Thoracic Surgery

Lung Cancers

Once lung cancer has been diagnosed and staged, treatment is carried out primarily with minimally invasive (VATS- video-assisted thoracic surgery) or conventional open surgical techniques.

Because lung cancer rarely causes symptoms before spreading to nearby areas, only about 15–20% of patients can be diagnosed at an early stage. For all types of cancer and disease, especially lung cancer, the chance of early diagnosis is very high when every healthy person has a check-up at least once a year. Smokers in particular should have a chest X-ray at least once or twice a year from the age of 40.

For people who smoke and have a family history of cancer, follow-up with low-dose lung CT after the age of 45 greatly increases the chance of early diagnosis and treatment.

The primary treatment for lung cancer detected at an early stage (the first 3 stages) is “surgery”. In stage 3A, performing surgery after neoadjuvant therapy (oncological treatment before surgery) offers a greater survival advantage. For this reason, it is very important that these patients are followed up and their treatment is managed in a “multidisciplinary” way (in cooperation with all relevant specialties).

Surgical treatment is followed by “pathological staging”, and depending on its result, oncological treatment and follow-up (chemotherapy, radiotherapy, immunotherapy, targeted therapy, etc.) may not be needed. In the “advanced” stages of the disease, however, postoperative chemotherapy, radiotherapy and/or immunotherapy and close follow-up are always required.

VATS (Video-Assisted Thoracic Surgery)

This is a “closed” operation performed under general anesthesia, in which endoscopic instruments are introduced into the chest cavity with the help of a video camera through one or, if needed, 2–3 incisions of a few centimeters in the chest wall, and the existing pathology is resected (by segmentectomy if it is confined to one segment, by lobectomy if it is confined to one lobe, or by pneumonectomy if it involves the whole lung).

This method is used for:

• Lung cancer surgery,

• Mediastinal tumors,

• Thymus cancers,

• Treatment of excessive sweating,

• Lung biopsies,

• Nodular lesions of the lung,

• Treatment of pneumothorax,

• Cystic and bullous lung diseases,

• Metastatic lung tumors / cancers,

• Selected (early-stage) lung cancers in patients with limited cardiac reserve.

• If previous lung diseases (or operations) have not caused severe adhesions, this operation can be performed by experienced surgeons.

Chest Wall Cancers

For mass lesions that may develop in the chest wall, a cellular diagnosis should be made first, and a tumor board should decide which further treatment method (surgery, chemotherapy, radiotherapy, immunotherapy, etc.) will be used. The approach should be multidisciplinary.

Patients who are to undergo surgery need detailed preoperative preparation. Pulmonary function tests must be repeated. As a surgical principle, at least 4 cm of healthy tissue should be removed around the chest wall mass (if it is malignant), and the remaining defect should then be closed very well using appropriate surgical materials and techniques.

Surgery for Esophageal Diseases (Benign & Malignant)

In thoracic surgery, detailed CT imaging, PET-CT and esophagoscopy are primarily used to diagnose diseases of the esophagus. Esophagoscopy examines problems related to diseases of this organ with an optical device, determines the size and width of the esophagus, and is used to take biopsies from suspicious lesions.

If a mass is detected, it must be evaluated and diagnosed in coordination with a multidisciplinary team (gastroenterologist, general surgeon, oncologist, radiologist, nuclear medicine specialist), and if surgery is needed, it must always be planned together with General Surgery.

Chest Wall Deformity Repair (Nuss & Abramson & Ravitch & Robicsek Techniques)

• Pectus Excavatum (Funnel Chest / 80%)

• Pectus Carinatum (Pigeon Chest / 15%)

• Pectus Arcuatum (<1%)

• Poland Syndrome

• Pentalogy of Cantrell

In the treatment of congenital or acquired chest wall deformities, the Nuss technique corrects pectus excavatum (funnel chest) by placing 1 or 2 metal bars behind the breastbone using the closed VATS method. The Nuss technique, an effective treatment for a sunken chest wall, allows treatment through small incisions in a short time of about 30–45 minutes. Recently, treatment with 3D implants custom-made for each patient, which offer better aesthetic results, has come into widespread use.

The Abramson method corrects pectus carinatum (pigeon chest) with a closed technique by placing 1 or 2 bars over the breastbone, under the skin.

Other conditions are generally corrected with open surgery.

Depending on the preferences of the patient and the surgeon, pectus excavatum & carinatum are still also treated using “open correction techniques” (Ravitch and Robicsek techniques). The success and complication rates of closed and open surgical techniques are very similar. However, closed operations take less time than open techniques, cause less pain and can achieve more aesthetically successful results.

Excessive Sweating (Hyperhidrosis) and Facial Blushing – ETS (Endoscopic Thoracic Sympathectomy)

Sweating is a physiological process, and in 1% of healthy people it reaches a disturbing level. Sweating in our body is regulated by sympathetic nerves controlled by the autonomic nervous system (to adjust body temperature to the ambient temperature). The most important causes of sweating (apart from internal diseases) are excitement and stress; smoking and alcohol use also increase sweating. Excessive sweating can be generalized or localized. Generalized sweating is usually caused by heat, stress and systemic diseases, whereas in localized sweating the most commonly affected areas are the face, hands, armpits and feet. This is due to increased sympathetic activity. Localized sweating threatens a person’s social life and, over time, their psychological well-being; the most common complaints of these people are being unable to make eye contact, to appear in public, to play a musical instrument, to write or to hold papers, and the accompanying bad odor in underarm/foot sweating. Today, 4 methods are used to treat sweating:

• Medical treatment (creams, lotions, etc.)

• Iontophoresis (15 mV electric current)

• Botox,

• ETS (Closed Thoracic Sympathectomy)

Iontophoresis (for hand and foot sweating; sometimes needs to be applied several times a week) and Botox are easily applied methods for palmar (palm)/axillary (underarm) hyperhidrosis; since their effects are temporary, they must be repeated every 4–6 months at the latest. ETS surgery is a procedure performed under general anesthesia with the help of a video camera through one or two 1.5 cm line-shaped incisions made in the chest wall along the underarm line, aimed at blocking the effect of the sympathetic nervous system (by applying clips).

Depending on the area of complaint, the sympathetic chain needs to be blocked by placing “clips” at the T2 level and below, which provides a permanent effect. The operation takes half an hour; because it is performed endoscopically with a video camera, no chest drain is required after surgery and the patient is discharged after one night in hospital. Both sides are usually treated in the same session. After this operation, dryness and warmth in the hands appear within the first 10 minutes, but there is absolutely no motor or sensory loss.

There is only one reason why the operation cannot be performed endoscopically: adhesion of the lung to the chest wall (as a result of previous operations or diseases such as infections with fluid in the lung), in which case the procedure is completed through a 6–8 cm incision in the armpit. Since the scars of both endoscopic and open sympathectomy are in the armpit, they do not cause a cosmetic problem. After surgery, compensatory sweating of mild to moderate degree is seen in 60–80% of cases. However, in a group of 3–5%, compensatory sweating may require medical treatment and/or nerve reconstruction surgery. Iontophoresis and Botox can be used for foot sweating; however, it has been observed to decrease in 50% of patients after ETS surgery.

ETS sympathectomy with clips is also used successfully in patients with facial blushing. Although its success rate is lower than for hyperhidrosis, it provides satisfaction in 65–70% of patients. The side effects are the same as those of ETS surgery for excessive sweating.

The important thing is that patients first try non-surgical treatments and, if they are not satisfied, apply for ETS sympathectomy with clips; this is the more appropriate approach.

Chest Trauma

Chest trauma is the disruption of the anatomical and functional integrity of the structures forming the rib cage as a result of direct or indirect force. It accounts for 25–30% of trauma-related deaths. Patients are usually men aged 25–50. Common causes include falls from height, traffic accidents, gunshot wounds, stab/cut injuries and crush injuries (compression of the rib cage). The most common type of trauma we see is blunt chest trauma, caused by falls, crush injuries and traffic accidents. The patient’s complaints are flank pain on the affected side, shortness of breath, subcutaneous emphysema and severe local pain (if there is a rib fracture). Rib fractures are present in 35–40% of blunt traumas, affecting ribs 4–9. A fracture of the 1st rib indicates an accompanying serious injury. Breastbone (sternum) fracture is seen in 4% of trauma patients and flail chest in 5–15%.
Thoracotomy is required in 5–15% of patients with chest trauma; in gunshot wounds, the trajectory of the bullet, the barrel length and the firing distance determine the extent of the damage. It should not be forgotten that people involved in traffic accidents may have injuries to more than one system, and that in combined chest + abdominal injuries, laparotomy takes priority if hemodynamics are unstable. In stab/cut injuries, internal organ damage must be examined carefully.

Thoracic Outlet Syndrome (TOS)

This condition, seen more often in women, causes pain, numbness or quick fatigue in both upper extremities (arms); the underlying pathology is compression of the vessels (brachial artery and vein) and ulnar nerves going to the arms at the upper opening of the rib cage. Patients often go back and forth between neurology, orthopedics and physical therapy, and are unhappy people who have not found a definitive solution to their complaints. Their complaints are neurovascular findings caused by compression of the vessels and nerves between the clavicle, the 1st rib and the scalene muscles (most often due to a cervical rib), and appear as quick fatigue, pain and numbness, tingling and even coldness in the arms while hanging laundry/writing or carrying heavy bags/objects.
Although the most important elements in diagnosis are a good physical examination and medical history, radiology and bilateral UNCV (ulnar nerve conduction velocity) (EMG) help guide treatment. In addition, patients must have Doppler ultrasound (both arterial and venous) of both arms (upper extremities) to determine whether there is a vascular pathology. Treatment is primarily medical and directed at the symptoms, but surgical treatment should be considered for those who do not benefit. Once the cause has been clearly identified, surgical treatment consists of scalene myotomy, cervical rib/1st rib resection, etc. Relieving the compressed area largely eliminates the patient’s complaints. The patient’s follow-up by their doctor should be continued.