Time to Eradicate Thoracic Ailments with Advances in Thoracic Surgery

Dr Arvind Kohli
India has the dubitable honor of being ranked first in the world with regards to thoracic disease burden, thoracic diseases encompass a wide spectrum of conditions affecting the chest organs, including the lungs, esophagus, and mediastinum. These range from infectious diseases like tuberculosis and fungal infections to cancers, particularly lung cancer, and chronic respiratory illnesses such as COPD and asthma. Thoracic trauma and deformities are also significant concerns.A good proportion of this disease burden is amenable to surgical treatment. However, patients have limited access to quality thoracic surgical care due to a number of obstacles the number of thoracic surgeons and thoracic care centres for tackling these problems is much less than the required
Disease called Tuberculosis has high incidence through out India and related complications related to TB need a thoracic surgeons care Chronic infections of the lungs from pneumonia, non-tuberculous mycobacterial (NTM) infections and influenza as well as fungal and bacterial infections can also be extremely serious, leading to pleural collections and subsequently Chronic empyema which are morbid for the patients
Lung cancer is a significant health concern in India, with rising incidence rates and high mortality. While smoking is a major risk factor, other factors like air pollution and genetic predispositions also play a role, particularly among non-smokers.
Rising Incidence:Lung cancer cases are expected to increase, with projections estimating over 81,000 cases among males and 30,000 among females in 2025.Another important issue is thatMost lung cancer patients in India are diagnosed in advanced stages, leading to high disease-specific mortality rates.
Other thoracic cancers with significant high incidence in India and managed by thoracic surgeons are Esophageal Cancers and Mediastinal Tumors.
Mediastinal tumours Mediastinal mass is an abnormal growth in the mediastinum, the middle compartment of the chest between the lungs. This crucial space contains vital structures like the heart, oesophagus, thymus gland, trachea and major blood vessels. Thus, a mass in the mediastinum can be significant even if it is benign. The anterior mediastinum is the most common site in adults and typically affects middle-aged and older people. The symptoms of mediastinal tumours often arise from the pressure of the tumour on surrounding structures, causing discomfort and other clinical manifestations
Recent advancements in thoracic surgery have focused on improved imagingminimally invasive techniques,and targeted therapies for lung cancer, leading to better patient outcomes with reduced pain, faster recovery, and shorter hospital stays
Enhanced Imaging and Navigation:
EBUS endobronchial ultrasoundAn endobronchial ultrasound (EBUS) is used to diagnose lung conditions and stage lung cancer. It combines bronchoscopy with ultrasound to visualize and sample lymph nodes and other structures in the chest, particularly around the airways
3D CT Scans and Intraoperative Navigation Systems:
These technologies provide surgeons with detailed views of thoracic structures, enabling more precise and targeted procedures. Navigational Bronchoscopy:
This technique uses 3D imaging to guide surgeons to nodules deep within the lung, previously inaccessible without major surgery.
Artificial Intelligence in Thoracic Surgery:
AI-driven Diagnostics:
AI models demonstrate high accuracy in diagnosing lung cancer, predicting lymph node metastasis, and aiding in data extraction from medical records. AI in Perioperative Management: AI can improve surgical precision, patient safety, and overall care efficiency in robotic-assisted thoracic surgery. AI for Enhanced Imaging: AI algorithms can analyze medical images to assist in diagnosis and treatment planning.
Thoracic Surgeries
Open thoracic surgery has stood the test of time and has been the mainstay of managing these thoracic ailmentsThe spectrum of surgical approach is increasingly changing from open procedures such as thoracotomy to muchmore currently visible video- or robot-assisted procedures or even minor- and major-procedures as nonintubated procedures under spontaneous breathing(NIVATS)
Video-assisted thoracic surgery (VATS), a minimally invasive procedure that involved the insertion of a thoracoscope (a tiny camera) and surgical instruments into three small incisions without any spreading of the ribs(Three port VATS)and now only one port called uniportal VATS. This operation is performed under anesthesia in the operating room. The Thoracic surgeon is able to remove restricting tissue around the lung(Decortication), insert a drainage tube or apply medicine(Sterile Talc) to reduce fluid accumulation and prevent lungs to collapse. A procedure called pleurodesis Further it has revolutionized the treatment of Lung Cancer and other thoracic and mediastinal Malignancies like Thymic& Esophageal malignancies
RATS utilizes a robotic platform to enhance precision and dexterity, Robot is an additional tool in the armamentarium of Thoracic surgeons It facilitates the procedure with minimal blood loss and precision The ability of robotic endowrist allows safe conduct of operation by giving better visualization of the operative area Robotic Thoracic platform enhances safety for all major thoracic interventions
Emerging evidence has revealed that video-assisted thoracic surgery (VATS) is also a safe and effective treatment method for Thoracic cancers compared with conventional thoracotomy
VATS patients have less postoperative pain, shorter hospital length of stay, fewer complications, faster physical recovery, and better postoperative lung function outcomes than thoracotomy patients. Based on these advantages, VATS (including uniportal, two-port, three-port, or four-port) has been widely used to treat Thoracic cancers. Although VATS is widely used in thoracic surgery based on its advantages, it also suffers from shortcomings, such as two-dimensional vision, difficult hand-eye coordination, amplification of hand tremor, steep learning curve, lack of flexibility, and limited ranges of instrument movement
Based on new emerging technologies and advances in medical knowledge, robot-assisted thoracic surgery (RATS) may be an alternative to VATS, as RATS can provide 3D high-definition visualization over the operative field, increase comfort for the surgeon, and improve the precision of manipulations with tremor filtration and instrument dexterity .
Some studies have confirmed the safety and feasibility of RATS and emphasized its advantages in less bleeding, lower conversion rate, shorter hospital stay, more harvested lymph nodes and stations, lower overall complication rate, and lower recurrence rate due to 3D high-definition visualization, tremor filtration, and instrument dexterity of robotic surgery systems. However cost effectiveness for this procedure is thought provoking and not every centre is having a robot
Advances in Thoracic AnesthesiaThoracic anesthesia has seen significant advancements, with a shift towards minimally invasive techniques, improved pain management strategies, and enhanced recovery protocols(ERAS). These developments aim to minimize surgical trauma, reduce postoperative complications, and facilitate faster patient recovery.
Lung isolation and separation techniques:
Advances in double lumen endotracheal tubes and endobronchial blockers enable safer and more reliable one-lung ventilation (OLV) during thoracic surgeries, which is crucial for many procedures. Regional AnesthesiaTechniques: Thoracic epidurals, intercostal nerve blocks, and serratus anterior plane blocks are used to provide targeted pain relief after thoracic surgery, often with better outcomes and fewer side effects compared to systemic analgesia .
Dedicated Thoracic Surgery Centres
The amount of surgically treatable thoracic pathology in India is large and Keeping in view the high ratio of Thoracic ailments which require surgical intervention by a dedicated Thoracic surgeon there is a need for bringing up Thoracic surgical care centres to attend to such needy patients. As the field of thoracic surgery continues to evolve, the training and skill development of surgeons have alsobecome paramount. Surgeons need to continuously update their knowledge and expertise to ensure the safe and effective implementation of new technologies and techniques. The availability of specialized training programs and workshops in India has played a crucial role in equipping surgeons with the necessary skills to provide high-quality thoracic surgery.A second, often neglected issue is the availability or lack thereof of qualified allied health workers. Thoracic surgery is not practiced in a vacuum. Good thoracic surgery involves the active participation of well-trained nursing staff, respiratory therapists, physical therapists and biomedical engineers hence a tremendous need to increase both the qualification and performance of allied health workers existsAs we look towards the future, the integration of artificial intelligence and the continued advancements in genetics will undoubtedly shape the field of thoracic surgery. With ongoing research, training programs, and technological innovations, thoracic surgery in India is poised to continue its upward trajectory, providing patients with cutting-edge treatments and improved prognoses.
(The author is Consultant CTVS SVMM Hospital Jammu)

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