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Thoracic
surgery, or surgery of the chest, is often a patient's
best chance at survival for lung cancer and multi-drug
resistant tuberculosis. Thoracic surgery also plays
a role in other diverse disorders, such as myasthenia
gravis, hyperhidrosis, and tracheal stenosis (narrowing
of the trachea).
An autoimmune neuromuscular disorder called myasthenia
gravis (MG) robbed Cristina Goncalves of her smile;
medicine and a thoracic surgical procedure gave it back.
Ms.
Goncalves was 14 when she developed some unusual symptoms.
First, she was unable to curve her mouth to smile; then
she began having trouble with speech and swallowing.
“My muscles didn’t do what I wanted them
to do,” recalls the Newark resident. “It
was very frustrating. I hardly spoke, and I hardly ate.”
Even more frustrating, a series of doctors was unable
to tell her why, with one asserting that her tongue
was too big for her mouth.
Then,
Ms. Goncalves went to University Hospital, where she
was examined by Dr.
Jennifer Michaels, assistant professor of neurosciences
at New Jersey Medical School. Dr. Michaels’ diagnosis
was MG, a condition in which nerve impulses to the muscles
are interrupted, causing muscular weakness. Doctors
believe the thymus gland, part of the immune system,
is somehow involved with the development of MG.
Once
correctly diagnosed, Ms. Goncalves was prescribed prednisone,
an immunosuppressive drug, which relieved her symptoms.
However, because the MG could reoccur as Ms. Goncalves
grew older, Dr. Michaels referred the teen for evaluation
by Dr. Paul Bolanowski, an associate professor of surgery
at New Jersey Medical School and chief of thoracic surgery
at University Hospital. He recommended that she have
a thymectomy—a removal of the thymus gland.
The
thymus gland is located underneath the breastbone. It
has an important role in regulating immunity in a person’s
early childhood, but as we age, the gland shrinks and
is replaced in part by connective tissue and fat. Still,
most people with MG have an abnormal thymus gland with
increase in the number of cells, and about 10 percent
of all MG patients will develop a tumor known as a thymoma.
Thymomas are usually benign, but they can become malignant.
Removal of the thymus gland relieves symptoms in about
70 percent of MG patients.
For
Ms. Goncalves, who had a thymectomy in 1998, the surgery
was preventive in nature. “I was so young when
I developed MG, that my chances of recurrence were higher
than average,” says Ms. Goncalves, now 22 and
a college graduate working in the marketing field. “For
me, there’s no question that having the thymectomy
was the best, most proactive choice. I’ve had
no symptoms since.”
That’s
the goal of thymectomy, according to Dr.
Paul Bolanowski, who performed Ms. Goncalves’s
operation. “Between 18 months and two years after
the surgery, most myasthenia gravis patients are able
to be completely off medication,” he says.
A
Critical Region
The thymus
gland may not be a household word, but it’s located
in a very familiar part of the anatomy: the chest, or
thorax. The major organs within the thoracic cavity
are, of course, the lungs and the heart, but there’s
also the trachea, the esophagus, the ribs and muscles
of the chest wall, and an intricate network of nerves
and blood vessels that travel through the area. The
surgeons who operate on structures within this region,
which includes the heart, are called cardiothoracic
surgeons. For the purposes of this article, the focus
is on non-cardiac procedures performed by thoracic surgeons
such as Dr. Bolanowski.
That still leaves much
to discuss, namely, conditions affecting the lungs.
Healthy lungs have a masterful architecture and are
essential to the most basic elements of human well being.
The bronchial tubes allow air to pass in and out of
the lungs, and the critical exchange of carbon dioxide
and oxygen occurs within tiny air sacs called alveoli.
Protective lymph nodes outside the lungs guard against
infection. The lungs are also well guarded by the diaphragm,
a sheet of muscle, and by the ribs.
Despite these safeguards,
the lungs are vulnerable to a number of life-threatening
conditions, such as asthma, cystic fibrosis, emphysema,
cancer, and even an old foe, tuberculosis. The American
Lung Association estimates that 35 million people in
the United States have chronic lung disease.
The
Breath of Life
Not all lung diseases
are treatable by surgery, but when they are, an operation
is usually one of a few options. Take lung cancer, for
example. Lung cancer has the dubious distinction of
being the leading cause of cancer death in the U.S..
Smoking, second-hand smoke, and exposure to substances
such as radon or asbestos can, over time, cause abnormal
cells to grow in the lungs, become cancerous, and form
tumors. Lung cancer often has symptoms similar to other
lung diseases—chronic cough, wheezing, hoarseness,
shortness of breath, and frequent bouts of bronchitis—so
anyone with these problems should be examined by a physician.
In addition to imaging scans, the doctor may order pulmonary
function tests and a mediastinotomy, a method of sampling
lymph nodes. “These tests provide important information,
such as the tumor’s location and extent within
the chest,” says Dr. Bolanowski. “We need
to know if the cancer is confined to the lungs or if
it has spread.”
Once lung cancer is diagnosed
and staged, the best approach is a team approach, believes
Dr. Bolanowski. “At University Hospital, pulmonologists,
thoracic surgeons, medical oncologists, pathologists,
and radiation oncologists meet to discuss each case
and develop a treatment plan,” he says. “Generally
speaking, if the disease is in an early stage, surgery
alone is the optimal, first line treatment. For a large
tumor, one possibility is reducing its size by radiation
or chemotherapy before attempting a resection. In advanced
cases of lung cancer, surgery is rarely an option and
chemotherapy and radiation become the primary therapy.”
When removing the tumor
is possible, the thoracic surgeon decides which is the
best type of procedure to use. With a lobectomy, the
most common type of lung cancer surgery, an entire lobe
(section of a lung) is removed. When the tumor is located
on the outer area of the lung, a segmental resection
(a portion of a lobe) can be performed for patients
with poor lung reserve. Sometimes the tumor is located
in the lung’s airways, the bronchii; performing
what is known as a sleeve resection, the surgeon removes
the diseased portion of the bronchii and reconnects
the ends. When the cancer is centrally located within
a lung, the surgeon may recommend removing the entire
lung, a pneumonectomy, to increase the patient’s
chances for survival. It is possible to breathe with
only one lung, but the pneumonectomy is only performed
in patients with sufficient lung reserve. Its purpose
is to remove the cancer with the patient able to function
post-operatively in a normal manner.
Lung cancer’s survival
rates have improved over the past few decades but are
low when compared with other cancers. A patient with
an early stage lung cancer (IA or IB)and no lymph node
involvement who’s had surgical treatment has an
estimated five-year survival rate of between 43% and
64%; a patient with advanced lung cancer (IIIB), treated
with chemotherapy and radiation, has a five-year survival
rate ranging from 7 % to 17%. Although lung cancer is
slow growing, most patients don’t seek treatment
until the cancer has reached an advanced stage.
There’s a way to
dramatically reduce the likelihood of developing lung
cancer: don’t smoke, or for smokers, “kick
the habit.” The American Lung Association reports
that 87 percent of lung cancer cases involve smokers,
and that quitting smoking can reduce a person’s
chances of developing lung cancer or other lung diseases.
While lung cancer is
an all-too-common lung disease, Dr. Bolanowski also
specializes in the surgical treatment of tuberculosis
(TB), a rare but serious disease that most Americans
wrongly believe has been eradicated. TB, as the airborne
disease is nicknamed, was a leading cause of death in
the United States until the development of antibiotics
in the 1940s. Today, overuse of antibiotics has enabled
mycobacterium tuberculosis to develop a multi-drug resistant
strain, and the disease has made an unwelcome comeback.
Worldwide, there are 10 million new cases of TB each
year, and 2 million people die from the disease. In
the United States, the numbers are much less dramatic:
in 2000, there were about 17,500 people with TB. People
with weakened immune systems, such as those with HIV,
as well as immigrants and visitors from countries where
TB is more common, have a greater likelihood of contracting
the disease.
TB can be treated with
a combination of medicines, and the National Tuberculosis
Center at New Jersey Medical School, under the direction
of one of the country’s leading experts on the
disease, Dr. Lee Reichman, is one of the foremost TB
treatment and research centers in the United States.
TB medical treatment requires commitment from the patient
because it involves taking medication every day for
a long period of time, usually between six and nine
months. Not everyone completes the treatment. However,
a new antibiotic, announced in December 2004, shows
promise for cutting TB treatment time in half, which
may help solve some of the problems with patient compliance.
The TB patients referred
to Dr. Bolanowski are typically those who have a multi-drug
resistant strain of the disease. He can perform a lobectomy
when the TB is localized or a pneumonectomy. “Once
the disease is removed, the prospects for a full recovery
are good, and the patient is no longer a danger to spread
the disease to others,” he says.
Challenging
Regions
In addition to lung cancer,
TB, and MG, Dr. Bolanowski specializes in repairs to
two other parts of the thoracic region: the chest wall
and the trachea. The bones, muscles, and joints between
the neck and the abdomen are known collectively as the
chest wall. Some people are born with defects that cause
the chest area to have a sunken appearance (pectus excavatum)
or protrude (pectus carinatum). Both conditions can
be corrected surgically. When cancer invades the chest
wall, the challenge is not only in removing the tumor,
but retaining the stabilityof the chest wall to breath
normally. Chest wall reconstruction is a complex yet
critical procedure that can involve placing plastic
mesh or metal struts within the wall and covering the
area with a flap of skin and muscle. This “myocutaneous
flap” procedure is not typically available in
community hospitals, but one that is commonly performed
at larger centers such as University Hospital.
The trachea provides
an airway from the larynx to the lungs. When the“windpipe”
narrows, whether because of tissue injury, a congenital
condition, or benign and malignant tumors, the airway
can become compromised and, in extreme cases, lead to
a person’s death. Using the CT scanner at University
Hospital in Newark, a virtual endoscopy can be performed
without the risks of bronchoscopy. However, an endoscopic
may be necessary. The surgeon can quickly and accurately
view the part of the trachea that has narrowed and ascertain
if dilation, tracheostomy, tracheal stenting, or resection
is necessary. For complex conditions involving both
the trachea and larynx (voice box), Dr. Bolanowski often
works together with Dr.
Soly Baredes, an otolaryngologist (ears, nose ,
and throat) surgeon at University Hospital.
Other
Thoracic Conditions
The “every day”
conditions that bring people to a thoracic surgeon can
turn out not to be so ordinary. Take pleural effusion,
a buildup of fluid around the lungs, for instance. “The
pleura is a membrane that has two layers, one that lines
the diaphragm and the rib cage, and the other that covers
the lungs,” explains Dr. Dennis Quinlan, Jr.,
an Elizabeth-based thoracic surgeon with privileges
at University Hospital and Dr. Bolanowski’s associate.
“When the fluid produced by the pleura is in excess,
it’s difficult for the lungs to fully expand.”
Someone with pleural effusion could have shortness of
breath and coughing.
The most common reason
for pleural effusion is an infection such as pneumonia,
but it can also be caused by heart failure or cancer
(typically stomach, breast, ovarian, or lung cancer).
The extra fluid is drained from the space between the
lungs and chest wall to relieve symptoms and diagnose
the cause. If necessary, a scarring procedure can be
performed to prevent the fluid from recurring. If the
condition warrants, the patient is referred to a cardiologist
or an oncologist.
Spontaneous pneumothorax,
or a collapsed lung, often results from a rupture of
abnormal air sacs ( known as blebs) within the lung.
In otherwise healthy people, trauma is the usual cause
of pneumothorax; it can also develop as a consequence
of many lung diseases. “The symptoms of a collapsed
lung include shortness of breath and chest pain or tightness
that’s made worse when the patient takes a deep
breath or coughs,” says Dr. Quinlan. “Treatment
involves removing air from the pleural space, either
through aspiration or a chest tube. Sometimes, though,
when air still leaks from the lungs after several days,
surgery is necessary to remove the blebs or scarring.”
A minimally invasive procedure to repair a collapsed
lung offers smaller incisions and a faster recovery
time than the traditional, “open” surgery.
On
the other hand
Oddly enough, thoracic
surgery could be the cure for someone suffering from
excessively sweaty palms. Hyperhidrosis causes excessive
sweating of the palms, underarms, feet, or even the
face. It’s caused by overcharged sympathetic nerves
that run along the spine inside the thoracic cavity.
There are non-surgical remedies for hyperhydrosis, such
as specially formulated antiperspirants and iontophoresis,
an application of low electrical current, but sometimes
they are not adequate for people who are affected severely.
Enter the thoracic surgeon:
thoracoscopic sympathectomy is a minimally invasive
alternative to an “open” procedure that
removes a specific ganglion (a cluster of cells) of
the sympathetic nerve chain. Each ganglion in the thoracic
region affects sweating in a particular part of the
body. In the minimally invasive procedure, rather than
opening the patient’s chest, small incisions are
made beneath his or her underarms for insertion of specially
designed surgical instruments, and the ganglion is removed,
bringing almost instant relief.
The body’s ability
to perspire is necessary and not completely shut down
by the procedure. One of thoracoscopic sympathectomy’s
possible complications is compensatory sweating, in
which there is heavier perspiration in other parts of
the body than the one impacted by the operation. Compensatory
sweating usually decreases over a few months. Nonetheless,
thoracoscopic sympathectomy is still a highly effective
procedure with a low complication rate that gives patients
the confidence to shake hands again.
The complex
problems that can develop within the chest are well
managed by experienced thoracic surgeons. To make an
appointment with Dr. Bolanowski at University Hospital,
call (973) 972-5678 or (908) 352-8110.
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