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Thoracic Surgery posted “International VATS 2018: Better than before – Extreme Fast track thoracic surgery” by Kristin Eckland.

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.

Thoracic Surgery posted “Dr. Hung, Dr. Chen and nonintubated and awake thoracic surgery” by Kristin Eckland.

After attending multiple recent thoracic surgery conferences, where the topic of nonintubated thoracic surgery sparked murmurs and outspoken criticism, thoracics.org conducted a brief review of the literature to attempt to discern if this criticism and skepticism was warranted.  As part of this review, we reached out to several of the leaders in the field, including Dr. Ming-Hui Hung, a well-respected Taiwanese anesthesiologist and widely acknowledged expert on this topic.

Thoracics.org asked for Dr. Hung’s commentary as well as his response to several specific questions on nonintubated thoracic surgery.  Here is his response in it’s entirety (re-formatted to fit the Question and Answer format posed by our correspondence).

Question:  Would you tell me more about your initial research in this area.   What lessons have you learned (overall) in patient selection for non-intubated thoracic surgery?  What additional tips or advice would you offer interested thoracic surgeons/ members of anesthesia?

As we had discussed in our publications, we are facing more and more aging and frail patients with minor thoracic procedures. As surgical approach evolves toward a minimally invasive thoracoscopic technique, we expect that there would be a need for less invasive anesthetic management (i.e. nonintubated VATS) as well. Traditional intubated one-lung ventilation does offer a safe and quiet surgical environment for surgery; however, we still suffer occasionally to have patients complicated with intubation-related adverse effects, not to mention the consuming procedures for successful one-lung ventilation. Actually, there was a short-stature elderly lady complicated with pneumo-mediastinum because of tracheobronchial laceration after a double-lumen tracheal intubation. We was driven by this case we suffered to find a solution and whereas we developed our nonintubated techniques since 2009. As you noted, now nonintubated VATS is a routine part of our armamentarium for thoracic surgery.

To summarize, there are important steps that we learned from our experiences:

1. Thoracic epidural anesthesia (TEA) vs internal intercostal nerve blocks (INB)

In the beginning, we applied TEA. It does provide satisfying analgesia but it is time-consuming and carries more risks for neurological complications. Once again, we had a nonintubated case coincidentally complicated with acute transverse myelitis after surgery. Although we excluded the epidural procedure per se, to be the direct cause of the regretful complication, we were still bothered by a legal suit against us. Then we learned that internal INB is equally effective as a thoracic epidural catheter. It saves time and risk free to do it as we do it under a direct vision by scope, and no touching on any spinal structures. Now INB is our routine part of nonintubated VATS. TEA is considered for those doing a bilateral VATS. We think this is important because it makes nonintubated VATS more safe and even more less invasive, for which our patients would accept this approach more. We Taiwanese are mostly reluctant to have someone doing anything on our spines, as we usually call them the “dragon bones”, the most important part of our bodies.

2. Intrathoracic vagal block

Since cough reflex is a visceral part of autonomic nerve, which is not blocked by TEA or INB, unpredictable cough reflex during surgery could quietly bothering and even dangerous. We soon learned that we could block the cough reflex via intrathoracic vagal nerves. It really works. It alleviates the tension upon surgeons who working on a spontaneously breathing lung and enable them more manipularity of lung parenchyma and hilar structures. Surgeons are still needed to be as gentle as possible for that excessive traction still can trigger cough reflex from the dependent side where vagal nerve function is intact.

3. Sedation and titration of its depth

We know there is an “awake, or not awake” issue on nonintubated VATS. We prefer to sedate our patients just because our patients do not want to be awake during surgery. Lateral decubitus position is not a confortable position. Most of our patients undergo surgery because of lung cancer or potential lung cancer. It usually takes 1-2 hours to have a diagnosis first and complete the definite treatment upon the final pathological result. We believe no one would like to be anxiously awake for the result with an open chest in an awkward position. In addition, the initial phase of iatrogenic pneumothorax would cause the patient dyspneic and tachypneic for a while, giving patient sedated with supplemental opioid is useful to alleviate the respiratory disturbances and accelerate the operated lung to collapse. By applying bispectral index EEG monitor, we can observe the BIS index increasing during the initial phase of open pneumothorax, it could be caused by inadequate analgesia, or just because of a dyspneic response. We may give the patients some more anesthetic and it usually recovered after effective vagal block. Carefully observe the respiratory pattern (from the video, or using an noninvasive end-tidal capnography) is of importance. Anesthesiologists should keep vigilant on the respiratory pattern and airway patency of the nonintubated patients, including a plan B for intubation conversion.

4. Patient selection

We operate on spontaneous breathing lungs (most of the time, the operated lung collapses well because of positive pressure introduced into the chest cavity). The remaining opposite lung is sufficient to maintain satisfactory oxygen saturation, despite unavoidable hypoventilation. However, a vigorous diaphragm would jeopardize the balance. For surgery, it causes excessive movement of the operated lung and makes hilar manipulation dangerous or even impossible. For respiration, CO₂ rebreathing (an to-and-fro phenomenon between the dependent and the non-dependent lung) would further exacerbate the breathing pattern and decrease the alveolar oxygen fraction of the nondependent lung, leading to oxygenation desaturation. It is the most common scenario of our difficult cases and we changed to intubation conversion in some of them, especially in major resections (i.e. lobectomy) for lung cancer. We learned that obese patients tend to be an abdominal breather because of an elevated diaphragm and they are usually associated with excessive diaphragmatic movement during nonintubated surgery. Other contraindications for nonintubated VATS are also listed on the literature. We suggest that are mostly at the discretions of the caring surgeon and anesthesiologist as their good clinical practice routines.

Question:  How have your findings of your work been received internationally?  At several recent conferences, there has been a lukewarm or even critical response towards nonintubated thoracic surgery.  Is this a frequent response? 

A typical unfriendly tone from other colleagues is “just because it can be done, should it be done?” We have the same feelings as you experienced in those meeting. Nonetheless, our findings are relevant and robust that nonintubated VATS is feasible and safe in selected patients with a variety of thoracic procedures. They were published in well-known surgical journals in cardiothoracic field, including Annals of Surgery, Journal of Thoracic and Cardiovascular Surgery, Annals of Thoracic Surgery and the European Journal of Cardio-Thoracic Surgery. Still, there are surgeons and anesthesiologists enthusiastic about less invasive alternative for their caring patients visiting our hospital for nonintubated VATS, including Korea, China, Switzerland internationally and other hospitals nationally.

We believe it is human nature being anxious and doubtful to do something you do not get familiar with, especially when intubated one-lung ventilation is nearly an unbreakable only golden standard for thoracic surgery for decades, and almost all thoracic surgeons in current generations would request a fully collapsed lung to operate upon. But at this time, we are approaching a 1000 nonintubated VATS case volume, and all thoracic anesthesiologists and thoracic surgeons in our hospital are dealing with nonintubated VATS if this is appropriate for their patients. We think it is quiet a milestone in our program.

Five years ago, I asked one of my colleagues, a nursing anesthetist [emphasis mine] whether she would choose nonintubated technique if she needs a VATS procedure.

She said, “Well, I need to think about it. You better give me an double lumen even though I know how big it is.”

One year later, her answer to the same question is a “Yes, please, no tube.”

Question: Are there any other obstacles for researchers in this area?  Do you have other on-going research programs at your facility?

Obviously, nonintubated patients recover from surgery fast. They can shift to the gurney on their own from the surgical table. They experience less pain and less PONV in PACU, which enables them to recover oral intake sooner with oral analgesics and early ambulation, not to mention those common adverse effects after double lumen intubations, such as a sore throat and a change of voice quality. Currently, we are drafting our manuscripts about nonintubated VATS pulmonary resection in patients with compromised lung function. Meanwhile, a randomized trial is under investigation to compare the recovery differences of nonintubated VATS vs. intubated VATS.   There are also several more nonintubated trials in Clinicaltrial.org in different countries.

Question: Do you know of any programs that have adopted your techniques and protocols?

To our knowledge, Dr. Jianxing He from the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China, is also an enthusiastic advocator and pioneer in nonintubated VATS. He is also leading journals such as Journal of Thoracic Disease andAnnals of Translational Medicine as an open forum to accelerate the impact of nonintubated VATS. He is going to publish a state-of-the-art monograph dedicated to nonintubated VATS in the near future. We believe you can get useful information regarding nonintubated VATS in China and different perspectives from him.

As always, we keep doing our best to satisfy our patients’ need during their curing and recovery processes, just because “our patients, first.”

Ming-Hui Hung, MD, MS
Anesthesiologist, Department of Anesthesiology

Jin-Shing Chen, MD, PhD
Professor, Department of Surgery
National Taiwan University Hospital

Thoracics.org would like to thank Dr. Hung and his colleagues for their continued work in this area.  Thoracics.org would also like to thank Dr. Hung for his willingness and frank candor in addressing some of the other issues in this area.

Additional References and Resources

Ke-Cheng Chen^1,3, Ya-Jung Cheng², Ming-Hui Hung², Yu-Ding Tseng³, Jin-Shing Chen (2012).  Nonintubated thoracoscopic lung resection: a 3-year experience with 285 cases in a single institution.  Journal of Thoracic Disease, Aug 2012, 4(4).

Hung MH, Hsu HH, Cheng YJ, Chen JS. (2014).  Nonintubated thoracoscopic surgery: state of the art and future directions. J Thorac Dis. 2014 Jan;6(1):2-9. doi: 10.3978/j.issn.2072-1439.2014.01.16. Review. (Best read in pdf form).

Liu YJ, Hung MH, Hsu HH, Chen JS, Cheng YJ. (2015).  Effects on respiration of nonintubated anesthesia in thoracoscopic surgery under spontaneous ventilation.  Ann Transl Med. 2015 May;3(8):107. doi: 10.3978/j.issn.2305-5839.2015.04.15. Review

Fast track thoracic surgery: nonintubated minimally invasive surgery for complex procedures.  October 4, 2015.

Readers: Thoracics.org has highlighted a key phrase in Dr. Hung’s response that also, unintentionally but directly addresses one of the criticisms recently advanced by a noted American thoracic surgeon who challenged Dr. Martinez as to whether he would ever delegate the care of a nonintubated patient to a nurse anesthetist.  When Dr. Martinez hesitated in his response, the surgeon claimed victory, stating, “See?  That would never work in American hospitals, [where certified nurse anesthetists oversee the majority of cases]”.  This was his rationale for dismissing this technique, even when it might make otherwise inoperable patients eligible for life-saving surgery.  That dismissal of both his American colleagues and the needs of the more fragile subset of our thoracic surgery population demonstrates some of the limitations in our so-called “masters” or “giants” of thoracic surgery.  While great, and influential surgeons, they are not infallible.  Their experiences carry wisdom, but their opinions shouldn’t carry more weight than any other published study.

Thoracics.org is committed to giving a voice and forum to all specialties and members of the thoracic surgery community.

Examiner.com posted “FDA warns: Caution when using your medicine cabinet” by Kristin Eckland.

Motrin (ibuprofen), Tylenol (acetaminophen) and Benadryl (diphenhydramine) are just a few of the over-the-counter medications that clutter our medicine cabinets. So much so, that the average American rarely thinks twice about popping one of these medications to treat a variety of ailments. Over the years, the federal Food and Drug Administration (FDA) has released a series of warnings regarding many of these medications, but much of the general public remains unaware of the dangers of these widely available medications.

The most dangerous drugs in the medicine cabinet

Here’s a review of the worst offenders and the most recent research of the effects of these medications on your health. While each of the medications discussed has a specific purpose and related benefits, use of these medications should be confined to a medically approved treatment regimen.

Acetaminophen

Acetaminophen (Tylenol) has its own place on the top of our list of the most dangerous drugs in the medicine cabinet due to both its toxicity and the use of acetaminophen as a hidden ingredient in multiple other medication compounds such as cough syrups and cold remedies. It is also the silent partner in multiple prescription medications such as Percocet and Vicodin.

While considered safe at relatively low doses, acetaminophen remains the number one cause of acute liver failure in the United States. What is a low dose? It’s hard to say, since researchers have been arguing to lower the current acceptable dosing threshold from 4 grams (4,000 milligrams) in a 24 hour period to just 2 grams for the last several years. If that dose seems like a lot, consider that just one extra strength Tylenol contains 500 milligrams or half a gram of acetaminophen. Just as little as four tablets a day would exceed what many clinicians consider to be the safe threshold. For this reason, in 2014, the FDA has asked manufacturers and healthcare providers to limit dosing to the 325 mg formulations, and better labeling but this still fails to protect unwary consumers who may not read the packaging of related medications and realize that they are getting additional acetaminophen or the dangers of cumulative dosing from multiple sources.

The FDA has also failed to revise dosage recommendations for pediatric use. Concerns over the rare but aspirin-associated Reye’s Syndrome have made acetaminophen the mainstay of treatment for worried parents and pediatricians in fevers and other childhood illnesses.

The concerns about acetaminophen aren’t restricted to home use by consumers. Long used in Europe, the recent arrival of intravenous forms of acetaminophen in the United States has also increased the risk of accidental overdose in hospitalized patients, including children.

Ibuprofen and the NSAIDs

While ibuprofen and the other “profens” (ketoprofen, fenoprofen and naproxen) have long been linked to severe kidney damage even in small chronic dosages, these nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for a multitude of common complaints such as arthritis, headaches, menstrual cramps and chronic low back pain. Other common NSAIDs have similar side effects and include indomethecin, diclofenac, ketorolac, meloxicam and aspirin in addition to the prescription only drugs like celecoxib (Celebrex).

Unfortunately, these anti-inflammatory activities in non-aspirin NSAIDs have also been implicated in an increase in cardiac and cerebrovascular disease (heart attacks and strokes). The most notable of these medications is Vioxx (rofecoxib) and its current counterpart, Celebrex. Vioxx was released in the United States by Merck in 1999 with much fanfare as the newest medication in the arsenal against arthritis and other inflammatory conditions. Within just a few years, this turned to dismay as the medication was linked to a drastically increased risk of heart attacks and strokes among users. Vioxx was removed from the American market in 2004. Several other medications in the coxib drug class have been restricted or removed from the market in Europe and around the world.

The remaining NSAIDs including the older, more heavily used medications have come under increased scrutiny since then, with researchers questioning the safety of these medications particularly in at risk groups, including patients with pre-existing cardiac or cerebrovascular disease.

In a 2008 Circulation article, Kathleen Taubert, PhD discusses the use of these medications in cardiac patients and compares common NSAIDs with aspirin use, which is a essential part of medical therapy in these individuals.

Note: The risks with aspirin differ from other NSAIDS. A prescribed aspirin regimen should never be discontinued without speaking with your healthcare provider.

Diphenhydramine and the anticholinergics

A new study by Grey et al. published in the widely respected medical journal, JAMA this spring, shows a possible association between the use of anticholinergic drugs in people 65 or older and the risk of developing dementia. Anticholinergic drugs are medications that block the neurotransmitter, acetylcholine. Acetylcholine works as a chemical messenger in the brain.

In many drugs like benztropine (Cogentin), amytriptylline (Elavil), chlorpromazine (Thorazine), and the popular anti-depressant paroxetine (Paxil) the neurotransmitter blockage is an essential part of the effectiveness of the drug. Psychotropic or neurological effects are expected or anticipated effects of many Parkinson’s and psychiatric drugs.

However, these anticholinergic effects also occur in medications that many consumers do not usually associate with having central nervous system effects such as allergy medications; diphenhydramine (Benadryl), hydroxyzine (Atarax), chlorpheniramine (Actifed) or bladder medications like oxybutynin (Ditropan) or tolterodine (Detrol). Anti-emetics or anti-nausea medications such as promethazine (Phenergan), prochloroperazine (Compazine) also make the list, as many of the medications are derived from, or related to, antipsychotics such as Thorazine.

What to do to limit your risk

Millions of Americans currently take many of these medications as part of their daily routine. For some people with chronic illnesses such as Rheumatoid Arthritis, or Parkinson’s disease, non-drug alternatives are not an option.

But formulary alternatives may lessen the risks. Individuals should consult with their pharmacists and healthcare providers to discuss whether alternative medications exist, and how to reduce their risk. Consumers should also know the signs of serious adverse effects like stroke and heart attack. Healthcare providers should be encouraged to perform mini-mental and cognitive evaluations on all geriatric patients on anticholinergic medications. Individuals in high risk groups such as people over the age of 65, or people with a history of cardiac disease will need to weigh their risks of adverse events against the benefits of therapy.

For people accustomed to medicating daily aches and pains without a second thought, consideration should be given to the basics of nonpharmacological treatments such as gentle stretching, yoga, application of heat / ice or massage. For many people, a hot shower followed by a ten minute stretch can ease the discomfort of mild osteoarthritis. A heating pad may be a good choice for chronic low back pain sufferers in conjunction with a range of physical therapy treatments.

Lastly, before reaching for the Advil automatically, think about it. Is the headache a minor annoyance or a full-blown pounding, throbbing ache? Is it a twinge in your joints or debilitating stiffness? Even a modest reduction in medication consumption, and an acknowledgement of the risks of many of these over-the-counter medications will promote longevity, health and wellness.

Examiner.com posted “Thoracic surgery goes wireless” by Kristin Eckland.

Thoracic surgery is the surgical specialty focused on the thorax or the chest. Thoracic surgeons perform procedures treating diseases of the lungs, trachea, esophagus and mediastinum. In some countries, like the United States, surgeons may specialize in cardiothoracic surgery, which also includes the heart and the great vessels of the aorta and vena cava.

Thoracic surgery as “Big” surgery

Traditionally these surgeries have been considered “big” surgeries; requiring large surgical incisions (thoracotomies, sternotomies, clamshell) and often requiring longer hospital stays. In comparison to procedures in other surgical specialities, such as appendectomies, cholecystectomies, hip and knee replacements, or gynecological procedures, thoracic surgery procedures often carried a higher risk of mortality or serious complications.

Surgical advances making surgery smaller, safer, and less painful

Ever since the first video-assisted thoracoscopic surgeries (VATS) were performed in the early 1990’s, modern technology has struggled to keep up with advances in thoracic surgery. As surgeons used more and more incision-sparing techniques for larger and more complex cases, surgeons have driven the development of many of the tools and instruments designed to aid in these minimally invasive endeavors. Traditional three and four port VATS for simple decortications has given way to uniportal (or single) port VATS for lobectomies, bronchial sleeve resections and chest wall cases.

Robotic surgery has become prominent in cases involving mediastinal masses, replacing the traditional sternotomy approach. All combined, these techniques have revolutionized the thoracic surgery specialty at a time when demand for thoracic surgeons and their skills in treating lung and esophageal malignancies is exploding.

Now Dr. Chih Hao Chen and his team of researchers at MacKay Memorial Hospital in Taipei, Taiwan have designed and tested a new wireless endoscope for use in uniportal and other minimally invasive surgeries. Published in the July 2015 issue of the International Journal of Surgery, Chen et al. describe how the more streamlined, cordless design facilitates use of uniportal and other minimally invasive surgical approaches by increasing mobility and flexibility of use.

No trailing or tangled cords

This wireless design allows for easier “tote-ability” which facilitates surgeons to perform some procedures outside of the operating room. In cases of critically ill patients needing smaller procedures such as limited biopsy, being able to readily transfer the procedure to the bedside in the intensive care unit without delaying the procedure for the lengthy set-up required for traditional units prevents unnecessary delays in patient care. Using a battery operated, cordless endoscope such as the endoscope used in the Chen study also limits the potential for interference or contamination due to trailing or tangled cords that are a continual consideration with traditional endoscopes. While the Chen thoracoscope is currently restricted to animal trials while the device specifications are finalized, maybe soon, it will be coming to a thoracic surgeon near you.

Thoracic Surgery posted “Dr. Ahmet F. Işık talks about pleural mesothelioma, HITHOC, and thoracic surgery in Gaziantep, Turkey” by Kristin Eckland.

It’s been over a year since I first read Dr. Isik’s work on treating pleural mesothelioma.  Since that time, Dr. Işik has continued his research into HITHOC and has now enrolled over 79 patients into the hyperthermic treatment group including one of the patients I met during my visit.  (There are 29 surviving patients in the study, 13 in the mesothelioma group, the remainder are secondary pleural cancers.).

First impressions are deceiving

I don’t know what I expected Gaziantep to look like as one of the world’s oldest cities, but from the moment the airplane begins its descent into a beige dust cloud, to the desolate brush and dirt of the airport outside the city, it isn’t what I expected.  Much of the antiquity of the biblical city of Antiochia has been replaced by a bustling modern city. Historic ruins and ancient Roman roads marking this as part of the original Silk Road are conspicuous, only by their scarcity.

There are a handful of museums and monuments to the area’s rich history, but like the new name of Gaziantep (replacing Antep after the first world war), Turkey’s sixth largest city is modern; a collection of traffic and squat square buildings of post-modern architecture.

The city is also a mosaic of people.  There are groups of foreign journalists in the lobby of our hotel, and convoys of United Nations vehicles cruising the streets.  Crowds of Syrian children play in the park, calling out in Arabic to their parents resting on the benches nearby. There is a smattering of Americans and English speakers interspersed, many are college students and other foreign aid workers on humanitarian missions to help alleviate the strain caused by large numbers of people displaced by the Syrian civil war.

But like a mosaic, there is always more to see, the closer you look.  For me, as I look closer, I just want to see more. I feel the same about Dr. Elbeyli’s thoracic surgery department.

The border (and the largest Syrian city of Aleppo) lies just to the south – and the impact of the Islāmic militants is felt throughout the region.  No where is this more evident than at the local university hospital, where I meet Dr. Ahmet Işık and the Chief of Thoracic Surgery, Dr. Levent Elbeyli.

Dr. Ahmet Feridun Işık

I like Dr. Işık immediately.  He is friendly and appears genuinely interested by my visit.  He’s from Giresun in the Black Sea region of northern Anatolia of Turkey.  He attended medical school at Ankara University and completed his thoracic surgery training in Ankara before going to Adiyaman State Hospital in the bordering Turkish province of Adiyaman in southeastern Turkey.

He was an associate professor of thoracic surgery at Yuzuncu Yil University in the far eastern province of Van, Turkey before coming to Gaziantep in 2005.  He became a full professor at the University of Gaziantep in 2013.  In additional to authoring and contributing to his own publications, he also served as a reviewer for the Edorium series of open access journals.

It helps that his English is miles better than my non-existent Turkish.  (Reading about the Turkish language in phrase books is one thing, pronouncing words correctly is another.)

He doesn’t seem to mind my questions tumbling out one after another.  I’d like to be the cool, sophisticated visitor, but I’ve been waiting so long to ask some of these questions – and frankly, I am just excited to be there.

Dead-ends in medicine

There are a lot of “dead ends” in medicine – treatments that at first appear promising, but then end up being either impractical or ineffective.  In fact, for the first ten years of HIPEC, most surgeons dismissed it as a ‘dead-end’ treatment; the surgery was too radical and mortality too high.  But researchers kept trying experimental protocols; tweaking medications (less toxic) and procedures – and finding the right patients (not too frail prior to surgery) – and the literature shifted; from a largely useless ‘last ditch’ salvage procedure to a large, but potentially life-saving treatment. HITHOC is HIPEC in another color…

So I fire away –

Since our last post about Dr. Işık – he has performed several more cases of HITHOC on patients with pleural mesothelioma, pleural based cancers and advanced lung cancers.  He now has 79 patients in the HITHOC treatment group. He has been receiving patients from all over Turkey, including Istanbul to be evaluated for eligibility for this procedure.  While the majority of patients are referred by their oncologists, others come to Gaziantep after reading about Dr. Işık on the internet.

None of the original patients (from 2009) are still alive, but their survival still exceeded all expectations, with 13 patients (of 14 HITHOC patients) living 24 to 36 months after the procedure.  (I don’t mean to be vague – but I was asking some of these questions in the operating room and I forgot to stuff my little notebook in my scrub pocket.)

While much of the literature surrounding the procedure cites renal failure as one of the major complications of the procedure, Dr. Işık has had one case of renal failure requiring dialysis.  Any other instances of elevated creatinine were mild and transient. He doesn’t use any chemical renal prophylaxis but he does use fluid rehydration to limit nephrotoxicity.

He reports that while many surgeons consider sarcomas to be a contraindication to this procedure, he has had good outcomes with these patients.

He does state that diaphragmatic involvement in mesothelioma is an absolute contraindication because while the diaphragm can be resected / patched etc, it is almost impossible to guarantee or absolutely prevent the seeding of microscopic cancer cells from the diaphragm to the abdominal cavity – which increases the risk of disseminated disease.

He still uses Cisplatin – since that is what the original HITHOC researchers were using, but he uses a slightly higher dose of 300mg.  He’d like to do some prospective studies utilizing HITHOC (these have all been retrospective in nature – comparing today’s patients with past patients that received PDD and pleurodesis for similar conditions).  Prospective studies would allow him to better match his patients and to compare treatments head to head. It would also allow him to compare different techniques or chemotherapeutic agents.

Unfortunately, as he explained, many of these types of studies of ineligible for government funding in Turkey because the government doesn’t want to pay for experimental / unproven treatments for patients even if there are few or no alternatives for treatment.  He is hoping to appeal this regulation so that he can continue his research since there is such a high rate of mesothelioma, that disproportionately affects rural Turkish patients.

The University of Gaziantep Hospital

The University Hospital is one of several hospitals in Gaziantep.  The academic institution has over 900 beds and 20 operating rooms spread out over three floors.  There is a large 24 bed surgical ICU which includes 4 dedicated thoracic surgery beds.

Thoracic surgery may not be the advertised superstar of the hospital but it is the backbone of patient care.  There are three full-time professors of surgery; Dr. Ahmet Isik, Dr. Levent Elbeyli and Dr. Bulent Tunçözgür, along with an associate professor, Dr. Maruf Sanli, several thoracic surgery fellows and research assistants.  Together the thoracic surgery team performs over 1000 cases a year.

Dr. Levent Elbeyli is the driving force for thoracic surgery.  A Gaziantep native, he founded the department in 1992, and has seen it grow from a few scattered beds to a full-fledged program with a full-time clinic, 2 dedicated operating rooms, 4 ICU beds and 15 to 20 cases a week.

For the thoracic nurse, the department of Thoracic Surgery is a dream come true; tracheal cases, surgical resections, esophagectomies, thoracic trauma – all of the bread and butter that makes our hearts go pitter-pat.  But then there is also plenty of pediatric cases, pectus repair, foreign body removal (oro-esophageal) and on-going surgical research. They do a large amount of pediatric and infant bronchoscopies (for foreign body obstructions, tracheal malformations etc).

There is the slightly exotic hydatid cysts and the more mundane (but my personal favorite) empyema thoracis to be treated.  Cancers to be staged, and chest wall resections to undertake. I feel almost overwhelmed in my own petite version of a candy store; everywhere I turn I see opportunities to learn, case reports to write and new things to see.

My non-medical readers might be slightly repulsed by my glee – but it is this intellectual interest that keeps me captivated, engaged and enamored with thoracic surgery and caring for thoracic surgery patients.   And then there is the HITHOC program. With a large volume of mesothelioma and pleural based cancers due to endemic environmental asbestos in rural regions of Turkey, there is an opportunity to bring hope and alleviate suffering on a larger level.  (Dr. Isik sees more cases here in his clinic in one year than I have seen in my entire career).

What’s not to love about that?

Article updates:

Since our original visit to Dr. Isik, he has continued his work on HITHOC for malignant pleural mesothelioma and other cancers.  You can read his latest paper, “Can hyperthermic intrathoracic perfusion chemotherapy added to lung sparing surgery be the solution for malignant pleural mesothelioma?”

In this study, Dr. Isik and hs team looked at 73 patients with malignant pleural mesothelioma (MPM) who were in three different treatment groups.  Group 1 received surgery only (extrapleural pneumonectomy). Group 2 received palliative treatment only. Group 3 received lung sparing surgery with hyperthermic chemotherapy (HITHOC).  Lung sparing surgery included pleural decortication.

While the treatment groups are small, the results show a clear survival benefit to the patients receiving HITHOC.   Surprisingly, the palliative group lived longer than the surgery alone group.

Survival based on treatment modality:

Surgery only:  5 months average surgery.  15% survival at 2 years

Palliative treatment only: 6 months average survival   17.6% at 2 years

HITHOC group:  27 months average survival    56.5% at 2 years

Selected Bibliography for Dr. Işık  

Işık AF, Sanlı M, Yılmaz M, Meteroğlu F, Dikensoy O, Sevinç A, Camcı C, Tunçözgür B, Elbeyli L (2013). Intrapleural hyperthermicperfusion chemotherapy in subjects with metastatic pleural malignancies. Respir Med. 2013 May;107(5):762-7. doi: 10.1016/j.rmed.2013.01.010. Epub 2013 Feb 23. The article that brought me to Turkey, and part of our series of articles on the evolving research behind HITHOC.

Isik AF, Tuncozgur B, Elbeyli L, Akar E. (2007).  Congenital chest wall deformities: a modified surgical technique.  Acta Chir Belg. 2007 Jun;107(3):313-6.

Isik AF, Ozturk G, Ugras S, Karaayvaz M. (2005).  Enzymatic dissection for palliative treatment of esophageal carcinoma: an experimental study.  Interact Cardiovasc Thorac Surg. 2005 Apr;4(2):140-2. Epub 2005 Feb 16.

Er M, Işik AF, Kurnaz M, Cobanoğlu U, Sağay S, Yalçinkaya I. (2003).  Clinical results of four hundred and twenty-four cases with chest trauma. Ulus Travma Acil Cerrahi Derg. 2003 Oct;9(4):267-74. Turkish.

Sanli M, Arslan E, Isik AF, Tuncozgur B, Elbeyli L. (2013). Carinal sleeve pneumonectomy for lung cancer. Acta Chir Belg. 2013 Jul-Aug;113(4):258-62.

Maruf Şanlı, MD, Ahmet Feridun Isik, MD, Sabri Zincirkeser, MD, Osman Elbek, MD, Ahmet Mete, MD, Bulent Tuncozgur, MD and Levent Elbeyli, MD (2008). Reliability of positron emission tomography–computed tomography in identification of mediastinal lymph node status in patients with non–small cell lung cancer. The Journal of Thoracic and Cardiovascular Surgery,Volume 138, Issue 5, Pages 1200–1205, November 2009.

Sanlı M, Isik AF, Tuncozgur B, Elbeyli L. (2009).  A new method in thoracoscopic inferior mediastinal lymph node biopsy: a case report.  J Med Case Rep. 2009 Nov 3;3:96. doi: 10.1186/1752-1947-3-96.

Sanli M, Isik AF, Zincirkeser S, Elbek O, Mete A, Tuncozgur B, Elbeyli L. (2009).  The reliability of mediastinoscopic frozen sections in deciding on oncological surgery in bronchogenic carcinoma. J Thorac Cardiovasc Surg. 2009 Nov;138(5):1200-5. doi: 10.1016/j.jtcvs.2009.03.035. Epub 2009 Jun 18.

Sanli M, Işik AF, Tunçözgür B, Arslan E, Elbeyli L. (2009).  Resection via median sternotomy in patients with lung cancer invading the main pulmonary artery.  Acta Chir Belg. 2009 Jul-Aug;109(4):484-8.

Sanli M, Isik AF, Tuncozgur B, Elbeyli L.  (2010). Successful repair in a child with traumatic complex bronchial rupture.  Pediatr Int. 2010 Feb;52(1):e26-8. doi: 10.1111/j.1442-200X.2009.03000.x

Sanli M, Işik AF, Tunçözgür B, Meteroğlu F, Elbeyli L. (2009).  Diagnosis that should be remembered during evaluation of trauma patients: diaphragmatic rupture].  Ulus Travma Acil Cerrahi Derg. 2009 Jan;15(1):71-6. Turkish.

Examiner.com posted “After cardiac bypass surgery: Understanding the recovery process” by Kristin Eckland.

In the first two articles, we discussed preparations for bypass surgery. Today’s article will focus on the initial recovery process, beginning with the morning after surgery. In most cases, patients will be awake, extubated and out of the bed, sitting in a chair by 6 a.m. the morning after surgery.

If the patient is hemodynamically stable, or not requiring intravenous medications to maintain heart function; many of the intravenous lines, like the yellow Swan-Ganz catheter and other medical equipment will be removed. After breakfast, the patient will be assisted out of the chair, to take the first of a series of many, many walks. Soon after that, many patients will be transferred to the telemetry or step-down unit so they can focus on completing the steps necessary for getting better and going home.

Understanding the recovery process

Post-operative recovery is more like training for a marathon than most people realize. We like to use the example of an out-of-shape athlete getting ready to run his first marathon after a long hiatus.

It’s also more patient driven that most people understand. That means that the patient is not a passive recipient of care in this situation. The patient is the driving force in pursuing wellness and restoration of health. Whether the patient walks or not can determine how quickly (or if) the patient gets better and goes home.

Less technology = Better

Most people think, “Technology = Superior” but that’s often just not the case. Many times, simpler interventions are far more effective than even our most advanced (and costly) technologies. That is particularly important when we talk about breathing, and pulmonary toileting after cardiac surgery.

We have the technology to intubate and ventilate patients with machines. We can even start powerful drugs like nitric oxide to enhance oxygenation in patients who are in respiratory failure despite being on a breathing machine. But in cardiac surgery, these technologies represent a failure or a poorer prognosis than our less invasive, and less fancy treatments. That’s a hard concept to convey to generations of people who have been sold on medical technology – but it is true.

The easiest and best ways for patients to get better after surgery – aren’t fancy, they aren’t expensive, and they aren’t high tech. But these interventions are amazingly effective, if we can get our patients to perform them. Too often people can’t get past preconceived notions about heart surgery and that hinders our care.

Not a melodrama

Now think about that – and mentally prepare yourselves. For many patients and their families, this is a huge change in their expectations. Years of “General Hospital”, “Grey’s Anatomy” and other quasimedical shows along with popular culture have shaded the public’s perceptions of health care and surgery. These television shows, along with other melodramas have led many people to envision in-hospital post-operative recuperation from cardiac surgery as being a long, drama-filled and drawn out process filled with a lot of handwringing, audible prayers and indrawn breaths from everyone in the vicinity, particularly from the significant other.

Babying the patient back into intensive care

Put away your hanky, and re-focus on the reality. For the vast majority of patients, this is not the case. Not only that – but these kind of over-solicitous, “here, let me feed you, help you, do-that-for-you” attitudes and behaviors will actually slow and hinder the patients recovery. In fact, many of the most frequent complications are more common in patients who have families who spend more time catering to, and babying patients than listening to experienced physicians and health care providers.

Not a democracy

The first thing to understand as you or a loved one goes thru this process, is that as many surgeons say, “It’s not a democracy.” This is important because as we discussed above, families don’t always know what’s best for their loved ones, and this is a hard concept for many people to swallow.

Patient care isn’t dictated by popular vote, or whether we want you to like us – it’s based on scientifically validated and evidenced-based practices. This means that the family’s desire to soothe, no matter how well-intentioned, comes secondary to our duty to heal the patient through cardiac rehabilitation measures such as fluid restriction, frequent respiratory exercises and walking.

But he’s thirsty!

Yes, we know the patient is thirsty, but no, you can’t bring a gallon of sweet tea. Patients often gain large amounts of fluid during the surgery and immediate post-operative period. Pounds and pounds of water weight in some cases. All that fluid has to go somewhere, and it usually settles in the lungs.

So doctors and healthcare providers work hard at getting that fluid off, by encouraging the patient to do breathing exercises, and giving the patient medications to make them urinate. But there is a limit to the amount of medication we can give without causing other problems like kidney failure so we strongly limit the amount of fluids some patients can take in after surgery.

All these body water shifts along with mouth-breathing during surgery give patients an amazing thirst. It’s unquenchable. Patients can drink gallons of fluid, and their mouths still feel dry. But drinking all of that extra fluid compromises breathing and puts the patient at increased risk of pneumonia and respiratory failure. It can even cause heart failure in our sicker, frailer patients. That sweet tea we mentioned earlier, is an even worse idea because all of the sugar will cause a serious hyperglycemia or high blood sugar in our patient. This hyperglycemia happens even in non-diabetic patients and it puts the person at risk for other serious consequences like poor wound healing and infection.

Friends and family play an important role in the care of loved ones

The “He’s thirsty” is just one of the battles we often encounter between families and health care providers and it illustrates how even the best of intentions from family members can have serious consequences for loved ones. But that doesn’t mean that friends and family can’t play an important role during this time. In fact, there is one role that family members can do to shorter recovery, decrease complications and help their loved ones feel better, and it’s something families and friends do better than anyone else: Cheerleader.

Encouraging and cheering your loved one to good health

The best way for families and friends to help their loved one starts by working as a team with health care providers. Help us care for your parent, spouse, sibling, child or friend by encouraging the patient to participate in cardiac rehabilitation activities. Walk with patients and therapists, and encourage the patient to walk farther and more frequently each day. Remind the patient to use their incentive spirometer to prevent pneumonia or to splint their incision when coughing to decrease pain and discomfort.

Caring friends and family can also participate in patient education sessions by taking notes and asking questions during sessions on diet, medications and post-operative activities. Learn what sternal precautions are, and help patients follow these precautions to prevent pain and injury.

Lastly, take care of your loved one by talking to us. We want to hear what you have to say, particularly if you’ve been at the bedside all day, because we can’t be. We want your insights, so tell us your concerns, and ask questions but remember to listen to our answers.

In the next article, we will talk more about the recovery process and restoring health and wellness after coronary artery bypass (CABG) surgery.