On the leading edge
Innovative procedure shortens recovery time for lung cancer patients
Lying on the operating table, anesthetized and in a sort-of fetal position, lung cancer patients go through some painful surgery to get cured.
First, the doctor makes a 6-to-12-inch-long incision between two ribs. He then cuts through the skin, the blood vessels, the fat, several layers of muscle and the inner lining of the chest to reach the lungs.
Along the way, he also uses a U-shaped, crank operated rib spreader to open the patient’s chest.
The operation is one of the more painful to recover from. But in Las Vegas, where lung cancer is all too common and deadly, there is another option: A minimally invasive techique known as VATS, or video-assisted thoracoscopic surgery.
With VATS, a doctor typically makes three small incisions in a triangular shape on the side of the patient’s chest and then inserts surgical instruments and a camera. The anesthesiologist temporarily cuts off the air supply to the diseased lung and essentially deflates it, allowing the surgeon to remove the cancerous part.
Surgeons still regularly perform the open surgery known as thoracotomy, which is often the best way to access and scoop out the cancer. But some doctors also use VATS, especially when they need to remove only part of the organ.
Doctors say the procedure is far from painless but has a somewhat shorter recovery period than a thoracotomy. The technique can reduce patients’ hospital stay, get them back to their daily routine faster and limit blood loss.
It also avoids the need for a rib spreader, which can easily break a patient’s ribs. Pain from a broken rib can last a year and makes breathing, coughing and sneezing difficult. Patients sometimes develop pneumonia because it hurts too much to cough up mucus and other fluids that build up in their lungs, said Arnold Chung, a thoracic surgeon at MountainView Hospital.
VATS has been used around the country for about 20 years. But only a few local doctors use it to treat lung cancer, said former thoracic surgeon Maurice Pockey, who retired last summer after 20 years in practice in Las Vegas and, before that, 20 years in Oshawa, Ontario.
There are “maybe two, I don’t even think two” in the valley who use it, Pockey said.
One of them is Chung, who joined MountainView in November because of his training in the technique. Physicians estimate about 30 percent of partial lung removals are performed with minimally invasive surgery.
“People have pain, there’s no doubt about it,” Chung said of VATS. “But I think it’s to a lesser degree.”
Lung cancer, which mostly afflicts the elderly, is the second-most common form of cancer nationwide and by far kills the most people, according to the American Cancer Society. More people die each year from lung cancer than colon, breast and prostate cancers combined.
An estimated 159,480 people nationally — 87,260 men and 72,220 women — will die from lung cancer this year, accounting for about 27 percent of all cancer deaths.
The disease is one of the most preventable types of cancer and strikes Las Vegas harder than other cities, at least for women: It’s more common and deadlier among women locally than nationally.
The exact reasons for this are unclear, but analysts point to Nevada’s high smoking rate and the legions of people who deal cards and serve drinks in smoke-filled casinos.
Some 21 percent of Nevada adults smoke cigarettes, the ninth-highest rate in the country. Meanwhile, about 32 percent of Southern Nevada’s workforce is in the leisure and hospitality sector.
Local women overall have a 19 percent higher risk of getting lung cancer than women nationally, and statewide they are 23 percent more likely to die of it, according to a report last year by UNLV and Nevada state health officials.
Nevada men smoke cigarettes and work in Las Vegas hotels and casinos at about the same rates as women. However, they only have a 2 percent higher risk of getting lung cancer than men nationally, and statewide they are actually 5 percent less likely to die of it, said the UNLV/state report, which analyzed 2006-2008 data.
Of course, VATS cannot cure this public health problem. But, with so many Nevadans living with diseased lungs, it can help ease their pain after surgery.
One of the technique’s pioneers in the early 1990s was Robert McKenna Jr., now the medical director of thoracic surgery and trauma at Cedars-Sinai Medical Center in Los Angeles. Before joining MountainView, Chung spent a year at Cedars-Sinai training under McKenna and other surgeons.
Cedars-Sinai’s fellowship program consists of only two doctors a year, and each performs 500 procedures there. About 100 to 200 are partial lung removals, said Harmik Soukiasian, associate director of thoracic surgery.
He said patients who undergo VATS can usually tolerate more chemotherapy than those who had a thoracotomy. They also are more likely to go home after surgery, while thoracotomy patients more frequently go to a skilled nursing facility.
Still, VATS is not always the best option. A medical diagnosis might not paint an exact picture of the size and scope of the cancer, and unlike open-chest surgery, VATS gives a limited view of the lungs and prevents surgeons from feeling the organs with their own hands, Pockey said.
Pockey, who sometimes used VATS on lung cancer patients, said it’s best used for easily accessible cancers and when a doctor knows there will not be any surprises inside the chest.
“You had better know exactly what’s in that lung before you go ahead with it,” Pockey said.