Thoracic Surgery

Surgical Treatment Of Lung Cancer

Lung cancer is one of the most deadly cancers. Its most important cause is undoubtedly smoking.
EARLY DIAGNOSIS is very important. Quitting smoking as soon as possible and avoiding even being in environments where smoking occurs is EXTREMELY important!
Before treating LUNG CANCER, it is necessary to make a correct DIAGNOSIS and accurately determine the STAGE of the disease. Complaints should be inquired about in great detail and recorded.

 

Diagnostic Tests & Procedures

• Chest X-Ray
• CT (Lung Tomography)
• PET/CT (Positron Emission Tomography)
• Brain MRI
• If necessary, bone scintigraphy, etc.
• PFT (Pulmonary Function Test)
• Bronchoscopy, FNAB (Fine Needle Aspiration Biopsy), Mediastinoscopy, etc.

 

Stages Of The Disease

• Stage 1A, B – Early Stage
• Stage 2A, B – Tumor slightly larger (still operable)
• Stage 3A – Tumor larger + lymph nodes involved (chemotherapy and/or radiotherapy may be performed before surgery if necessary)
• Stage 3B – Tumor larger, lymph nodes and surrounding and/or adjacent organs involved (the role of surgery is evaluated only after chemoradiotherapy)
• Stage IV – Advanced stage tumor; distant organ involvement present (only chemoradiotherapy and/or immunotherapy)

 

Surgical Options For Lung Cancer

Depending on the location, size, and histopathological cell type of the lung cancer:

• Part of the lung
• Wedge resection
• Segmentectomy
• Lobectomy or removal of the entire lung
• Pneumonectomy

 

Duration Of Surgery:

• Generally, limited surgeries (wedge resection and segmentectomy) are shorter (2–3 hours)
• Major surgeries (lobectomy and pneumonectomy) are longer (4–5 hours). These durations vary from patient to patient!

 

Surgery Details:

Under general anesthesia, the patient is placed in a side position with the lung to be operated on facing upward. In endoscopic-closed surgery (minimally invasive VATS – video-assisted thoracic surgery), a surgical incision of approximately 4–5 cm is made; most surgeries are completed through this incision. This is called a “single incision” or “uniportal” VATS closed surgery.
During surgery, the vessels of the lung part to be removed are first cut with a stapler (special metal stapler), and finally, the bronchus of the lung part to be removed is also cut with a special metal stapler.
After this procedure, the cancerous tissue is removed, and the surgery is completed. Compared to the open surgery technique, post-surgical recovery is:

• Shorter
• Less painful
• More comfortable
• The patient begins walking the same or the next day
• Starts consuming fluids and soft foods
• Discharged within one week

 

Postoperative:

• The most important point after surgery is pain in the surgical area. Pain can be easily controlled with effective painkillers.
• For 1 week or 10 days after surgery, both painkillers and antibiotics are recommended.
• Most patients can return to their daily routines within 2 weeks.
• It is important to perform regular daily walks of 30–45 minutes at a moderate pace after surgery.
• The pathology result is usually available in about 1 week. This pathology report must be reviewed and evaluated by both a Medical Oncologist and a Radiation Oncologist from the Oncology Department.

 

Thoracic Surgery

Surgical Treatment of Lung Cancer

Lung cancer is one of the deadliest cancers. Its most important cause is undoubtedly smoking.
EARLY DIAGNOSIS is very important. It is VERY, VERY important to quit smoking as soon as possible and to avoid even entering environments where smoking occurs!
Before the treatment of LUNG CANCER, its DIAGNOSIS must be made correctly, and the STAGE of the disease must be determined accurately. Complaints must be questioned in detail and recorded.

 

Diagnostic Tests & Procedures

• Chest X-Ray
• CT (Lung Computed Tomography)
• PET/CT (Positron Emission Tomography)
• Brain MRI
• Bone scintigraphy, if necessary
• PFT (Pulmonary Function Test)
• Bronchoscopy, FNAB (fine needle aspiration biopsy), Mediastinoscopy, etc.

 

Stages Of The Disease

• Stage 1A, B – Early Stage
• Stage 2A, B – Tumor slightly larger (still operable)
• Stage 3A – Tumor larger + lymph node involvement (Chemotherapy and/or Radiotherapy may be applied before surgery if necessary)
• Stage 3B – Tumor larger, lymph nodes and surrounding and/or adjacent organs involved (Surgery is considered only after ChemoRadiotherapy)
• Stage IV – Advanced stage tumor; distant organ involvement present (only ChemoRadiotherapy and/or Immunotherapy)

 

Surgical Options For Lung Cancer

Depending on the location of the lung cancer, its size, and histopathological cell type:

• Part of the lung
• Wedge resection
• Segmentectomy
• Lobectomy or removal of the entire lung
• Pneumonectomy

 

Surgery Duration:

• Limited surgeries (wedge resection and segmentectomy) are generally shorter (2–3 hours)
• Major surgeries (lobectomy and pneumonectomy) are longer (4–5 hours) These durations may vary from patient to patient!

 

Surgery Details:

Under general anesthesia, the patient is placed in a lateral position with the lung to be operated on positioned uppermost. In endoscopic-closed surgery (minimally invasive VATS – video-assisted thoracic surgery), an approximately 4–5 cm surgical incision is made, and most of the surgeries are completed through this incision. This is called “single incision” or “uniportal” VATS closed surgery.
In the surgery, the vessels of the lung section to be removed are first cut with a stapler (special metal staples), and finally, the bronchus of the lung section to be removed is cut with a special metal stapler as well.
After this procedure, the cancerous tissue is removed, and the surgery is completed. Compared to open surgery, the postoperative period is:

• Shorter,
• Less painful, and
• More comfortable.
• The patient starts walking the same or the next day,
• Begins consuming liquids and soft foods,
• Is discharged within one week.

 

Postoperative:

• The most important point to consider after surgery is pain in the surgical area. Pain can be easily controlled with effective painkillers.
• Painkillers and antibiotics are recommended for 1 week or 10 days after surgery.
• Most patients can return to their routine life within 2 weeks.
• Regular daily walks of 30–45 minutes at a moderate pace are important after surgery.
• Pathology results are available in about 1 week. This pathology report must be reviewed and evaluated by both a Medical Oncologist and a Radiation Oncologist in the Oncology Department.

Pigeon Chest (Pectus Carinatum) – What Is It?

These deformities can be seen in mixed type (%6.8) in the same patient; pectus excavatum (funnel chest) and pectus carinatum (pigeon chest) may occur together. It may be caused by the depression of the costal cartilages (the rib consists of a bony rib and a cartilaginous rib) on one side, protrusion on the other, and rotation of the sternum. The most common clinical appearance of this deformity is protrusion of the sternum itself and symmetrical protrusion of the lower costal cartilages. Rarely, deformity may be seen only in the upper part (chondromanubrium). Here, the upper costal cartilages are affected, and the sternum itself is relatively depressed.

 

The cause of pectus carinatum is unknown. Although the exact cause has not been identified, the presence of a family history and associated diseases suggests “a connective tissue development abnormality.” Other theories suggest abnormal diaphragm development and hypertrophy (enlargement) of the costal cartilages.

 

The general prevalence of pectus carinatum is 0.06% (seen in only 6 out of 10,000 people). It is less common than pectus excavatum. It is three times more common in males than females.

 

Pectus carinatum usually appears during childhood and adolescence (ages 11–15), unlike pectus excavatum. It is very rarely detected at birth. Almost half of the patients notice the disease during the growth spurt of puberty.

 

Pectus Carinatum May Cause the Following Complaints:

There is usually no direct heart-lung disorder associated with pectus carinatum. Some scientific publications have reported that lung complaints are more common in pectus carinatum than in pectus excavatum. Shortness of breath, rapid breathing, emphysema (lung tissue damage) due to reduced lung capacity over time, and infection (such as pneumonia) may develop.

Some publications have reported congenital heart disease at a rate of 20% in children with pectus carinatum with early sternal closure.
As a result, although pectus carinatum does not cause complaints in most cases, it may cause heart rhythm problems and decreased contraction of the heart muscle. In the long term, it may prevent the lungs from expanding adequately (due to rigidity of the chest wall), leading to reduced breathing capacity, shortness of breath, rapid breathing, and lung inflammation.

 

The only criterion to consider for the repair of pectus carinatum is the severity of the deformity. Patients may complain of tenderness in the protruding area due to frequent impacts. Reduced physical capacity (exercise capacity) may also be observed.

 

Pectus Carinatum May Occur With Certain Diseases:

25% of patients with pectus carinatum have a family history of chest wall deformity. 20% of patients have accompanying scoliosis (lateral curvature of the spine). 12% have a family history of scoliosis.
In patients with accompanying scoliosis or severe deformity, Marfan Syndrome (a connective tissue disease) should be suspected. Rarely, pectus carinatum may be accompanied by Morquio Syndrome (mucopolysaccharidosis IV; a polysaccharide storage disease), hyperlordosis (excessive inward curvature in the lumbar spine), and kyphosis (hunchback).

 

Treatment Methods

Surgical Treatment:

• Endoscopic (closed surgery) removal of costal cartilages and simultaneous incision to the sternum.
• Open surgery: Many techniques have been described by Fonkalsrud (2008), Matos (1997), and Shamberger (1987).
• Minimally Invasive Surgery – ABRAMSON PROCEDURE; A pectus bar is endoscopically passed in front of the sternum and under the muscles, and the protruding anterior chest wall is pressed backward to restore the chest wall to a normal position, fixing the pectus bar in place.

 

Abramson Surgery for Pigeon Chest Treatment

Argentine thoracic surgeon Dr. Horacio Abramson modified the Nuss technique (used for pectus excavatum correction) for pectus carinatum patients and announced his successful results to the world for the first time in 2005. After five years of follow-up, he reported the results of 40 patients: among 20 patients whose pectus bar was removed after 2 years, 10 had excellent results, 4 good, 4 moderate, and only 2 poor. The success rate of the Abramson technique is therefore quite high; in 18 of 20 patients, results were highly satisfactory.

 

Preoperative Procedures for Abramson Surgery

• The patient first undergoes a physical examination.
• After the patient and their relative are informed about pectus and its treatment, and after they are given time to think and decide, and their informed consent for the surgery is obtained, other examinations are initiated.
• Routine blood tests (complete blood count, blood type, bleeding time, pulmonary function test if necessary, etc.) and anesthesia consultation are requested to determine suitability for general anesthesia.
• Cardiology consultation is essential to check for any heart problems; ECG and echocardiography are performed if necessary to detect any potential problems, and if required, treatment of the heart problem is completed before planning pectus treatment.
• For patients with internal diseases (diabetes, high blood pressure, etc.), relevant specialist consultations are requested.
• Detailed discussions are held with the patient and their relative about the disease, possible treatment options, and their success rates.
• Necessary chest X-rays (posteroanterior and computed tomography) are obtained.
• The surgery date is determined.
• The patient’s questions regarding the disease and the surgery are answered before the operation.
•  

The success rates of the open surgical technique (classic open surgery) and the endoscopic minimally invasive (closed surgery) Abramson technique are similar. However, the Abramson method has begun to be preferred because it can be performed in a shorter time, the rate of complications during and after surgery is much lower, hospital stay is shorter (early discharge), and the patient can return to normal social life in a shorter period (2 weeks).

 

The ideal age for corrective surgery for pectus carinatum is between 7–14 years. Performing the surgery within this age range is preferred because the chest wall is softer, making the intervention easier, and it allows the anterior chest wall to develop in a normal anatomical position after surgery. However, it can also be performed successfully in adults with similar success rates.

 

Abramson Surgery

Abramson surgery is performed under general anesthesia and lasts about 60 minutes. A 2 cm skin-subcutaneous incision is made on the right side of the anterior chest wall (at the mid-axillary line) to access the chest wall.

 

A PVC (polyvinyl chloride) tube is passed with the help of a trocar (guide rod) in front of the sternum (at the most protruding level of the sternum) and under the pectoral muscles, creating a tunnel towards the opposite side.

 

On the opposite side, another 2 cm skin-subcutaneous incision is made at the same level (mid-axillary line) to complete the tunnel’s exit.

A Lorenz pectus bar, a colorless steel bar, is used to press the chest protrusion backward.

 

The Lorenz bar (pectus bar) is selected according to the patient’s anterior chest wall measurements and shape, and the necessary curvature is given to both ends of the bar before starting the procedure. One end of the bar is inserted into the PVC tube, and it is slowly pulled from the opposite side so that the pectus bar enters the tunnel.

 

When the bar reaches the opposite end of the tunnel, the PVC tube is removed over the bar. Before or after placing the bar into the tunnel, stabilizers (butterfly or stabilizer plates) are sutured tightly to the ribs with steel wire sutures.

 

Once the sternum is confirmed to be in the desired position, the skin-subcutaneous incisions are closed with appropriate sutures in anatomical position, and the procedure is completed. Detailed information about the ABRAMSON TECHNIQUE can be found in scientific publications.

 

Removal of Bars

Depending on the patient’s age and the condition of the chest wall (based on follow-up observations and development), pectus bars are removed under short general anesthesia (about 30 minutes) within 2–4 years.

 

Risks of Abramson Surgery

Overall, the risks of the surgery are very low: pneumothorax (only 1 in 40 patients – air between the lung and the chest wall), wound infection (only 1 in 40 patients), fluid accumulation at the wound site (in 6 out of 40 patients), and wire suture breakage (in 3 out of 40 patients). Wound site infection occurs in less than 0.7% of patients.

Excessive Sweating & Reactive Sweating Treatment (ETS)

How is ETS Treatment Performed in Excessive Sweating?

Excessive sweating surgeries are performed using two techniques: “classic” and “endoscopic.” Classic sweating surgery is the traditional open surgery performed by making long incisions in the skin. Endoscopic ETS surgery, which has become widespread recently, is known among the public as closed surgery. Both surgeries have the same therapeutic effect on the disease. Clipped ETS surgery can be performed comfortably in any season (if the patient is fit for surgery).

 

Clipped ETS surgery provides a solution for excessive sweating and/or blushing on the face, excessive sweating in the hands, underarms, and feet. The surgery stops sweating in the sweat glands of the area where the sympathetic chain sends its nerves (for example: T2 sympathetic chain to the face; T2–T3 sympathetic chains to the hands; T3–T4 sympathetic chains to the underarm area, etc.). ETS is not used for general body sweating.

 

The name “clipped ETS surgery” comes from its technique and the anatomical region where it is applied. The term “Thoracic” refers to the anatomical region encompassing the chest or thoracic cavity and all organs and tissues inside it. The term “Endoscopic” comes from the endoscope, a lighted camera instrument used during the surgery.

 

In this technique, two 1 cm skin incisions are made in the underarm area, and the endoscope is used to enter the chest cavity to reach the area where the sympathetic chains are located. The surgeon performs the surgery by viewing images projected onto a television screen. Unlike classic surgeries, no long skin incision is made; incisions of 1–1.5 cm are sufficient.

 

Normal vs. Clipped ETS Surgery Difference:

ETS surgery can be performed by either clipping the nerve or cutting it. In the clipped method, especially in patients whose compensatory sweating becomes unbearable and disturbing after surgery (5–8% of patients), there is a 10–20% chance of reversal. After explaining this detail to the patient, the choice between surgery with a clip or complete removal of the nerve ganglion is left to the patient. Success rates are similar in both methods.

 

Effect of ETS Surgery:

The effect of the surgery begins immediately (within the first 10 minutes) when the nerve is cut or clipped during the operation. It is noticed during surgery that the hands become dry, and as the sympathetic pressure is relieved, the blood vessels in the hands dilate, oxygenation increases, and they warm up. The patient wakes up free from the excessive sweating problem.

Nuss Surgery: Pectus Excavatum (Funnel Chest) Surgery

 

Nuss Surgery was first described by Donald Nuss in 1987. It is a minimally invasive method for correcting pectus excavatum; it is a surgical technique that requires fewer incisions, less intervention, shorter procedure time, faster postoperative recovery, and has highly satisfactory long-term results. Its use has become widespread today.

 

The method lifts the sternum forward by supporting it from behind with a bar (steel rod) without cutting or dividing the ribs and cartilages. The Nuss Procedure, or Nuss Surgery, has been developed over the years and is now widely used.

 

The most appropriate and ideal age range for correction of pectus excavatum is between 7–14 years. If possible, it should be done before puberty so that the rib cage can more easily take its normal shape at the end of this rapid growth period. However, with the Nuss technique, very good results are now obtained even in patients in their 30s and 40s.

 

Preoperative Procedures:

• The patient first undergoes a physical examination.
• The patient and their relative are informed by the doctor about pectus excavatum and its treatment so they can make the best treatment decision, and their questions are answered.
• To determine the severity of the chest deformity, two-way chest X-ray (posteroanterior and lateral) and chest computed tomography images are taken [Haller Index – severity of pectus: if the ratio of the transverse (horizontal) diameter of the rib cage to the anteroposterior diameter is more than 2.5, this is considered significant, and if it is more than 3.2, the patient is usually a surgical candidate].
• Routine blood tests and pulmonary function tests are performed if necessary, and anesthesia consultation is requested to determine suitability for general anesthesia.
• Cardiology consultation is requested (to check for any heart problem; if necessary, ECG and echocardiography are performed to identify possible problems, and if needed, treatment is completed before planning pectus treatment).
• For patients with internal diseases (diabetes, high blood pressure, etc.), relevant specialist consultations are requested.

 

Postoperative:

The first 3 days after surgery are painful. Therefore, as explained before the operation, pain is controlled in a controlled manner using epidural anesthesia (epidural catheter placement). After 3 days, pain control is continued with oral medications or intravenous injections if needed. Most patients can control their pain at home with oral painkillers after discharge.

 

The hospital stay is usually 3–5 days. Dressings are sufficient for the first 3 days. After that, the incision sites can remain open without requiring further care. In rare cases, the ends of the pectus bar may be felt under the skin. Light massage to these areas can prevent the bar from adhering to the skin. Most of the time, the pectus bar completes its task without any problems.

 

Light sports activities are recommended only after 3 months post-surgery. After 6 months, regular sports activities (swimming, tennis, running, etc.) can be performed. However, during this period, contact sports, wrestling, karate, boxing, and weightlifting are strictly prohibited. It is preferable to engage in more individual sports activities for life instead of contact sports.

 

Within The First 1 Month After Surgery, The Patient Should Not:

• Bend from the waist (should bend from the hip joint).
• Twist from the waist.
• Roll to either side.
• Run or perform aerobic activities.
• Perform any strenuous activities.

 

Within The First 3 Months After Surgery, The Patient Should Not:

• Lift heavy objects (including school books and backpacks).
• Perform aerobic activities.