Thoracic Surgery

personal-counselor-s-710400

Conditions and treatments

Our thoracic surgeons treat a wide variety of thoracic diseases and disorders, ranging from cystic fibrosis to lung cancer. A brief summary of some common conditions follows. To learn more about a specific condition, click on the links.

Acute Respiratory Distress Syndrome (ARDS) occurs when the millions of tiny air sacs in the lungs, called alveoli, fill with excess fluid. This can be the result of any kind of injury to or illness in the lung. Prompt evaluation of the underlying cause and intervention is required to reverse ARDS promptly. Management of these complex cases requires a cooperation between multiple specialties.  

Cystic fibrosis is a severe, genetically-determined disease involving the lungs and gastrointestinal tract, as well as other organs. This disease affects the glands that secrete sweat and mucus. Cystic fibrosis is often treated at home with antibiotics and special exercises for draining mucus in the chest.

COPD is the most common form of pulmonary dysfunction today. Together with asthma and chronic bronchitis, Emphysema is part of a group of diseases that share a common feature—difficulty in expelling air from the lungs. We refer to this group as Chronic Obstructive Pulmonary Disease (COPD). Some patients with localized emphysema can benefit from a surgical procedure (LVRS or lung volume reduction surgery). Dr. Ginsburg a major contributor to the NIH sponsored NETT trial, has over 20 year of experience in surgical treatment of emphysema

Our thoracic surgeons have wide experience in treating all forms of benign and malignant esophageal disorders. The most common surgical disorders we treat are; GERD and hiatal hernia, achalasia, Zenker’s diverticula. The prevalence of the most common form of esophageal cancer, adenocarcinoma, is increasing faster than any other tumor in North America. Esophageal Cancer and Disorders,

Gastroesophageal reflux disease (GERD), a common digestive disorder with symptoms of heartburn, is a much less dangerous form of esophageal disease that afflicts millions of Americans each year.

Hyperhidrosis refers to excessive sweating in the hands, feet, and other regions of the body that is caused by hyperactivity of the autonomic nervous system. Approximately 1% of adults are estimated to suffer from hyperhidrosis, which can be treated medically or through a non-invasive surgical procedure known as an endoscopic thoracic sympathectomy (ETS).

Interstitial lung disease and pulmonary fibrosis are general terms used to describe inflammatory and fibrotic disorders of interstitium (lung tissue). There are over 100 known causes of interstitial lung disease and pulmonary fibrosis, including familial and genetic disorders, inhaled substances, infections, medications, and connective tissue diseases. Based on symptoms and CT scan appearance, a lung biopsy may need to be performed to confirm the exact diagnosis. This is always performed by VATS, with patients going home the next day. Many novel new treatments for ILD are available, and new advances in treatment are imminent

Lung cancer is the most common form of cancer in the United States. With 170,000 new cases each year, it is the leading cause of death from cancer. Early detection can improve survival, by low dose Ct screening, now readily available and covered by most insurance providers including Medicare. When lung cancer is further advanced, surgery in combination with chemotherapy or radiation therapy may still be curative.

Lung Transplantation can prolong and dramatically improve the quality of life for patients with severe end-stage, non-malignant pulmonary disease and no alternative treatment options. Because our thoracic surgeons have appointments at New York Presbyterian hospital and the largest transplant program in the region, patients in need of transplantation can be quickly referred for assessment.

Mediastinal tumors, which can be benign or cancerous, form in the area of the chest that separates the lungs and is called the mediastinum. Mostly involving the anterior mediastinum, these tumors are usually resected by thoracoscopy or VATS, thereby minimizing post-operative pain, and speeding recovery.

Pectus excavatum is an abnormal development of the chest wall in which several ribs and the sternum grow abnormally, resulting in a caved-in, or sunken appearance. Our goal is to provide complete clinical resources for the patient and family for diagnosis and decisions about treatment, and if surgical treatment is chosen, for recovery, rehabilitation, and return to school or work, and exercise. Dr. Gorenstein, a leading surgeon in chest wall surgery in the region, has immense experience in both minimally invasive repair of PE, (NUSS procedure). He has performed more NUSS procedures on adults than any other surgeon in the tri-state area.

Thoracic Outlet Syndrome (TOS) is a term used to describe symptoms that arise from the compression of either the brachial plexus (neurogenic TOS) or the subclavian artery or vein (vascular TOS).  Neurogenic TOS is far more common than vascular TOS. When symptomatic, and non-responsive to physical therapy, neurogenic TOS requires first rib resection, to decompress the brachial plexus. Vascular TOS always requires surgery to decompress the vein or artery, and on occasion vascular reconstruction. Working together Drs. Ginsburg, Gorenstein and Schwartz, working together as thoracic and vascular surgeons provide years of experience to patients with TOS.

Tracheal Diseases involve the trachea, or windpipe, the airway that leads from the larynx (voice box) to the bronchi, which are airways that lead to the lungs. Diseases include tracheal stenosis, tracheobronchomalacia, and tracheal tumors. Dr. Gorenstein’s training at the University of Toronto, equipped him to diagnose and treat complicated tracheal problems.

 

Lung Cancer

Lung cancer is the most common form of cancer, and the leading cause of cancer deaths  in the United States, accounting for more cancer deaths, than the next three most common causes of cancer combined. There are more than 250,000 new cases of lung cancers diagnosed each year. It is also the leading cause of death from cancer.

Of the two categories of lung cancer, non-small cell lung cancer is the most common, accounting for nearly 90% of cases. It often grows and spreads less rapidly than small cell lung cancer. There are three types of non-small cell lung cancer — squamous cell carcinoma, adenocarcinoma and large cell carcinoma. Small cell lung cancer is less common than non-small cell lung cancer. It grows more rapidly and is more likely to spread to other organs in the body.

Smoking is the biggest single risk factor for lung cancer in general, although non-smokers may also develop small cell lung cancer. Exposure to substances such as asbestos, radon gas, uranium, arsenic, and diesel exhaust are also known to increase the risk of lung cancer. A family history of lung cancer also can be a risk factor.

Many lung cancers are identified when patients undergo a chest X-ray or CAT scan for an unrelated reason — a cold, cough, or other respiratory symptoms. Symptoms of lung cancer include: persistent cough, coughing of blood, shortness of breath, a hoarse voice, and recurring respiratory tract infections such as pneumonia, unusual fatigue, and weight loss.

Lung cancer usually begins in one lung. If left untreated, it can spread to lymph nodes or other parts of the chest, including the other lung. Lung cancer can also spread throughout the body to the bones, brain, liver or other organs.

Lung cancer survival is related to the cancer's stage — the size and location of the tumor, whether the cancer has spread to surrounding lymph nodes, and whether it has spread to distant sites.

Schedule Your CT Lung Screening Now at 212.326.8505.

 

Multidisciplinary Approach to Lung Cancer

NewYork-Presbyterian/Columbia University Medical Center's thoracic surgeons work closely with practitioners from multiple departments to provide a multidisciplinary program of comprehensive care for patients with lung cancer. 

The role of the medical oncologist is pivotal in our multi-disciplinary approach to lung cancer. More than simply administering chemotherapy, the medical oncologist is part of a team comprised of thoracic surgeons, radiation oncologists, pulmonary medicine specialists, radiologists, and pathologists. Often the medical oncologist is the physician who coordinates and tailors the ever-expanding diagnostic and therapeutic options available to each patient. Medical oncologists of the Herbert Irving Comprehensive Cancer Center of NYPH/Columbia specialize in treating a wide range of cancers through the use of medical treatments such as chemotherapy, stem-cell transplantation, hormonal and biologic therapies, and gene therapy.

Decisions about each patient's care are made in weekly meetings that combine the expertise of thoracic surgeons, pulmonologists, medical oncologists, radiation oncologists, radiation therapists, and pathologists. Benefiting from our team approach, patients are offered individualized treatment, which may include preoperative or postoperative multimodality therapy, for example, a combination of chemotherapy and radiation therapy in conjunction with surgery. Such an integrated effort has been shown to improve survival from lung cancer.

In addition to providing specific therapies for lung cancer, the lung cancer team is concerned with supporting the patient's quality of life. Therefore, we provide supportive measures such as pain management, anemia treatment, and use of bisphosphonates, as well as other maneuvers to relieve local symptoms. Referrals to the extensive complementary medicine services at NYPH/Columbia are also available.

Moreover, the advent of personalized medicine is changing how we treat patients by employing targeted treatment strategies based on a tumor's specific molecular characteristics. Learn more about how our team is using this approach at Personalized Medicine.

 

Surgical Treatment for Lung Cancer

Treatment of lung cancer is stage dependent. For complete information on cancer staging, go to the American Joint Committee on Cancer.

If surgery is recommended, the type and extent of surgery will depend on the patient's specific stage, location, and form of cancer. The larger the nodule, the more lung tissue needs to be removed. A lung resection is a surgical procedure to remove a damaged or diseased portion of a lung, or a whole lung. Lung resection surgery offers the best opportunity for curing lung cancer when the disease is caught in its early stages.

In some cases, surgical removal may not be an option. For those patients who are candidates for lung resection surgery, a range of approaches is available. Whenever possible, we prefer to use minimally invasive techniques that reduce pain and aid in the patient's recovery.

Lobectomy: Video-Assisted Thoracoscopic Surgery (VATS)
In this technique, the surgeon makes two or three one-inch incisions between the ribs. A camera attached to a telescope (which magnifies the field of view), is placed in one of the incisions. The camera is used to examine the entire chest cavity, including portions of the lung. The surgeon then excises the nodule and gives it to the pathologist to examine under a microscope. If the nodule is cancerous, the surgeon can remove the entire lobe where the cancer has grown.

A VATS lobectomy offers a significant advantage to the patient because it reduces both the recovery period and the amount of postoperative pain, lowering the need for pain medications. Patients who undergo this procedure return to normal activities much faster than those who undergo a more extensive lobectomy performed through a thoracotomy incision. Read more about video-assisted thoracoscopic surgery (VATS).

Lobectomy: Thoracotomy
After neoadjuvant therapy or if the tumor is very large, a thoracotomy may be required. A thoracotomy incision is made between the ribs. It extends from the patient's side, under the arm, and up the back. The incision extends for about eight to nine inches. It requires dividing some chest wall muscles and spreading the ribs. If a thoracotomy incision is required to remove the lung cancer, our surgeons are able to perform the surgery with far less patient discomfort than was possible a decade ago. All of our patients are given an epidural catheter through which we provide postoperative pain medication. The pain relief from the epidural is quite effective. Patients are able to get out of bed on the first day after surgery and walk around as required.

Pneumonectomy
Occasionally, if the cancer is quite large or very central in the lung — close to where the major bronchus separates from the trachea — the only way to completely remove the cancer is to take out the entire lung. This procedure is referred to as a pneumonectomy. When you remove the entire lung, you obviously eliminate more viable lung tissue as well. A higher complication rate, therefore, is associated with this procedure. We try not to remove the entire lung unless absolutely necessary to try to cure the cancer.

 

 


Esophagus

Achalasia
What is Achalasia?
Achalasia is a rare disorder of the smooth muscle layer of the esophagus in which muscular ability to move food down the esophagus (peristalsis) is impaired, and the entry to the stomach or the lower esophageal sphincter (LES) fails to relax properly in response to swallowing. Onset of symptoms is usually gradual, with patients complaining of difficulty swallowing both solids and liquid, often regurgitating undigested food, and occasionally having cough or other respiratory complications. Because symptoms are progressive, achalasia should be treated, once the diagnosis is confirmed

Achalasia: Podcast by Lyall A. Gorenstein, MD »

Barrett's Esophagus
Barrett’s esophagus is a condition in which repeated contact with gastric acid (gastroesophageal reflux, or GERD) transforms a patient’s esophageal cells from normal squamous epithelium to abnormal intestinalized columnar epithelium. Barrett’s esophagus greatly increases the risk of developing esophageal cancer.

Risk Factors
Risk factors for Barrett’s esophagus include chronic, long-lasting gastroesophageal reflux, obesity, and smoking.

Diagnosis
Barrett’s esophagus is diagnosed with upper GI endoscopy and biopsy. Our endoscopists use the latest technology for the minute inspection of abnormal areas in the esophagus, including a modified blue light examination called narrowband imaging (NBI) for patients with Barrett's esophagus. In conjunction with high-resolution video endoscopes and electronic magnification, remarkably detailed views of the surface lining of Barrett's esophagus can be obtained to direct precision biopsies and guide therapy.

Capsule endoscopy, which has been shown to be effective in diagnosing conditions of the small intestine, is being evaluated as a non-invasive alternative for diagnosing Barrett's esophagus.

Treatments

Treatments for Barrett’s esophagus include: medications, endoscopic ablation therapies, endoscopic mucosal resection, and surgery.

personal-counselor-s-710400

Ablation Therapy

Endoscopists at Columbia use BARRX HALO technology, an advanced form of ablation that delivers heat energy in a precise and highly-controlled manner. This catheter delivers a short burst of radiofrequency energy circumferentially to the esophagus, which eliminates the abnormal Barrett’s epithelium and allows the normal squamous epithelium to regrow. It is capable of achieving complete removal of the dysplastic Barrett’s epithelium without damage to the normal underlying structures.

Our physicians are actively testing combining of radiofrequency ablation with acid suppression so a normal lining grows back with healing. Early results are highly promising, showing high efficacy for complete removal of Barrett's esophagus with a very low incidence of serious side effects. Efficacy and safety appear clearly improved compared with prior laser-based ablation therapies.

 

 

Endoscopic Mucosal Resection
Patients with Barrett's esophagus who develop a small focus of cancer can often be spared a radical surgical procedure by opting instead for endoscopic mucosal resection (EMR).

Performed through the endoscope, EMR involves injection of a solution under the abnormal area of the esophagus. Suction is then applied to create a small polyp of tissue, and a snare is used to resect the area, much like the process of removing a colon polyp. While this procedure cannot remove tissue from the entire circumference of the esophagus, EMR can be used to remove a small superficial cancer or a localized area of high-grade dysplasia.

Endoscopic ultrasound (EUS) is used to judge whether EMR is appropriate and is also effective for staging, providing definitive evidence on the depth of the tumor.

 

Esophageal Cancer
The two most common types of esophageal cancer are squamous cell carcinoma, most often occurring in the upper and middle portions of the esophagus, and adenocarcinoma, affecting the mucous-secreting cells in the lower portion near the stomach. Other rare forms of the disease include sarcoma, lymphoma, small cell carcinoma and spindle cell carcinoma. In addition, breast and lung cancers can metastasize (spread) to the esophagus.

Signs & Symptoms
Symptoms of esophageal cancer include:

  • Difficulty swallowing (dysphagia) is the most common symptom of esophageal cancer. It doesn't appear right away but only after a tumor has grown large enough to prevent food from passing normally.
  • Unintentional weight loss because of reduced eating due to difficulty swallowing.
  • Pain in the throat, mid-chest or between the shoulder blades.
  • Hoarseness, hiccups and sometimes vomiting of blood appear when cancer is quite advanced.

 

Risk Factors
Esophageal Cancer Risk Factors
Researchers have identified several factors that can lead to esophageal cancer, including:

  • Heavy alcohol consumption
  • Tobacco use
  • Barrett’s esophagus
  • Acid reflux
  • Diet — a diet low in fruits and vegetables appears to contribute to esophageal cancer. Especially implicated are diets lacking in vitamins A, C and B-1 (riboflavin). People with low levels of the mineral selenium have a higher risk of esophageal cancer than do people with normal blood-selenium levels. Because high doses of selenium can be toxic, experts recommend getting selenium from foods such as fish, whole-grain bread, Brazil nuts and walnuts rather than from supplements.
  • Obesity — having a body mass index greater than 25 has been linked to an increased risk of adenocarcinoma.

 

Sometimes esophageal cancer is associated with certain rare medical conditions, including:

  • Achalasia
  • Esophageal webs, thin tissue protrusions in the esophagus
  • Plummer-Vinson or Paterson-Kelly syndrome
  • Tylosis — a rare inherited disorder in which excess skin develops on the soles of the feet and palms of the hands. Close to half the people with tylosis eventually develop esophageal cancer. A genetic defect appears to be responsible for both tylosis and the associated cancer.

 

Diagnosis
Diagnosis of Esophageal Cancer
Diagnosis is achieved through esophagoscopy and biopsy.
Once diagnosis has been established, accurate staging of the cancer is necessary in order to permit optimum therapeutic decision-making. We use endoscopic transesophageal ultrasound (EUS) to visualize tumor depth, surrounding lymph nodes, and the tumor's relationship to adjacent structures. In combination with PET (positron emission tomography) and CT scanning, EUS is highly effective in properly staging tumors of the esophagus.

Surgery
Patients with more advanced tumors are encouraged to undergo multimodality therapy with chemotherapy and radiation therapy followed by surgery. Preoperative therapy increases the likelihood of complete removal of the tumor, and increases cure rate.

We perform many of our esophageal resections for cancer using laparoscopy or thoracoscopy. These minimally invasive approaches can significantly reduce the post operative convalescence, and speed recovery. Most patients are candidates for minimally invasive esophagectomy, but our considerable experience with open surgery enables us to select appropriate patients for minimally invasive procedures.

Read more about esophagectomy.

Radiation Oncology
Our radiation oncology colleagues offer sophisticated treatment technology for patients with esophageal cancer, including the placement of small catheters threaded to the site of the tumor to deliver a high dose of radiation. Radiation therapy may be used with curative intent or to relieve symptoms, such as an inability to swallow solid foods.
Please click here to learn more about the Department of Radiation Oncology.

 

Gastroesophageal Reflux
Gastroesophageal reflux disease (GERD), also called acid reflux, is a common digestive disorder in which stomach contents regurgitate (reflux) into the esophagus. Also called heartburn, GERD often causes inflammation and damage to the esophagus and occasionally to the lungs and vocal cords. Prolonged untreated GERD can lead to Barrett’s esophagus, a dangerous precancerous condition.


Signs & Symptoms
Patients with GERD may suffer from a wide spectrum of symptoms including heartburn, regurgitation and dysphagia (difficulty swallowing).


Diagnosis
It is important that the diagnosis and particular cause of the GERD be confirmed. The patient's history of signs and symptoms is reviewed, and tests are performed including:

  • Manometry
  • pH probe
  • An upper endoscopy may also be necessary to look for possible areas of stricture. Biopsies (small tissue samples) can also be obtained from an endoscopy to confirm the diagnosis of esophageal inflammation and to exclude Barrett's esophagus, the transformation of esophageal cells into stomach lining cells after years of reflux.
  • Other tests include an upper GI series or a barium swallow x-ray, which can show the acid reflux and inflammation of the esophagus as well as the presence of hiatal hernia, which occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm, often causing LES dysfunction.

Treatments
Medical therapy, consisting of anti-acid medications and lifestyle modifications, results in symptomatic relief for most patients. Surgical therapy is indicated for patients in whom medicine has proven ineffective, is poorly tolerated, or is too expensive to continue. It is also indicated for complications of reflux disease such as an esophageal stricture (narrowing) and the development of pre-cancerous changes in the esophagus.
For those patients in whom a medical regimen has not been successful, anti-reflux surgery can offer gratifying, durable results with relief of GERD. While GERD can have several causes, surgery is most effective for those patients whose GERD is caused by a defective lower esophageal sphincter (LES), the muscle connecting the esophagus with the stomach.
Both surgical and endoscopic techniques are available depending upon the patient's specific case. Our gastrointestinal specialists were among the first to perform endoscopic suturing for gastroesophageal reflux and continue to evaluate its efficacy. They are actively testing new endoscopic devices. These minimally invasive procedures may enable the patient to return home the same day.

 

Fundoplication Surgery
he fundus (top of stomach) is wrapped around the esophogastric junction (the connection between the stomach and the lower esophagus).
The fundus (top of stomach) is wrapped around the esophogastric junction (the connection between the stomach and the lower esophagus).
More than 90% of patients who undergo fundoplication have no reflux after surgery. The goal of the procedure is to restore the physiologic equivalent of the LES by wrapping the stomach around the lower esophagus.


As the stomach becomes distended during a meal, the wrap compresses the lower esophagus, preventing reflux, thus imitating the action of a valve. Hiatal hernia, if present, may be repaired during the procedure. For patients who have other problems contributing to or accompanying their GERD, such as a swallowing disorder, a shortened esophagus, or gastric outlet obstruction, there are variations to this surgery so that there is a better overall control of symptoms.


During the operation, the surgeon raises the liver to expose the junction between the stomach and the esophagus. A space is created behind the esophagus and the fundus of the stomach and freed from its attachment to the spleen. The fundus is then pulled behind the esophagus and secured in place. Depending on the type of procedure, the wrap is either sutured to the esophagus itself, or it is sutured to the stomach on the other side of the wrap.

 

Endoscopic Repair of GERD
Instruments and a small camera are inserted through the mouth and advanced to the junction between the esophagus and the stomach, where the stomach is tacked alongside the esophagus in order to create a more effective barrier to reflux. The surgeon performs the procedure entirely through the mouth without making any external or internal incisions. Read more here about the totally incisionless procedure now offered at NYP/Columbia.
This procedure is ideal for patients who:

  • Have a positive pH test
  • Are at least partially responsive to proton pump inhibitor medicines (PPIs)
  • Who have significant non-acid regurgitation
  • Who prefer to be off medication

 

Hiatal Hernia
In a hiatal hernia (also called hiatus or diaphragmatic hernia), a portion of the stomach penetrates (herniates) through a weakness or tear in the hiatus of the diaphragm, the small opening that allows the esophagus to pass from the neck and chest to its connection with the stomach. Often there are no symptoms, and the condition may not cause any problems. The patient may not be aware they have a hiatal hernia.

ttp://columbiasurgery.org/sites/default/files/styles/large/public/hiatal_hernia_stages.png?itok=U5_wmYjs

Sliding Hiatal Hernia
The term sliding is employed when hiatal hernia involves the lower esophageal sphincter where the esophagus attaches to the stomach. It can also involve a small portion of the stomach. The patient may experience heartburn and gastroesophageal reflux. Because reflux may damage the lining of the esophagus, treatment is essential. Symptoms can usually be managed with medications and behavior modification such as elevating the upper body on a pillow during sleep. Surgery may sometimes be required to correct a sliding esophageal hernia.


Paraesophageal Hernia and Intrathoracic Stomach
In more severe cases of hiatal hernia, the fundus, or upper portion of the stomach, may slide upward into the chest cavity through the hiatus. The condition occurs as an intensifying of a sliding hiatal hernia. In rare cases, the entire stomach and even some of intestines may migrate through the hiatus and rest on top of the diaphragm next to the esophagus, a condition known as giant esophageal hernia.


Giant Hiatal Hernias: Podcast by Lyall A. Gorenstein, MD »  


Risk Factors
Hiatal hernia is initiated by pressure in the abdomen occurring through:

  • Heavy lifting
  • Hard coughing or sneezing
  • Violent vomiting
  • Pregnancy and delivery
  • Obesity may also cause hiatal hernia because of pressure on the abdomen
    caused by extra weight.
  • Heredity
  • Smoking
  • Stress
  • Short esophagus (paraseophageal hernia)

Signs and Symptoms
Most small hiatal hernias do not cause symptoms. The most common symptom of hiatal hernia is gastroesophageal reflux (GERD).
Giant hiatal hernias may cause symptoms including heartburn/regurgitation, anemia, aspiration, chest pain associated with eating, vomiting after meals, difficulty swallowing, fatigue, and shortness of breath.


Symptoms of parasophageal hernia may include problems swallowing, fainting, and vomiting.
Diagnosis
Hiatal hernia is diagnosed with an upper GI series or endoscopy.
In an upper GI series, or a barium swallow, also called barium contrast X-ray, the patient swallows a solution of barium, a compound that will appear inside the body during X-ray so the physician may observe how fluid moves through the esophagus as well as the appearance of the stomach.
In esophagoscopy/endoscopy of the esophagus, a thin, flexible tube with a camera is inserted through the mouth into the esophagus, allowing the physician to view the interior of the esophagus and obtain small tissue samples for biopsy, if necessary.
Treatments
Hiatal hernias require repair for two main reasons:

  • The patient's reflux symptoms are not successfully controlled with GERD medication therapy.
  • The patient has a giant esophageal hernia (also known as intrathoracic stomach.)

If surgical treatment is required, our surgeons nearly always use minimally invasive anti-reflux techniques, including laparoscopy and endoscopy, with the type of procedure used depending upon the amount of stomach that has migrated through the diaphragm into the chest. GERD medications are not necessary after surgery.
Repairing the Hiatus
ttp://columbiasurgery.org/sites/default/files/styles/large/public/gerd_techniques.gif?itok=r4c0JN4z
An early-stage hiatal hernia may be repaired by decreasing the size of the enlarged hiatus (the opening in the diaphragm through which the esophagus travels on its way to the stomach). This is accomplished by means of sutures and a prosthetic mesh to reinforce the diaphragm tissue.
Nissen Fundoplication
he fundus (top of stomach) is wrapped around the esophogastric junction (the connection between the stomach and the lower esophagus).
The fundus (top of stomach) is wrapped around the esophogastric junction (the connection between the stomach and the lower esophagus).
To repair and prevent a sliding hiatal hernia, Nissen fundoplication involves wrapping of the fundus (upper part) of the stomach around the bottom portion of the esophagus to create a bulge of tissue that holds the stomach in place below the diaphragmatic hiatus. Nissen fundoplication also reinforces the lower esophageal sphincter and alleviates reflux when it is present.


Collis-Nissen Gastroplasty
Paraesophageal hernia and intrathoracic stomach may be complicated when a short esophagus pulls upward on the stomach. In Collis-Nissen gastroplasty, the surgeon uses the upper portion of the stomach to extend the esophagus and ease this tension. Our team routinely uses minimally invasive laparoscopy to perform this procedure, which was traditionally performed through a major chest incision.

 

 

Acute Respiratory Distress Syndrome (ARDS)/Lung Failure

Acute respiratory distress syndrome (ARDS) occurs when the millions of tiny air sacs in the lungs, called alveoli, fill with excess fluid. This can be the result of any kind of injury to or illness in the lung. Pneumonia, trauma, sepsis, and inhalation of stomach contents or smoke can all cause the body to initiate an inflammatory response, sending excess fluid to the lungs.


In healthy lungs, the alveoli fill with inhaled air, transferring oxygen into the blood carried by small neighboring vessels. The oxygen-rich blood can then travel throughout the body to deliver its cargo to the kidneys, brain, liver, and other organs. But when fluid accumulates in the alveoli, they can no longer fill with air, and oxygen cannot pass as easily into the blood. Soon after the initial injury or illness, blood oxygen levels decline, and breathing becomes fast and difficult as the body tries to compensate. There may also be signs, such as confusion or low blood pressure, that the vital organs aren't getting enough oxygen. In some patients, the lung may try to heal itself, creating scar tissue that decreases the lung's elasticity and makes it still harder to breathe.


ECMO for ARDS
Extracorporeal membrane oxygenation (ECMO) is one of several terms used to describe a circuit outside the body ("extracorporeal") that directly oxygenates and removes carbon dioxide from the blood. ECMO functions as an artificial lung working in addition to the patient's own failing lungs.
When ECMO is used for respiratory failure, a catheter is placed in a central vein, usually near the heart. A mechanical pump draws blood from the vein into the circuit, where the blood passes along a membrane (referred to as an "oxygenator" or "gas exchanger"), providing an interface between the blood and freshly delivered oxygen. The blood may be warmed or cooled as needed, and is returned either to a central vein ("veno-venous ECMO") or to an artery ("veno-arterial ECMO"). Veno-venous ECMO provides respiratory support alone, while veno-arterial ECMO provides both respiratory and hemodynamic (blood pressure) support. Examples of scenarios where ECMO may benefit patients include the following:

  • If a patient has life-threatening acute respiratory failure with profound gas exchange abnormalities, ECMO may be used as salvage therapy to rescue the patient.
  • ECMO may also be used in patients with ARDS who would benefit from lung-protective ventilation strategies but who are unable to tolerate such strategies.

NewYork-Presbyterian/Columbia's Center for Acute Respiratory Failure specializes in ECMO.


In addition to receiving oxygen therapy, ARDS patients are given medication to:

  • Prevent and treat infections
  • Relieve pain and discomfort
  • Prevent clots in the legs and lungs
  • Minimize gastric reflux

 

Emphysema and Chronic Obstructive Pulmonary Disease (COPD)

Emphysema is a progressive, destructive lung disease in which the walls between the tiny air sacs in the lungs are damaged. As a result, the lungs lose their elasticity and exhaling becomes more and more difficult. Air remains trapped in the overinflated lungs.


Emphysema patients report increasing shortness of breath, especially with activity, as well as variable degrees of coughing and wheezing, and irreversible airflow obstruction. Heredity may play a part in the tendency to develop emphysema, but the disease is clearly worsened by smoking, air pollution, exposure to dust and fumes, and lung infections.
Together with asthma and chronic bronchitis, emphysema is part of a group of diseases that share a common feature – difficulty in expelling air from the lungs. We refer to this group as Chronic Obstructive Pulmonary Disease (COPD). COPD is the most common form of pulmonary dysfunction today.


The fourth leading cause of death in United States, COPD is also the second major cause of disability (behind coronary artery disease). Over 15 million adult Americans have COPD. While hereditary and environmental factors can play a role in causing or aggravating COPD, smoking is responsible for 82% of cases.


Lung Volume Reduction Surgery for COPD
Lung Volume Reduction Surgery (LVRS), the removal of sections of damaged lung tissue, has shown promising results for patients with end-stage emphysema. By removing the most diseased tissue (up to 30% of the lung volume), the goal is to improve the residual lung function and respiratory mechanics. LVRS can be performed through either median sternotomy (open chest) or video-assisted minimally invasive technique.


NewYork-Presbyterian/Columbia University Medical Center is the only medical center in the tri-state area designated by the National Institutes of Health as a center of excellence in LVRS for the treatment of emphysema. If you are interested in being evaluated for lung volume reduction surgery, please call the Center for Lung Failure at 212.305.1158 to obtain a patient questionnaire. You will need to discuss your interest in LVRS with your primary physician, who will be asked to provide your medical information to us including history, pulmonary function, and x-ray studies.


Our staff will review that information to determine whether you're a candidate for an on-site evaluation. If you qualify, you will be invited to the center for 2 days of outpatient testing, including:

  • Chest X-ray
  • Chest CT scan
  • Perfusion scan of lungs
  • Blood tests (alpha1 antitrypsin; Cotinine level)
  • Complete pulmonary function test with lung volumes by plethysmography
  • Room air arterial blood gas
  • Dobutamine stress test of heart
  • Cardiopulmonary exercise test

After these tests are done, you will be examined by a pulmonologist and surgeon who make final decisions about your eligibility for lung volume reduction surgery. All patients, whether surgical candidates or not, are evaluated for and prescribed a pulmonary rehabilitation program by the rehabilitation medical physician during their evaluation at the Center.
Patients accepted for surgery are referred to a 6-week program of outpatient pulmonary rehabilitation prior to surgery as well as a preoperative checkup in the final week of the program. At this time surgical consent is obtained, surgery scheduled and preoperative testing including an evaluation by an anesthesiologist is performed. All arrangements are made with the patient and his or her family and the staff at the Center for Lung Failure.


Most private insurance plans cover the procedure, while Medicare covers lung volume reduction surgery with condition.


Learn more about Lung Volume Reduction Surgery here.


Lung transplantation offers a return to improved breathing and an excellent quality of life for patients suffering from advanced emphysema. NYP/Columbia is a leading center in the field of lung transplantation.


Not all patients with advanced emphysema are candidates for LVRS or lung transplantation, however. For such patients, we provide other treatment options, including redirection of airflow by means of bronchoscopically implanted stents and valves. These endobronchial stents enable trapped air to escape and improve overall lung function.

Interstitial Lung Disease and Pulmonary Fibrosis
Interstitial Lung Disease and Pulmonary Fibrosis are general terms used to describe inflammatory and fibrotic disorders of lung tissue (interstitium). There are over 100 known causes of interstitial lung disease and pulmonary fibrosis, which include familial and genetic disorders, inhaled substances, infections, medications, and connective tissue diseases.


Idiopathic Pulmonary Fibrosis (IPF) is an interstitial lung disease characterized by chronic inflammation, accompanied by an uncontrolled healing response that causes progressive scarring or thickening (fibrosis) of tissues between the lung's alveoli, or air sacs. The cause of IPF is unknown, although the body's own immune response seems to play a major role. Recent data suggest approximately 28 cases per 100,000 population. The usual age at diagnosis is between 40 and 70, but often there is X-ray evidence of disease two to five years before the diagnosis is made. The disease affects more men than women.


Patients usually present with a subtle onset of breathlessness with exercise. Over time there is a progressive worsening of breathlessness, as oxygen transfer to the blood decreases. Heart failure often develops. The median survival for people with IPF is five years.


The diagnosis of interstitial lung disease has become significantly more accurate as a result of thoracoscopy, a minimal access procedure that uses small incisions and video-endoscopic instruments to view the chest. Multiple areas of the lung can be biopsied and scanned to determine the presence of this disorder without the need for a large incision.


Standard treatment for IPF is intended to improve symptoms and slow progression of the disease. Corticosteroids and cytotoxic drugs aim to reduce the inflammatory reaction and prevent the scarring and thickening of lung tissues. A new FDA approved drug to treat pulmonary fibrosis will soon be available, providing an additional treatment option for patients with this disease. Lung transplantation has been successful as a treatment of last resort.

 

Chest Wall

Pectus Excavatum
 16-year-old male with pectus excavatum
A 16-year-old male with pectus excavatum


Pectus excavatum is a malformation of the chest wall in which several ribs and the sternum grow abnormally, resulting in a caved-in, or sunken appearance. It is a relatively common congenital deformity and occurs more often in males than in females. Approximately 40% of pectus excavatum patients have one or more family members with the defect.


Often present at birth, the condition may also develop during puberty and can range from mild to severe. Although its causes are not completely understood, the condition is believed to arise from excessive growth of the cartilage connecting the ribs to the breastbone, which pulls the sternum inward.


Pectus excavatum can compromise lung and heart capacity, especially when it is severe, causing the patient to experience fatigue, shortness of breath, chest pain, and a fast heartbeat. In some patients, the proximity of the sternum and the pulmonary artery may cause a heart murmur. For ordinary everyday activities, a person with pectus excavatum may have no symptoms, but with rigorous exercise, symptoms often appear. Lung capacity may be curtailed because lungs are confined and cannot properly expand. During exercise, the patient compensates by engaging the diaphragm in breathing in order to enable the lungs to expand more and obtain adequate oxygen and carbon dioxide exchange for the demands of the body. The additional energy utilized for breathing in this manner contributes to fatigue. Patients with severe pectus excavatum often notice that they are incapable of similar levels of activity as their peers. This can be especially difficult for adolescents, who often withdraw from participating in sports or other high stress physical activities.


 CT scan of a 14 year old male with severe pectus excavatum
A CT scan of a 14-year-old male with severe pectus excavatum
In addition to its more serious symptoms, pectus excavatum may have negative psychosocial effects in children and teenagers, who experience self-consciousness and difficult peer interactions stemming from their appearance. Often these patients avoid activities that expose the chest.


Multiple tools are used to diagnose the condition and gauge its extent, including:

  • Visual examination of the chest
  • Ausculation — analysis of sounds of the heart and chest to detect the condition's effect on heart and lung function
  • Electrocardiogram (ECG)
  • Echocardiogram (a noninvasive test that takes a picture of the heart taken with sound waves)
  • Pulmonary function testing (patient breathes into a mouthpiece connected to an instrument that measures the amount of air breathed over a period of time)
  • Chest X-ray
  • CT-scan
  • Haller Index: A measure of the extent of pectus excavatum by means of the CT scan. It is calculated by obtaining the ratio of the horizontal distance of the inside of the ribcage and the shortest distance between the vertebrae and sternum. A Haller Index of greater than 3.25 is generally considered severe (a normal Haller Index is 2.5).

Pectus Excavatum: Podcast by Lyall A. Gorenstein, MD » 


Surgical Treatment
The ideal age for surgical treatment of pectus excavatum is between 12 and 18 years. The goal of surgery to correct a pectus excavatum defect is to improve the patient's breathing, posture and cardiac function, in addition to giving the chest a normal appearance. This is typically accomplished by repositioning the breastbone. Surgical repair has excellent success rates, with cardiovascular and lung function return to near normal in the majority of patients. Our surgeons are able to treat most pectus excavatum patients — both adolescents and adults — using minimally invasive techniques.

Recovery after pectus excavatum repair varies depending on the patient's age and the amount of chest depression. Most patients leave the hospital within 3 to 5 days and can return to school or work within two to three weeks. Patients must avoid vigorous exercise for the first month after surgery, and contact sports for three months after surgery.
Nuss Procedure
-ray of a 15 year old male after undergoing the Nuss procedure.
X-ray of a 15 year old male after undergoing the Nuss procedure.
The minimally invasive Nuss procedure is performed with general anesthesia. Performed using video-assisted thoracoscopic surgery or VATS, the Nuss procedure creates a horizontal passage underneath the sternum through two small incisions in the side of the patient's chest. A separate, small incision enables the surgeon to view the inside of the chest with the thoracoscopic camera. A convex bar known as the Lorenz pectus bar is specially shaped to fit the patient's anatomy, inserted through the passage, and then turned to push the sternum outward. The bar must remain in place for a minimum of three years while the chest contour re-forms to its new shape. The bar is removed as an outpatient procedure.
Many adults have undergone minimally invasive pectus repair with the Nuss procedure, which was originally developed for the repair of pectus excavatum in children. The results appear to be as good as with the modified Ravitch procedure (description follows below), which has been the traditional approach to repairing pectus excavatum in adults. 
Modified Ravitch Repair
The procedure is performed with the patient under general anesthesia.
Utilizing a horizontal incision, the modified Ravitch technique involves removing small pieces of deformed chest cartilage and repositioning the protruding ribs and sternum. To support the repaired chest architecture, titanium bars are secured to the ribs and sternum.
Previously, the supports used to keep the sternum in place needed to be removed after several years. The bars currently used are secured to the chest wall in such a fashion that they can remain permanently in place, thereby avoiding the need for a second operation.

 

Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a term used to describe symptoms arising from compression of either the subclavian artery that supplies blood to the head and arms, and passes beneath the clavicle (arterial TOS); the subclavian vein (venous TOS); or brachial plexus, a group of spinal nerves emerging from the neck and leading into the arms (neurogenic TOS). Symptoms of TOS include pain in the neck and shoulder areas and numbness in the arm and hand.

Although arterial and venous TOS are well-recognized entities, they account for less than 5% of patients with the condition. By far, the majority of patients with this diagnosis have neurogenic TOS. The diagnosis of TOS is established based on symptoms, physical examination, imaging studies such as MRI and EMG, and nerve conduction studies.

Surgical Treatment
Some patients with TOS require surgery for relief of their symptoms. All patients with neurogenic TOS are first prescribed physical therapy to increase motion in the neck and shoulders, strengthen muscles, and improve posture. Only those whose severe symptoms persist after physical therapy are considered eligible for surgery.

Depending on symptoms and which structures are involved, TOS surgery can be performed by either a supraclavicular or transaxillary approach. While some surgeons who perform TOS surgery only have experience and expertise with one approach, surgeons at NewYork-Presbyterian/Columbia tailor the approach to TOS based on symptoms. In patients who have venous compression such as in Pagett-Schroeder syndrome, our surgeons favor a transaxillary decompression, whereas in arterial compression they favor a supraclavicular approach. In patients with neurogenic TOS our surgeons select the approach based on several patient factors. This affords the best results in patients with TOS.

  • Thank you all so very much! ------------- Dawn B. (Stony Point, NY)
  • I was very pleased with the staff and treatment received. --------- Adele P. (Piermont, NY)
  • Great job, Great staff! ---------------- Steve R. (West Nyack, NY)