when to call a thoracic surgeon
TRANSCRIPT
When to call a
thoracic surgeon
Hussein Elkhayat,MD
Without a perfect
preoperative assessment
We are operating on the dark
Preoperative assessment
– History
– Imaging
– Lab.
– Interventional procedures
– Pulmonary function
– Treatment given
– Counselling
– metastatic workup
Assiut Cardiothoracic Surgery Dpt.
– Founded as a unit in 1987
– Started closed heart surgery before being a unit in 1980
– Started open heart surgery in 1987
– Expanded to be a department in 1999
– Specialized unit for pediatric cardiothoracic surgery founded in 2009 with one OR and 9 PICU beds
– Now dpt. includes 2 professors, 4 assistant professors , 7 lecturers, 9 assistant lecturers and 12
residents.
– Department is sharing in Assiut trauma unit.
1096bronchoscopy
&esophagescopy
from 2011-2015
Post chemoradiotherapy resection
PECTUS
VATS
Assiut university HEART
hospital 2016
– Soft opening in 26 Jan. 2016
– Total of 174 thoracic surgery cases (versus 211 cardiac cases)
– 82 by one thoracic surgery dedicated team so far ( total of 45 last year )
– 43 VATS (52.4% )
– 39 UNIPORTAL (TOTAL OF 57case since 2012) (thoracic duct ligation , achalasia , wedges, extraction of penetrating FB, clotted hemothorax, decortication for stage 3 empyema, sympathectomy and LEFT UPPER LOBECTOMY ,LEFT LOWER LOBECTOMY )
– 4 VATS lobectomy (7 in total from 2015) ( one bilobectomy for bronchactasis via 2 port , one uniportal pneumonectomy with expert , one uniportal LUL for aspergilloma and left lower lobectomy for sequestrated lobe).
– Two postoperative mortality in VATS cases (day 3 and 4 postop in IPF cases)
– 3 VATS cases need reoperation (2 for bleeding and open for esophageal perforation )
Do we really need VATS ?
The most dangerous phrase in the language is “ we’ve always done it this way “
Innovation There’s a way to do it better - Thomas Edison
Uniportal VATS
Video Assisted Thoracoscopic Surgery (VATS) Resection of Anterior Mediastinal MassCardiothoracic Surgery Department , faculty of Medicine , Assiut University
Removal of penetrating FB
Bullectomy
VATS LOBECTOMY
• 69 yrs old male pt• Cancer larynx from 8 yrs• Operated for total laryngectomy with permanent tracheostomy• Receive postoperative adjuvant chemotheryapy and radiotherapy • Esophageal stricture with frequent endoscopic dilatation • Accidentally discovered left upper lung zone opacity • CT scan left upper lobe mass with no detectable LNs.• Oncolgist consultation suggest it is a second primary NOT a mets
and recommend surgical treatment • PFT : !!!
Left VATS 2 ports access
VATS 2 ports LUL
Common conflicts
Between surgeons and phycisians
Chest tube; insertion
NEJM VIEDO !
Chest tube;indications
Chest tube;securing
Chest tube; common problems
– Malposition
– No drainage
– Bleeding
– Pain
– Perforation
– Massive air leak
– Surgical emphysema
Chest tube; care
– Dressing
– Pain management
– Chest x ray ?
– Follow up
– Removal
– Chest tube for how long ?
– CLAMPING
Empyema
– Definition ,stages ,clinical presentation
– Order of investigation ?
– Treatment options
Empyema; ttt options
– Chest tube
– Rib resection
– Early debridement
– Streptokinase
– Decortication
– VATS decortication
VATS decortication
Pneumothorax
BTS 2010 Accepted indications for surgical advice should be as follows:
– Second ipsilateral pneumothorax.
– First contralateral pneumothorax.
– Synchronous bilateral spontaneous pneumothorax.
– Persistent air leak (despite 5-7 days of chest tube drainage) or failure of lung re-expansion.
– Spontaneous haemothorax.
– Professions at risk (eg, pilots, divers).
– Pregnancy.
The future that we are looking
for
Thank you