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Ask the Thoracic Surgeon (Dr. Murthy 11/8/11)

Sudish Murthy, MD
Staff Thoracic Surgeon, Department of Cardiothoracic Surgery Miller Family Heart & Vascular Institute

Thursday, November 8, 2012 - Noon

Description

As one of the largest, most experienced cardiac and thoracic surgery groups in the world, our surgeons offer virtually every type of thoracic surgery. We specialize in very complex cases as well as groundbreaking surgeries procedures, such as minimally invasive thoracic surgery. Dr. Murthy answers your questions on a variety of thoracic surgery topics.

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Hyperhydrosis

MickyT: I have been thinking of having treatment for my hyperhydrosis. Wondering what the success rate and how you make a decision to have surgery - vs. trying botox.

Dr__Murthy: Hyperhidrosis is generally categorized as one of 2 conditions: 1) a localized (focal) version or 2) a systemic disease.

  • Systemic hyperhidrosis is generally encountered in a variety of endocrine conditions as well as gross abnormalities in the autonomic nervous system.
  • Focal hyperhidrosis is generally encountered in younger people and manifest as severe and profuse sweating of the palms, armpits, and balls of the feet. Treatment for hyperhidrosis is based on the type of hyperhidrosis.

Focal hyperhidrosis (Palms etc.) is initially treated with topical drying agents as well as prescriptions such as anti-depressive medications, anti-anxiety medications and other systemic medications. Iontophoresis is used if these measures fail. Iontophoresis is a special bath for your hands that consists of an electrical field.

For patients with severe hyperhidrosis with significant social and physical debilitations, more definitive therapy is usually indicated. The 2 major therapies currently being employed are Botox injections or surgical interruption of the thoracic sympathetic chain using video-assisted thoracic surgical techniques. The major problem of Botox is that it usually has to be repeated several times.

Outcomes following surgical sympathectomy demonstrate that greater than 90% of patients will be satisfied. Risks of surgical intervention include compensatory sweating and some pain syndrome. Compensatory sweating occurs in a high percent of patients, but in the majority of patients resolves within a few months. There are a few operations that are performed by me that are better tolerated and have better outcomes than sympathectomy for focal hyperhidrosis.


Pulmonary Nodules

Katrina297: my husband has pulmonary nodules and may need to have part of his lung taken out. He has a history of rheumatoid arthritis. Have you seen this before? Can you do this surgery through the thoracoscopic surgery or is it a large incision?

Dr__Murthy: Rheumatoid arthritis is a systemic disease that not only affects the joints, but also a variety of other systems. In the lungs, rheumatoid arthritis can present as scattered nodules. Operative intervention for nodules usually occurs in the setting of some diagnostic dilemma. Most commonly this involves determining whether a nodule is of rheumatoid etiology or lung cancer.

Depending on the location of the nodules, a wedge resection (relatively small operation) can be performed. There is no reason or indication to take out nodules if they have been documented to be rheumatoid in origin unless the nodule presentation has been complicated by bleeding or rupture of the nodule.

Consequently, I suspect that the nodules in question in her husband are not properly diagnosed at this point and an operation has been suggested in order to determine the true nature of nodules.

PeterKL: Last year I had pulmonary nodules removed from my lung. Since that time I have not felt well, tired, no energy but the nodules were biopsied and seemed ok. I had a xray a couple weeks ago and apparently I have them again. I am very worried. My doctor said I may need surgery again. I am not sure what is going on. I think I need another opinion but if you have any ideas...

Dr__Murthy: To provide you an answer, it would be nice to know the working diagnosis that your primary care team had. Pulmonary nodules are often nonspecific and reflect a variety of different diseases. Most nodules when removed will lend significant information as to the systemic disease that was responsible for them.

I would be curious to review the pathology reports of your resected nodules especially in light of them having returned. A variety of disease processes jump to mind. These include systemic inflammatory diseases, sarcoidosis, or infectious diseases. Most nodules that are removed at this Institute are sent not simply to the pathology team but also to the infection team on the odd chance that there has been significant fungal or other bacterial exposure.

For your case, of recurrent nodules, I would be sure that your treating team has a clear list of diagnoses that they are considering so that the removal of any nodule could be looked at specifically to fit one of these diseases. The infection disease team is usually engaged in cases like this, as are members of the pulmonary medicine team and the surgical team. Hopefully you have access to a group (multidisciplinary) of physicians who can collaborate and achieve a diagnosis and hopefully a treatment plan. If not, we are happy to arrange such a consultation at this institute.


Achalasia

JohnMac: Who do you see to diagnose and then treat achalasia, thoracic surgeons or gastroenterologists?

Dr__Murthy: Achalasia is a primary motor disorder of the esophagus. It manifests as loss of proper neurologic input into the esophagus specifically affecting the muscle at the base of the esophagus and causing this muscular structure (lower esophageal sphincter) to improperly relax. This results in the gradual dilatation (expansion) and progressive dysfunction of the esophagus and the symptom of dysphasia (difficulty swallowing).

There are several treatments for achalasia. Some are performed by surgeons and some by gastroenterologists.

The most reliable treatment is a surgical intervention called a Heller myotomy. This can be performed by open incision by a video laparoscope and my personal preference, robotically. The durability of this procedure is well-established though it is not cure the disease. It will allow the esophagus to empty into the stomach and relieve dysphasia. The durability of the procedure seems to extend to greater than 5 years though some patients will ultimately require removal of their entire esophagus depending upon how advanced and how diseased the esophagus was at time of myotomy.

Gastroenterologists perform a procedure called a pneumatic dilatation using endoscopes. The durability of this procedure seems to be less than Heller myotomy though is a reasonable procedure done through the endoscope. The major risk of this procedure, however, is uncontrolled rupture of the esophagus. This then leads to emergency open repair and myotomy and occurs in approximately 3% of patients. Heller myotomy can be performed after a failed pneumatic dilatation though the durability of myotomy in this setting seems less.

CarlafromPA: My mom has achalasia. She had a balloon procedure and it did not help. What's her other options?

Dr__Murthy: Please read the answer to the question above. As described, the balloon dilatation performed for achalasia is less durable and comes with some risk despite being performed through an endoscope.

Dr__Murthy: Heller myotomy would be indicated for failure of the balloon procedure. Her myotomy is slightly less effective in this setting because of the prior damage created by the balloon. But if your mother truly has type II achalasia and has failed balloon dilatation, and is otherwise in reasonably good physical health, Heller myotomy performed as described above might be reasonable.

S5543Cali: My husband has achalasia. He has had 2 surgeries - last one being a stent that failed. I have heard from chat rooms that you have experience at Cleveland Clinic with difficult to treat achalasia. Can you tell me if there would be other treatments for my husband?

Dr__Murthy: Achalasia is one of specialty diseases treated by the Swallowing Center at Cleveland Clinic. This case sounds quite complex and in situations like this, the diagnosis of achalasia needs to be confirmed. For this to have failed 2 operations and have required a stent is quite curious and does mandate a thorough investigation. It is possible that your husband has a variant of achalasia (type 1) that would likely not respond to Heller Myotomy or some other cause of swallow dis-coordination. We would be happy to evaluate your husband's case through our Swallowing Center and help sort out his swallowing difficulties.


Thoracic Outlet Syndrome

mikey12: I had an accident a few months ago and since have sharp pains in my collarbone and numbness down my arm. My doctor said that the fracture and healing of the collarbone may be pushing down and compressing the nerves in that arm. Is that thoracic outlet syndrome? Would surgery help?

Dr__Murthy: Thoracic outlet syndrome is compression of the vascular structures between the first rib and muscular attachments that extend up into the neck. It is a very nebulous (commonly made but seldom proven) diagnosis and results in a significant number of referrals with very few people actually having the condition.

The most common effectively treated form of TOS is compression of the subclavian vein and spontaneous thrombosis (clotting) of the vein. This syndrome is called “effort thrombosis” and the disease is often referred to as Paget-Schroeder's disease. This form of vascular thoracic outlet syndrome is very well treated by removal of part of the first rib and severing the muscular connections of that portion of the first rib to the neck. My suspicion in your case is that you may very well have a chronic pain syndrome that resulted from the fracture of your clavicle.

X-rays and CT scans along with MRI should be able to assist your clinical team in determining whether your fracture is displaced downward towards your brachial plexus. If so, it might be possible for you to have developed arm numbness from compression on the brachial plexus by a displaced collar bone fracture.


Chest Deformities

Cleveland_Clinic_Host: Dr. Murthy, can you talk about patients with severe chest deformations?

Dr__Murthy: Severe chest deformities generally come in two flavors. One is cosmetic and one is that some chest deformities can cause severe heart and lung dysfunction.

Most of the severe deformities come under pectus excavatum category. This is also known as sunken chest. To some degree there is a normal variation among the human population as to how concave (sunken) one's chest is. There are also some patients who present with significant pigeon chests - this defect is called pectus carinatum.

For patients with sunken chests - depending on how depressed the breast bone is - the structures underneath it (heart) can be compressed and mildly dysfunctional especially as patients age and their heart enlarges, which is fairly typical for the average person's heart. Consequently, we have encountered patients with a lifetime of a chest deformity that only in later adult years (age 25 - 40) has actually become symptomatic and caused shortness of breath and heart palpitations. The vast majority of these defects remain asymptomatic and do not require repair for structural reasons.

When diagnosed in the pediatric population there is a minimally invasive procedure called the Nuss procedure which has been proven effective to correct this sunken chest defect. In adults this minimally invasive procedure seems to not work as well because the structures of the chest have become more rigid and a more conventional approach is utilized.

For adult patients with severe pectus excavatum, and heart and lung compromise, open repair can often restore patients to a quality of life that they cannot remember having. In our practice, we have seen patients that preoperatively have been short of breath climbing stairs and 2 years post op have run marathons. We screen our patients very carefully and offer this complex repair only when a documented compromise of heart or lung function can be made.


Thoracic Surgery: Thoracotomy

Cynthia1282: My husband is going in for a thoracotomy next week. What will the recovery be like for him?

Dr__Murthy: It would be nice to know what the indication for the thoracotomy is. Most thoracotomies are performed for lung cancers although others are performed for other conditions or cancers that have come to the chest from other sources (colon; extremities; kidney; etc).

For lung cancer many operations are done with video cameras or robotically at larger centers. Thoracotomy is reserved for larger operations and for other unusual circumstances where lesser operations are inadequate. For a patient with normal lung function who undergoes a thoracotomy the amount of lung that is removed, if in fact the thoracotomy was performed for a lung process, often dictates recovery time.

Pain is a large contributing factor to a slowed recovery and you should not be surprised if narcotics are used for 8 - 12 weeks after a thoracotomy. In my practice, when thoracotomy is needed I inform my patients for each day in hospital the expected out of hospital recovery is 10 - 12 days. So, for a standard lung cancer case in a patient with reasonable underlying lung function, the expected hospital stay would be between 4 - 5 days at this Institute. Consequently, the expected duration of out of hospital recovery would be between 40 - 60 days.

Age does factor in to this computation as does overall vigor and vitality of the patient. If there is one thing that the patient or family can do to prepare for this trauma, I would suggest focusing on nutrition and instilling a regular low impact exercise protocol (walking the block for 40 minutes a day). If this light or low impact exercise program with good nutrition is instituted within 3 weeks of an operation there will be a tangible benefit and improvement of the post operative course following this type of major surgery.

The advantage of video or robotically assisted procedures is that generally trauma is less and the expectation for length of recovery is shorter despite that the magnitude of the operation performed within the chest is often the same as within thoracotomy. Hospital stay from a standard video assisted or robotic lung resection performed for cancer at this institute is between 3 - 4 days. This translates into an out of hospital recovery of 3 - 4 weeks.


Thoracic Surgery: Minimally Invasive Options

Moderator: Are there any less invasive surgical options for various chest diseases?

Dr__Murthy: Video assisted thoracic surgery (VATS) and robotic thoracic surgery are increasingly being utilized to improve outcomes from major chest and abdominal operations. As experience with these technologies increases, particularly with robotics indications for these less invasive operations are dramatically expanding.

We have performed 20 different robotic thoracic and abdominal operations at this institute that have ranged from removal of the thymus for myasthenia gravis or tumors; to removal of the lung for lung cancer; and included removal of a variety of cysts scattered in the chest and under the heart; and even extended to operations on the esophagus and stomach.


This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

Reviewed: 11/12

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