From tissue resection to lung transplantation

The ward you chair has obtained an NFZ (National Health Fund) contract for thoracic surgery procedures. What does it mean?

We receive full refund for procedures on patients with lung diseases, chest wall or diaphragm conditions. Therefore, we are able to use all the advanced techniques and apparatus while ensuring satisfactory financial results for the hospital.

How many procedures are performed weekly at the ward?

I have been working here for less than two years. As far as thoracic surgeons are concerned, we started as two people without an NFZ contract, whereas today there are three of us already. Initially, we were performing four procedures a week, while now we are reaching the level of eight. It is my ambition to make the number of procedures as high as possible, even three a day. We have the right background for that. Thus, our goal is to build a ward with 20 beds and 15 surgeries a week.

Thoracic surgery is considered one of the harder specializations – why is this?

These procedures are undertaken in the chest, on organs through which 100% cardiac output flows. Besides, lungs have a large surface so infection complications or any other complications can be severe.

What kinds of procedures are most common?

Most frequently we do lung tissue resection in lung cancer patients. This can be done conventionally (“open lung” surgery) or with the use of low invasive methods. These procedures are serious. We should bear in mind that only 20% lung tumors can be removed through resection at the time of the initial diagnosis. In certain more advanced cases, there is infiltration on the mediastinum and we have to consider whether this job is technically feasible, or conservative treatment is preferred.

You mentioned low invasive methods – what is the difference between these and conventional surgery?

In order to conventionally open the chest, we make a 12 cm long cut. Then we apply a metal retractor that spreads the ribs to the sides with enormous force so that the surgeon can put their entire hand inside the chest. For the surgeon, such an open chest surgery is convenient because they can see everything and palpation is possible as well. But it involves a major blood loss for the patient, as well as excruciating post-surgery pain and prolonged hospital stay. 
On the other hand, video-assisted thoracoscopic surgery (low invasive VATS technique) is better for the patient. Professor Tomasz Grodzki made a graphic comparison of performing these procedures through a keyhole. We do not make a 12-centimeter cut here. Instead, we apply one or possibly two or three approaches plus an additional port for a camera or a different tool. The maximum width of these cuts is one centimeter. Such a surgery only leaves a small scar and the pain is significantly less severe. Drain tube is quickly removed from the patient’s chest and the patient stays in hospital for half the time they would have to spend there after traditional surgery.

Can low invasive procedures be used in the same cases as traditional surgery, or is it still true that more serious procedures are done on an open chest?

Indeed, major surgery used to be done in the conventional way. The current approach is to do as many procedures as possible using the mini-invasive methods. All types of lung surgery except transplantation can be done in this way. So, the surgeon has a choice. The decision always depends on their skills and available equipment.

Are such low invasive procedures being performed at the thoracic surgery department of UCK WUM?

Certainly, we have been performing these for six months. These include resection procedures on lung tissue in cases of lung cancer, such as video-assisted segmentectomy, video-assisted lobectomy, as well as mediastinum tumor resections. As well as any surgical procedures on the pleura, i.e. pleurectomy. Even decortication (removal of all or part of the external surface of the organ) in the event of an infection of the pleura, whether for diagnostic purposes or as a life-saving procedure in the event of hemorrhaging to the pleural cavity. Sometimes this is plastic surgery of the diaphragm in the case of relaxation.

You also perform so-called twin surgery, what is it?

We work together with professor Mariusz Kuśmierczyk, head of department, as cardiac and thoracic surgery. We sometimes perform combined procedures. It means that in one session in the operating ward, the patient’s heart is treated, while we do a lung resection because of a tumor. Four such combined procedures have taken place already. Patients appreciate these because two organs are rectified under one anesthesia.

You said that lung transplants are done on an open chest. How does such treatment proceed?

In Poland, lung transplants are traditionally performed from a dead donor where brain death has been pronounced. The organ appears unexpectedly, so that we need to be prepared almost all the time for having to go there and procure the organ. One team procures the lungs, the other implants them afterwards. Sequential transplantation as such involves thoracotomy, i.e. a broad opening of the chest to take out the patient’s own diseased lung and then insert a new one from the donor. We resect the recipient’s first lung and implant the donor’s lung. Then we remove the recipient’s other lung and implant the donor’s other lung. After the procedure, immunosuppressive, anti-infectious and other medicines are needed as well.

 
When can we say that a transplant has been successful?

The first week is critical. Unless something concerning happens during that period, the patient should be extubated and start breathing by themselves. Preferably, this should occur during the initial one or two 24-hour periods after the transplant. When the patient takes up breathing by themselves, we may say that the prognosis is good. But obviously we have to be aware of multiple complications that may happen after the transplantation, such as acute rejection, infection, PGD (primary graft dysfunction), kidney failure, and more. Therefore, post-transplantation patient care is a team play. Not only do we need a transplant surgeon but also an internal medicine specialist, a cardiologist, an infectious diseases specialist, physical therapists, etc.

Which patients can be candidates for a lung transplant?

Most often these are chronic obstructive pulmonary disorder (COPD) patients who have developed such complications as emphysema. This is quite a common disease in smokers. And this is the primary indication. Another one is lung fibrosis. This may occur as a consequence of certain conditions of the connective tissue, but the cause may be unknown, too. The third group of patients qualifying for a lung transplant are cystic fibrosis patients - it is a genetic condition demonstrated through mucus build-up in the respiratory tract. The patient has trouble expectorating the phlegm, they will develop pneumonia and ectasia. Recently, surgery on CF patients is less frequent because new drugs acting on the root cause have appeared, so-called caftor drugs, which help thinning the mucus and surgery is not needed.
It should be emphasized that a lung transplant is not the treatment of choice for patients with extreme organ failures.  There is a so-called transplantation slot. This is a phase of lung disease in which the patient is feeling worse each month and meets the criteria for a transplant, while treatment with pills and inhalation drugs is no longer effective. One of the criteria is also the estimated survival time not exceeding two years. This is not easy to estimate but an experienced pulmonologist can do that. Such a patient is qualified for a transplant and should receive it within two years.

 
How many lung transplants are performed in Poland?

It is estimated that in a country of the size of Poland, 200 to 300 lung transplants should be performed each year, whereas the actual value is 60 to 70. Currently there are active hospitals in Zabrze, Gdańsk, Szczecin, and two in Warsaw, ours included. But still not all the patients needing such a transplant are able to get it.

Is it possible to transplant lungs from a living donor?

Yes, transplants from family members. Those are already being done worldwide. In that system, one parent donates one lung and the complete organ is then implanted to a child, for example being a cystic fibrosis patient, to replace the child’s own lungs. The advantage of such surgery is that it can be planned very thoroughly. Living transplants are very frequent in Japan where their Shinto religion forbids any intervention in a corpse for seven days following death. It is possible that we will be performing such procedures more often in Europe as well, considering that there are not enough organs from dead donors for all the patients in need.

Interviewed by Iwona Kołakowska
Photo by Michał Teperek
University Communication and Promotion Office