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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

when to call a thoracic surgeon

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.

1096
bronchoscopy
&esophagescopy
from 2011-2015

Post chemoradiotherapy resection

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

Video Assisted Thoracoscopic Surgery (VATS) Resection of Anterior Mediastinal Mass
Cardiothoracic Surgery Department , faculty of Medicine , Assiut University

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 : !!!

Common conflicts
Between surgeons and phycisians

Chest tube; insertion
NEJM VIEDO !

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

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

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when to call a thoracic surgeon

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when to call a thoracic surgeon