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'thoracic' posts

A new treatment for GERD: The LINX - Reflux Management System

Acid reflux, heartburn and indigestion are all forms of gastroesophageal reflux disease or GERD. This common problem afflicts over 20 million people in the United States on a daily basis. As a surgeon who treats patients with some of the most severe symptoms of GERD, I was recently struck by the fact that very little has changed in the treatment of the debilitating problem over the last several decades.

Medications have always been the primary treatment for patients with GERD. TUMS, Rolaids, alka seltzer are easy over the counter remedies that could provide instant but only short-term relief. More potent medications called H2 receptor antagonists (commonly known as Zantac, Pepcid AC) brought about longer lasting relief. These medications were great but many patients experienced a relapse of symptoms.

The newest medications for GERD...

Pectus excavatum – it looks like the chest is sinking inward

Have you ever noticed someone whose chest sinks inward in the front, kind of like a funnel? The first time I ever noticed this bony malformation was when I was in high school, and a friend of mine on the soccer team had one. It was called “pectus excavatum,” he told me.

In my thoracic surgery training, I was often called upon to evaluate patients with this chest wall abnormality. As a result, I began to delve deeper into some of the issues that may affect people with this type of defect.

Pectus excavatum is the most common chest wall deformity and results from abnormal development of the sternum and its attachments. Most patients are self conscious about the defect and usually focus on its appearance but because this is usually present for much of a person’s life, symptoms associated with it may not be totally obvious. Individuals affected generally get used to how they feel and try to overcome any limitations to the best of their abilities without even knowing that’s what they are doing. Most patients describe some chest discomfort, shortness of breath when exerting themselves, lack of endurance, or feeling embarrassed in social situations when their shirt is off. It is not uncommon to hear patients say that they have trouble keeping up with their friends during activities, or that they avoid any activities that would require them to take off their shirt in public-such as going to a pool.

Most physicians aren’t even aware that there is an effective treatment for pectus excavatum...

Palmar hyperhidrosis

Everyone sweats – but what if you had a condition that caused uncontrollable sweating in your hands?

Palmar hyperhidrosis is a benign condition where individuals experience uncontrollable sweating of their hands, way beyond their physiological needs. Hand sweating in such a scenario is often described as being present 24/7, may be worsened in situations of stress but also occurs out of nowhere in times of total rest and serenity. From the constant dampness the hands are exposed to, ulcerations and other skin related changes may develop. Many patients with this condition adopt a line of work and a life style that minimizes public encounters and avoid hand contact such as having to shake hands.

It has been known since the 1920s that by dividing the sympathetic chain (nerve) high up inside the chest, a procedure called thoracic sympathectomy, we can make the hands stop sweating. To achieve this surgically was quite an undertaking back then. The surgical trauma was such that historically very few individuals with hyperhidrosis opted to have corrective surgery. With the development of videoscopic surgery, however, it has become possible to perform the sympathectomy with minimal trauma to the patients. In addition, the magnification provided by the optics of videoscopic surgery has made the surgery safer.

What is involved in an ETS (Endoscopic Thoracic Sympathectomy)?

Nowadays, we offer surgery under general anesthesia as a day surgical procedure (meaning most patients are expected to go home the day of surgery). Two small incisions are needed, and we preferentially place those on your sides. At Swedish, our preferred approach is to clamp the nerve by placing titanium clips on the nerve at appropriate levels. The advantage of clipping the nerve instead of removing a segment of the nerve (as we did prior to 2005) is for possible reversal of the sympathectomy in the rare instance where a patient may be unhappy with the side effects of the surgery (see below).

What results should I expect?

In our hands, ETS will render the hands dry in 99 to100% of cases ...

Using robotic technology to improve outcomes in myasthenia gravis and thymoma

New technologies have the potential to improve patient outcomes but need to be carefully studied so that patients will maximally benefit.  Robotic thymectomy for myasthenia gravis and thymomas was introduced at Swedish in May of 2009 after careful evaluation of our outcomes with traditional sternotomy and VATS thymectomy.

One of the more challenging aspects of being a surgeon is to understand how new technologies can benefit your patients and how those technologies might become part of your practice. If you’ve watched Grey’s Anatomy, read Time magazine or the Wall Street Journal or surfed the web recently, you’ll be aware of the da Vinci surgical robot. The robot has allowed many different surgical specialties to operate in confined areas of the body with tiny instruments placed through equally small incisions thereby avoiding a larger incision. In thoracic surgery, one of the confined spaces is an area in front of the heart where a gland called the thymus resides.

Most people don’t even realize they have a thymus nor do they know it’s responsible for the development of immunity. However, for a small number of patients the thymus can be source of disease either by generating a tumor called a thymoma or by producing antibodies that block transmission of nerve impulses making the patient fatigue or weaken very quickly which is called myasthenia gravis (MG). Removing the thymus gland (thymectomy) is an important part of the treatment in both diseases.

Traditionally, thymectomy is accomplished ...

Lung Cancer Screening

We screen for breast cancer with mammography, colon cancer with colonoscopy, and prostate cancer with blood tests and exams – why not lung cancer?

If you’re a smoker or a former smoker, or even if you’ve had significant second-hand smoke exposure, you’ve probably worried about your chances of getting lung cancer, and whether there is anything you can do about it. Perhaps you even asked your doctor about getting an x-ray; he or she may have told you that there is no proof that it helps. That’s because a national study done years ago showed no benefit from getting chest X-rays, and therefore it’s not recommended.

The studies

However, since 2000, Swedish has participated in an international study – the International Early Lung Cancer Action Project (I-ELCAP) - to see whether CT scans or CAT scans – very highly detailed X-rays – might be able to find lung cancer earlier and improve cure rates. The study was begun by a group of investigators from Cornell University in New York. They knew that CT scans were very sensitive and would probably show a lot of abnormalities, and that most of them wouldn’t be cancer, so they worked out a system to determine which abnormalities were likely to be cancer. Their system worked, and they showed that when lung cancer was discovered through their screening system the cure rate was over 80%. That’s remarkable, because the normal cure rate for lung cancer is only 15%.

Because of their success, the National Cancer Institute (NCI) began a randomized study with over 50,000 participants. Half of them got annual CT scans and the other half got only chest X-rays. The results were just completed and were very exciting. The group that got CT scans had 20% fewer deaths from lung cancer than the other group!

The results are still being analyzed and there are concerns about safety from too many interventions, radiation exposure, and cost. It will take time to work through these issues, and there is still no general endorsement of lung cancer screening. However, several national organizations now cautiously support screening in high risk groups that meet the criteria for the national study.

Who should get screened, and how?

Lung Cancer staging

What stage is my cancer, doc?

This is often the first question we get asked when meeting with a patient newly diagnosed with lung cancer. In this blog, I would like to briefly review the notion of lung cancer staging and its implications.

Staging allows us to define the extent of a cancer and determine its best available treatment. It also allows us to statistically estimate the prognosis of the cancer. Finally, adequate staging allows us to group patients with cancers of similar extent across different institutions or even countries and evaluate the efficacy of the treatment strategies and compare with new ones.

Staging can be clinical or pathological. Clinical staging is based on the information we obtain from X-rays and scans as well as from procedures where samples (biopsies) of different tissues are obtained in an effort determine what structures may be involved with the cancer. Pathological staging is only available when the cancer has been removed by surgery: i.e. when the pathologist has measured the size of the tumor, its extent and whether or not any lymph nodes were involved with cancer. One should be aware that pathological and clinical stagings don’t always concord 100%. Sometimes clinical staging under-evaluates how extensive the cancer may be, and at times it over-evaluates it, particularly when clinical staging is based only on X-ray information. This is particularly true with the evaluation of lymph nodes that drain the area where the cancer has come from. The role of your lung cancer surgeon in adequately gathering that information to develop the best treatment plan cannot be emphasized enough.

The system we use to define a stage is called the TNM system.

Restoring Independence to Patients With Pleural Effusion

The first thing Mrs. G said when she came for the evaluation of her pleural effusion was “I have been active all my life”. However, the simple task of bending over to tie her shoes had become impossible because she could not breath. She described the build up of fluid as terrifying and robbing her of her independence.

The accumulation of pleural fluid or fluid around the lung is a common problem which can occur in a number of disease states. The most common symptom associated with pleural fluid is shortness of breath. It is our goal to rapidly manage and effectively control this problem and restore independence to every patient.

As the fluid built up around Mrs. G’s lung, she described a sensation of shortness of breath and a complete inability to take a deep breath. She said she could no longer exercise; walking was taxing and the shortness of breath made it impossible for her to lay flat at night; she was now sleeping upright in a recliner. In the office, under ultrasound guidance, she had her fluid drained – improving her breathing “almost immediately”. We then formulated a plan to restore her independence and give her control over the accumulation of the fluid.

What is a pleural effusion?

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