathology result is reported approximately within one week. The pathology report must be reviewed and commented by both Medical Oncologist and Radiation Oncologist.

 

What is pectus carinatum?

This structural deformity can be mixed type in the same patient (6.8%); same person can have both pectus excavatum (sunken shape of the chest wall) and pectus carinatum (abnormal protrusion of the breastbone). It may be secondary to inward protrusion of cartilaginous parts of ribs (ribs are composed of two sections; osseous rib and cartilaginous ribs) at one side, outward protrusion at the other side and the twisted breastbone. The most common clinical picture of this deformity is characterized with outward protrusion of the breastbone and the symmetrical protrusion of the cartilaginous parts of the lower ribs. The defect is rarely located only in the upper section (chondromanubrium). Here, cartilages of the upper ribs are affected and the breastbone appears relatively sunked in.

 

The underlying mechanism of the pectus carinatum is not exactly known. Although the cause cannot be strictly clarified, positive family history and associating diseases suggest a “development abnormality in the connective tissue”. Other theories advocate abnormal development of the diaphragm and hypertrophy (increased volume) of cartilaginous parts of ribs.

 

Prevalence of pectus carinatum is 0.06 percent (only 6 out of 10.000 persons) (2). Pectus excavatum is less prevalent. It is three times more common in boys than girls.

 

On the contrary to pectus excavatum, pectus carinatum occurs in childhood and adolescence (age range: 11 to 15 years). Pectus carinatum is very rarely detected in the birth. Almost half of the patients notice the abnormal growth in the adolescent period.

 

Pectus carinatum may cause following symptoms:

 

There is no well documented heart and/or lung disease that is directly related to pectus carinatum. Some scientific studies report that pectus carinatum leads to more lung complaints than pectus excavatum. Potential symptoms include shortness of breath, abnormally rapid breathing, emphysema that develops over time secondary to decreased capacity of lung (damaged lung tissue) and infection (pneumonia etc.).

 

Some studies reported congenital heart diseases by 20% in children with pectus carinatum that is secondary to early close of the breastbone.

 

In conclusion, pectus carinatum does not cause a complaint in most cases, but it may lead to cardiac rhythm disorders and decreased contractility of heart muscle. It may cause decreased ventilation capacity, shortness of breathing, rapid breathing and lung inflammation by preventing the sufficient expansion of lungs in the long term (due to rigidity of the chest wall).

 

Even so, severity of the deformity is the only criterion that should be taken into consideration to repair the pectus carinatum. Patients may complain of sensitivity in the protruded segment, as they crash the protruded bone frequently. Physical capacity (exercise capacity) may also decrease.

 

Pectus carinatum may be associated with certain diseases;

 

Family history is notable for chest wall deformities in 25% of the patients with pectus carinatum. Sideways curve of the spine (scoliosis) is detected in 20% of the patients. Twelve percent of the patients have family history of scoliosis.

 

A high index of suspicion is required for Marfan syndrome (a connective tissue disease) in patients with associating scoliosis or very severe deformity. Pectus carinatum is rarely associated with Morquio Syndrome (Mucopolysaccharidosis IV; a disease characterized by accumulation of a polysaccharide) that is characterized with inward curve (hyperlordosis) at lower or lumbar segment of the spine and kyphosis.

 

Treatment Methods

 

Surgical treatment:

 

• Endoscopic (closed surgery) removal of cartilaginous ribs and division of the breastbone.
• Open surgery; many techniques are defined by Fonksalsrud (2008), Matos (1997) and Shamberger (1987)
• Minimally Invasive Surgery – ABRAMSON PROCEDURE; the pectus bar is placed with endoscopic technique anterior to the breastbone and beneath the muscles. The protruding anterior chest wall is pushed backward to correct the position of the anterior chest wall and next, it is stabilized with pectus bar.

 

Abramson Procedure for Treatment of Pectus Carinatum

 

Argentinean Thoracic Surgeon Horacio Abramson is the first scientist who modified and performed the Nuss technique (minimally invasive correction surgery for pectus excavatum) for patients with pectus carinatum and announced the successful outcomes in scientific meetings for the first time in 2005 (1). 5-Year Follow-up outcomes of Abramson Procedure are reported for 40 patients in a scientific platform. Accordingly, perfect results are obtained in 10/20 patients whose pectus bar is removed 2 years later, while good, moderate and bad results are noted in 4, 4 and 2 patients, respectively. As it can be seen, the success rate of Abramson technique is very high; promising outcomes are revealed out in 18 of 20 patients who pectus bar is removed.

 

Preoperative Procedures

 

• The first step is the physical examination.
• After the patient and family member(s) are informed about the pectus carinatum and its treatment, they are allowed and asked to think and make a decision; next, informed consent form is obtained for the surgery and subsequently, other tests are started.
• If the tests do not indicate a contraindication for general anesthesia, routine blood tests (complete blood count, blood group, bleeding time and pulmonary function test, if required, etc.) and anesthesiology consultation are requested.
• Cardiology consultation is ordered to determine whether the patient has a heart disease or not and ECG and ECHO are tested to reveal out a potential problem; after the heart disease is treated, if required, treatment of pectus carinatum is planned.
• Patients with medical problems (diabetes mellitus, hypertension etc.) are consulted with relevant physicians.
• The patient and the family member are informed in detail about the disease, available treatment options and their success rates.
• Required chest imaging studies (anteroposterior view and computerized tomography) are scanned.
• The day of surgery is decided.
• Questions of the patient about the disease and the surgery are preoperatively answered.

 

Success rates of open surgery (conventional surgery) and endoscopic minimally invasive surgery (closed surgery) are comparable in Abramson procedure. However, Abramson technique is preferred, as it can be performed within a shorter time, prevalence of pre- and post-operative complications (adverse events) is far lower, hospital stay is shorter or the patient is discharged earlier and patients can engage in activities of daily life sooner (2 weeks).

 

Optimal age to perform correction surgery for Pectus Carinatum is 7 to 14 years. If the operation is performed in this age range, the softer chest wall will not only facilitate the operation, but it will also enable to restore normal postoperative anatomic position of the anterior chest wall. However, the success rate of the procedure is comparable for adult patients.

 

Abramson Procedure

 

Abramson procedure is performed under general anesthesia and it takes 60 minutes in average. An incision (2 cm) is made on the right lateral side of the anterior chest wall (the mid-axillary line) and thus, the chest wall is exposed.

 

A polyvinyl chloride (PVC) tube is inserted through a port (guide bar) anterior to the breastbone (the most protruding part of the breastbone) and beneath the muscles of anterior chest wall (pectoral muscles, breast muscles) and thus, a tunnel is created that extends to the contralateral side.

 

Another incision is made on the contralateral chest wall at the same level (the mid-axillary line) and thus, the exit orifice of the tunnel is created.

 

A non-stained steel bar, Lorenz Pectus bar, is used to compress the protruded segment of the chest wall.

 

Lorenz bar (pectus bar) is selected according to size and shape of the anterior chest wall and both ends of the bar are curved before the intervention is started. One of the bars is inserted into a PVC tube that is slowly pulled from the contralateral side of the tunnel, while the bar is inside the other end of the tube, and thus, the pectus bar is inserted into the tunnel.

 

The PVC tube is removed over the bar when the bar reaches the other end of the tunnel. Stabilizers are strongly secured to the rib with steel wires, before or after the bar is inserted into the tunnel.

 

After the position of the breastbone is verified, cutaneous and subcutaneous incisions are stitched with appropriate sutures and the procedure is terminated. Detailed information on ABRAMSON TECHNIQUE is available in scientific publications.

 

Removal of Bars

 

Pectus bars are removed under short-lasting (30 min) general anesthesia in 2 to 4 years depending on age and condition of the chest wall (the prognosis and improvement in follow-up visits).

 

Risks of Abramson Procedure

 

Risks of operation are usually very low (5); pneumothorax (only 1 of 40 patients – presence of air between the lung and the chest wall), wound site inflammation (only 1 of 40 patients), fluid collection at the wound site (only 6 of 40 patients) and dehiscence of sutures (only 3 of 40 patients) have been noted. Wound site infection is less than 0.7 percent.

 

 

Treatment of Excessive Sweating and Reactive Sweating (ETS – Endoscopic thoracic sympathectomy)

How is ETS performed in excessive sweating?

“Conventional” and “endoscopic” techniques are used in surgical treatment of excessive sweating. Conventional surgical treatment of excessive sweating is the open surgery and long incisions are made. Recently, endoscopic ETS is more commonly used that is the colloquially called closed surgery. Therapeutic effect of both surgeries is identical. Endoscopic thoracic sympathectomy with clip can be easily performed in any season (as long as overall health of the patient tolerates).

Endoscopic thoracic sympathectomy with clip offers solution for excessive sweating and/or redness in face and excessive sweating in hands, armpits and feet. Sweating is suppressed completely in the sudoriferous glands in the region that is innervated by the sympathetic chain, which is surgically removed (for example; T2 sympathetic chain for face, T3 sympathetic chain for hand and T3-T4 sympathetic chain for armpits). ETS is not used for generalized sweating function of the body.

Endoscopic thoracic sympathectomy with clip is named after the technique and the target site. The term “thoracic” refers to an anatomic region that covers the chest wall, chest cavity and all organs and tissues. The term “endoscopic” means use of a device with integrated light source and camera, called endoscope.

In this technique, two skin incisions, each measuring one centimeter in length, are made in the armpit and the endoscope is inserted to the target part of the chest cavity and extended to the location of sympathetic chain; the surgeon performs the surgery while watching the surgical site on a monitor. On the contrary to the conventional surgery, this technique does not require long skin incisions; skin is incised in 1- to 1.5-cm length.

 

Difference between classical ETS and Clipping:

ETS can be performed in two ways; clipping or dividing the nerve. When a clip is used, the risk of recurrence is 10-20% in the group of patients who suffer from intolerable compensatory sweating in the postoperative period (5-8%). After the patient is informed about this detail, the preference of clipping or complete removal of the nerve is left to the discretion of the patient. Success rates are comparable for both techniques.

Effect of ETS

Effects of the surgery emerge immediately after a nerve is divided or clipped in the operation (within the first 10 minutes). Hands of the patient start drying in the operation and moreover, oxygenation boosts and hands start getting warm, as the blood vessels of hands dilate after the sympathetic pressure is eliminated. The problem of excessive sweating already disappears when the patient is recovered from anesthesia.

 

Nuss Procedure: Surgical Treatment of Pectus Excavatum

Nuss Procedure was first defined by Donald Nuss in 1987 (1). It is a minimally invasive technique that is used to correct Pectus Excavatum; the surgery is accompanied by some advantages such as fewer incisions, fewer procedures, shorter operation time, and faster recovery after surgery, and positive long-term outcomes. Recently, it is gaining popularity day by day.

Posterior side of the breastbone (sternum) is supported with a bar (steel bar) and pushed anterior without need to divide or cut ribs and cartilages. Nuss Procedure or Nuss Operation has been developed over years and it has been more commonly used.

The optimal age range is 7 to 14 years to correct the pectus excavatum. It should be, if possible, performed before adolescence so that the chest wall easily gets its normal shape at the end of the rapid growth period. However, thanks to Nuss technique, very promising outcomes are obtained even for 30 to 40 years old patients.

Preoperative Procedures;

• First, physical examination is made.
• The patient and the family member are informed by the doctor about the pectus excavatum and its treatment in order to allow them make the best treatment decision and their questions are answered.
• Chest X-ray, two views (Anteroposterior and Lateral views), and computerized tomography of thorax are scanned to determine the severity of the chest wall deformity (Haller index – severity of pectus excavatum: If the ratio of transverse diameter of the chest wall to the anteroposterior diameter is above 2.5, it is regarded a significant condition and the patient is a candidate of surgery, if the ratio is above 3.2.
• If the tests do not indicate a contraindication for general anesthesia, routine blood tests, pulmonary function test, if required, and anesthesiology consultation are requested.
• Cardiology consultation is ordered to determine whether the patient has a heart disease or not and ECG and ECHO are tested to reveal out a potential problem; after the heart disease is treated, if required, treatment of pectus carinatum is planned.
• Patients with medical problems (diabetes mellitus, hypertension etc.) are consulted with relevant physicians.

Postoperative Period

Patients may suffer from pain in first 3 days of the postoperative period. Therefore, the pain is relieved in a controlled manner with epidural anesthesia, as the patient is preoperatively informed. Pain management is usually maintained with pain killers that are given by mouth or injected into a vein after the third day. The pain is mostly controlled with pain killer tablets at home, after the patient is discharged.

Hospital stay is usually 3 to 5 days. Wound dressing is required for the first 3 days. The wound site can be left open thereafter. No other care is required. The ends of pectus bar can be felts beneath the skin, albeit rate. Gentle massage to these regions may prevent adhesion of the bar to the skin in the postoperative period. Pectus bar mostly works properly without a problem.

Patients are recommended to start non-strenuous sports activities only after postoperative Month 3. Usual sports activities (swimming, tennis, jogging etc.) can be performed six months after the operation. However, contact sports, wrestling, karate, box and weight lifting should be strictly avoided at this interval. Individual sports can be preferred over the contact sports, if possible, in the rest of the life.

In the first month after the surgery, the patient

• Should not use low back region to bend forward (the hip joint must be used).
• Should avoid lumbar rotation.
• Should not roll to either side.
• Should avoid jogging or aerobic activity.
• Should not do any strenuous activity.

In the first three months after the surgery, the patient

• Should not lift weight (including school books and bag).
• Should not do aerobic activity.

 

Ekleme Tarihi: 10/6/2023
Güncelleme Tarihi: 10/6/2023
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