Lung Surgery, Advances and Options Live Webchat Transcript
October 16, 2008
David Mason, MD
Staff surgeon, Joint appointments:
Department of Thoracic and Cardiovascular Surgery - Miller Family Heart & Vascular Institute
Cleveland Clinic Cancer Center
Cleveland Clinic Host: Welcome to our Online Health Chat with Dr. David Mason. Dr. Mason is a staff surgeon in the Cleveland Clinic Department of Thoracic and Cardiovascular Surgery. He holds joint appointments as a staff surgeon in the Clinic's Transplantation Center in the Division of Surgery and in the Cleveland Clinic Cancer Center.
Speaker - Dr. David Mason: Thank you for having me.
averyab: What determines a single- vs. double-lung transplant? Cleveland Clinic survival rates on each?
Speaker - Dr. David Mason: Most patients receive double lung transplant at Cleveland Clinic. Over 75 percent received double lung transplant due to a belief that outcomes are better after a double lung transplant. Patients over 60 years old usually receive a single lung transplant due to the lack of data that double lung transplant is beneficial for this age group. Five year survival for all comer patients is 60 percent for double lung transplant and 40 percent for a single lung transplant at 5 years.
averyab: How long are the single- and double-lung operations, typically?
Speaker - Dr. David Mason: Single lung transplant is approximately 5 hours and a double lung transplant is about 7 hours start to finish.
averyab: Have there been advancements in lung transplant surgery over the past few years that show an increase survival rates both within the initial 90-day post-op period and during the first year? If yes, please explain what they are.
Speaker - Dr. David Mason: Most major advancements in lung transplant surgery have occurred in the last decade and there have been few changes over the last few years that have had major impact on survival. However, improved ICU care have clearly enabled us to take better care of sicker patients in the immediate period after lung transplant.
averyab: What are the major factors that impact long-term survival?
Speaker - Dr. David Mason: Preoperative disease diagnosis that lead to lung transplant is one of the largest determinants of postoperative survival. Patient age and co-morbidities clearly influence survival with older patients having somewhat lower survival rates after lung transplant.
janema: Your above answer about preoperative diagnosis determining transplant survival -- can you elaborate on that? Do patients with one diagnosis do better than patients with a different lung disease?
Speaker - Dr. David Mason: In general patients with a diagnosis of pulmonary fibrosis have a slightly decreased survival when compared with other disease diagnoses for which lung transplant is performed.
Patients with pulmonary arterial hypertension and cystic fibrosis seem to fair particularly well. All patients however, seem to benefit with lung transplantation in the setting of end-stage lung disease.
James: How long is your waiting list for lung transplantation?
Speaker - Dr. David Mason: The waiting time for lung transplant is about 90 days from listing. The time to transplant however, can be quite variable dependent on your size, your blood type and luck.
averyab: During or post lung transplant surgery, is the patient put on a ventilator?
Speaker - Dr. David Mason: A ventilator is required during lung transplant surgery. However most patients usually come off the ventilator within hours of surgery.
James: How many lung transplantations do you do each year?
Speaker - Dr. David Mason: Cleveland Clinic performs approximately 65 lung transplants a year. This has been our average over the last 4 years. We are among the top two to three lung transplant programs in regards to volume in the country consistently.
jimmundy: I understand that after a lung transplant breathing may be easier but there are other issues, especially with respect to antirejection drugs and kidney function. Is this true?
Speaker - Dr. David Mason: Maintenance therapy after lung transplant aimed at preventing rejection are mandatory. Rejection means the patients immune response targets the donor organs and therefore medicines are required that allow the body's acceptance of these foreign tissues. Side effects of these medications are considerable - although most patients find quality of life to be quite high after lung transplant.
Kidney dysfunction can occur as one of these side effects. Although, the overall percentage of patients who develop severe kidney dysfunction is still small.
janema: How soon after lung transplant do you recommend the patient begins / resumes pulmonary rehab?
Speaker - Dr. David Mason: Pulmonary rehab begins almost immediately after lung transplant, starting in the ICU with breathing tests and walking with respiratory therapy. In general, no formal rehab is necessary after successful lung transplant due to a patient's rapid recovery with pulmonary function.
averyab: How long after the patient arrives in the ICU after surgery can family visit?
Speaker - Dr. David Mason: The patient's family can typically visit within one hour after arrival to the ICU.
prolunger: I received a double lung transplant four years ago, breathing fine but would like to reduce the negative side effects of the many medications I take...How risky is it to reduce or discontinue immune suppressant and corticosteroids and still avoid rejection and infection?
Speaker - Dr. David Mason: I am certain that you are being carefully followed by your lung transplant team. They are best qualified to manage your immune suppression in the context of your overall clinical status. Cessation of Immunosuppressant is not an option.
averyab: I understand that you monitor aspiration of acid reflux before and after surgery. (1) Are there any surgical procedures that you use to prevent aspiration of gastric reflux? If so, please explain what they are. (2) If you detect it after transplant, does the patient then undergo an additional surgery to stop the aspiration?
Speaker - Dr. David Mason: Anti-reflux surgery is one potential surgical procedure aimed at preventing aspiration after lung transplant. Careful selection is important to identify the appropriate candidates for this type of procedure.
Lung Volume Reduction Surgery (LVRS)
jusane: How many LVRS's are done each month or year?
Speaker - Dr. David Mason: At Cleveland Clinic, approximately 25 LVRSs are performed a year. This represents a very carefully selected subset of patients with emphysema.
rhet42: My aunt has had emphysema for some time. It is difficult for her to breathe. Do you have procedures you are doing to treat this? I heard there are some new types of surgery being researched for emphysema.
Speaker - Dr. David Mason: Lung volume reduction surgery (LVRS) is a therapeutic option for a carefully selected patient with emphysema. Careful evaluation by pulmonary medicine as well as thoracic surgery to establish if she was a candidate for this procedure.
Lung transplantation is also an option - Dependant on her age and other risk factors.
jusane: What improvement in lung function can be expected after LVRS?
Speaker - Dr. David Mason: For the appropriate patient undergoing LVRS, length and quality of life have clearly been demonstrated. Most striking is a patient's improved ability to carry out acts of daily living, increased ability to walk distances, and decreased sensation of shortness of breath. These improvements on average last several years. And for many - even longer.
jusane: How do I find the best surgeon possible to do LVRS?
Speaker - Dr. David Mason: Lung Volume Reduction Surgery is performed in a carefully selected patient population. Multi-disciplinary evaluation is critical to successful outcomes. There are only a few centers with extensive experience with LVRS, Cleveland Clinic being one of them.
I would be happy to evaluate you in conjunction with our advanced lung disease team.
jusane: Can I get an evaluation without going to the clinic in Ohio? As much as I would like to be evaluated there it would be very expensive to travel and stay there.
Speaker - Dr. David Mason: A local pulmonologist can begin the evaluation, which should include pulmonary function testing, cardiac stress testing, arterial blood gasses, and CT scan.
These data points could be forwarded for evaluation prior to making the trip to Cleveland. You can call my office at 216.444.4053 and make arrangements for collecting the studies. Please mention to my secretary that you were a part of this chat.
Antioxidant Therapy and COPD
Stephenson: Has there been any new research concerning antioxidant deficiency in COPD? and age longevity expectation for COPD?
Speaker - Dr. David Mason: Anti-oxidant therapy, while holding theoretic advantages, has not been clearly demonstrated to benefit in the clinical arena. Therefore it is not possible to say that this form of therapy would improve longevity.
Minimally Invasive Approaches – Video Assisted Thoracic Surgery (VATS)
Ann_D: My husband needs a lobectomy. Someone suggested VATS lobectomy. When is VATs lobectomy a choice rather than regular surgery? How do they know they will get all of the cancer with a VATs procedure?
Speaker - Dr. David Mason: VATS stands for video assisted thoracic surgery. It is a minimally invasive surgical technique that allows more rapid recovery from surgery and less postoperative pain than conventional thoracotomy.
A thoracotomy is a larger incision that requires spreading of the ribs. Small lung cancers and lung cancers that tend to be more toward the surface of the lung are the best candidates for VATS however most lung cancers can be removed by VATS. The CT scan should be able to identify the location of the tumor and the likelihood of removal with VATS.
Surgical outcomes for cancer clearance suggest that VATS is as good as open techniques.
Cleveland Clinic Host: Dr. Mason, can you talk a little more about the advances in minimally invasive lung surgery and what conditions can it be applied to?
Speaker - Dr. David Mason: Minimally invasive lung surgery is clearly beneficial to patients for almost all thoracic diseases that require surgery. However, few surgeons are trained in these techniques and only a minority of thoracic surgery procedures are performed minimally invasively around the country. At Cleveland Clinic, all thoracic surgery patients are considered for minimally invasive surgery first and expertise in these techniques exists.
In our experience, outcomes for cancer cure is identical to more traumatic techniques and clearly this is not a compromise procedure. More rapid return to work and resumption of regular activities is clearly faster.
Diagnosis of lung disease
Theresa_G: What is the best diagnostic procedure to look at the lungs?
Speaker - Dr. David Mason: CT scan usually give the most information in evaluating lung processes.
daraTI: My husband had an xray the other day. They said he had nodules in his lungs. Does that mean he has cancer?
Speaker - Dr. David Mason: No. There are many other causes of lung nodules than cancer. Most lung nodules are not cancer. Clearly follow up for diagnosis and treatment is required.
brianK: What’s the best way to treat a pleural effusion?
Speaker - Dr. David Mason: There are several options for treating pleural effusions. Selection of options is dependent on the size and cause of the effusion. Treatment options include thoracentesis, chest tube placement, or VATS (video assisted thoracic surgery). Careful patient evaluation is required for optimal outcomes.
DJHS: What causes pulmonary fibrosis and how does it affect the lungs?
Speaker - Dr. David Mason: The most common form of pulmonary fibrosis is idiopathic pulmonary fibrosis or IPF. Unfortunately despite tremendous research - the cause of IPF is still unknown. Multiple theories exist although none is proven.
Protocols for treatment of IPF and expertise in management in treating this are available at the Cleveland Clinic.
Partial Lung Removal
Annie167: How does it work to have partial lung removed? Can they do it through a small incision?
Speaker - Dr. David Mason: Minimally invasive surgery is feasible for all types of lung surgery. Resection, or removal of a portion of the lung, can be performed with VATS - which is video assisted thoracic surgery.
Most patients are candidates for this surgery. This has been shown at our own institution to shorten hospital stay and speed recovery.
Lung Surgery Recovery
davideric: Can you fly after lung surgery?
Speaker - Dr. David Mason: Yes - it is possible to fly after lung surgery. It is preferable to wait one week prior to flying.
EdKr: My wife has been told she needs a lung wedge resection. Her doctor said she should return to normal and she will be able to go back to normal life. Is that reasonable?
Speaker - Dr. David Mason: Yes - that is reasonable. Recovery after wedge resection is typically rapid - certainly a minimally invasive approach should be considered to maximize recovery.
becky: What’s a pericardial cyst? How is it caused and how is it treated?
Speaker - Dr. David Mason: A pericardial cyst is a fluid filled sac that typically lies next to the heart. Usually they are asymptomatic and do not require intervention.
Scar Tissue on Lungs
TimCr: A couple years ago I had pneumonia. The doctor said my xray showed scar tissue on my lungs. Will that cause problems later in life?
Speaker - Dr. David Mason: Scarring from pneumonia or inflammation in general, is not problematic. However, certain lung diseases mimic scar and a follow up CT scan might be in order.
melissa: My grandfather has a lung abscess. How is that treated? Does he need surgery? Why does someone get a lung abscess?
Speaker - Dr. David Mason: Most lung abscesses result from an aggressive pneumonia. An abscess is basically a pocket of pus. Typically they respond to intravenous antibiotic therapy and resolve completely. Occasionally surgical removal is necessary if these other techniques have failed.
Emphysema and Endobronchial Treatment
janema: The new valve and stent procedures to help the patient exhale excess air. How widely are those being done and are they successful?
Speaker - Dr. David Mason: Endobronchial techniques for improving emphysema, which I think you are referring to, are being performed at the Cleveland Clinic. Presently, enrollment is on a "protocol" basis, meaning that trials are underway to determine their value. However, our early experience is promising in performing the equivalent of lung volume reduction surgery without incisions.
Alpha 1 antitrypsin deficiency
bobwe: From bobwe: I am an Alpha-1 and am wondering if there are alternatives to transplant? and when should an individual begin the process for listing on the transplant waiting list?
Speaker - Dr. David Mason: Patients with Alpha 1 antitrypsin deficiency require close follow up with an experienced pulmonologist. It is never too early to be seen for consideration of lung transplantation and interventions such as enzyme replacement should be considered. Of course, smoking cessation is critical if you are a smoker.
meganmccully: My father had bypass surgery in 2000. Since that he has had a diaphragmatic paralysis on one half of his diaphragm. This makes it hard for my father to breathe – is there anything to do to treat this?
Speaker - Dr. David Mason: Diaphragmatic plication is a good option for improving respiratory function in the setting of diaphragmatic paralysis. We would consider evaluating your father to establish if he would be a good candidate for this surgery.
janema: What is Diaphragmatic Plication? Basically, what is done?
Speaker - Dr. David Mason: The diaphragm is floppy and inefficient when it become paralyzed. A plication is a surgical procedure, where the diaphragm is "remodeled" through sewing techniques and shaped so that it behaves more efficiently and, therefore improves breathing.
jusane: Thank you, Do you happen to have an 800 number that you can be contacted at? Or an email address?
Speaker - Dr. David Mason: You can call my office toll-free at 800.223.2273, extension 4-4053
Cleveland Clinic Host: Unfortunately our time with Dr. Mason is up for today. Thank you for participating in this chat, Dr. Mason!
Speaker - Dr. David Mason: It was my pleasure.
Technology for web chats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).