Mediscene

Welisara showing the way in thoracoscopic operations

By Kumudini Hettiarachchi, Pix by M.A. Pushpa Kumara

The tragic misconceptions are many -- if you are a victim of lung disease including cancer, the writing is on the wall for you. There is no hope only despair because there is no treatment in Sri Lanka.

No words are needed to dispel these misconceptions, only a visit to the Welisara Chest Hospital, in the suburbs of Colombo to confirm the fact that many a chest disease with tongue-twisting and jaw-breaking names is not only being treated but treated successfully here. The strongly embedded view that this Chest Hospital is solely for the treatment of tuberculosis also vanishes, after speaking to a few patients.

Many are the chest operations as well as minimally invasive procedures (keyhole surgery) being carried out by the thoracic surgical team under whom come Wards 3 and 4 with 60-80 beds.

Fifty-six-year-old Hassan* of Narammala who had come into hospital with a severe pant and much difficulty in breathing and 35-year-old Nihal* of Moneragala who could hardly talk due to breathlessness were preparing to go home, and no more proof was needed about the rapid advances made in lung disease treatment in Sri Lanka.

Earlier Hassan had been rushed to Kurunegala Hospital where an X-ray found, according to him, “that there was phlegm round the lung”. Suggesting that a piece of the lung needed to be taken for testing, he was referred to Welisara. Now having undergone a thoracoscopic bullectomy, he was ready to go home a few days later.

“There is no pain and the day after the ‘operation’ I was asked to walk about,” says a relieved Hassan, having come back from a long bath. “The breathing difficulty has vanished.”

Nihal’s story is more or less similar. Having undergone some tests, it had been found that there was pus around his lungs. “After the procedure, which is called Decortication for Empyema, the lung is fully expanded,” says a doctor pointing to Nihal’s latest X-ray.

“If these diseases are untreated, the patients will die in a short time,” says a surgeon, explaining that now at least two major lung operations are performed at the Chest Hospital every day with a total of at least eight per week, along with many minimally-invasive procedures.

The wards are spick and span and MediScene understands that not so long ago they were not only dilapidated, but had cattle occupying the corridors. The drastic changes now augur well for those with diseases in the chest area.

About 70% of the procedures at these two wards at Welisara are carried out with the minimally-invasive thoracoscope. Explaining the three parts of the thoracoscope -- a light source, a fibre optic tube that feeds the light into the chest and a camera – the surgeon says the light is directed through the fibre optic tube into the chest so that the view inside the chest is transmitted back to the camera, allowing it to be displayed on a TV.

These thoracoscopic operations entail two or three small one-cm incisions on the side of the chest rather than opening up the chest cavity (thoracotomy) or three-cm incisions for Video Assisted Thoracoscopic Surgery (VATS), MediScene learns.

The other advanced techniques used here are mediastinoscopy carried out with a special scope to biopsy intra-thoracic lymph nodes without doing a thoracotomy and rigid operating bronchoscopy for removal of endo-tracheal and endo-bronchial benign tumours.

The procedures include lung biopsies; atypical lung segmentectomy for tumours; metastatectomy for lung secondaries from other tumours (sarcoma/colon tumours); VATS lobectomy for lung cancer; lung bullectomy for bullae; lung volume reduction operations for emphysema, bronchogenic cysts, mediastinal tumours (neurofibroma) and cysts; pleurectomies for spontaneous pneumothorax; pleurodesis (talc) for malignant effusions (fluid); and decortication for pleural fibromas.

The mortality (death) and morbidity (illness) rates in thoracoscopic procedures are very low when compared to major surgery, the surgeon stresses, adding that it prevents many complications of open chest surgery. It reduces pain, the number of days a patient has to stay in hospital and the recovery time.
Open surgical procedures, meanwhile, are performed with 5-6 cm incisions allowing muscle-sparing thoracotomies without damaging any muscles or nerves. “This allows us to operate on severely ill patients and will reduce post-operative complications and facilitate early discharge from the hospital,” he said. The open-chest operations are carried out for central lung cancer (involving the central vessels and air passages which restrict thoracoscopic resection).

Here too new techniques such as arterial bronchial sleeve resection (avoiding a pneumonectomy or removal of the whole lung) which saves lung tissue; carino plasty and atrial resection (heart) for previously unresectable cancers; and thoracic lymphadenectomy are carried out in each cancer patient to reduce the recurrence rate and prolong the disease-free survival time.

Here is a description of some of the procedures performed at the Chest Hospital:

  • Atypical resection -- the removal of the diseased part of the lung.
  • Bullectomy -- the removal of a bulla, which is a large, distended air space in the lung greater than half an inch in diameter that does not contribute to the breathing function.

In those afflicted with emphysema, a chronic progressive disease mainly caused by smoking, the walls of the air sacs of the lung breakdown, enlarging the sacs abnormally, leading to poor oxygenation. The small airways which carry the air to and from the air sacs also collapse during breathing, particularly exhalation.

A patient recovering after surgery.

The enlarged air sacs fill easily with air during inhalation but lose their ability to empty the lung through the small airways during exhalation. Once the bulla is removed, the healthy air sacs around it have room to expand, and the muscles (intercostals and diaphragm) which help the patient to breathe, function better.

  • Decortication – the draining of pus (empyema) and removal of the layer covering the pleura.
  • Lobectomy – the anatomical dissection or removal of the lobe of the lung which is affected.
  • Lung volume reduction – if the entire thorax is over-inflated due to some disease, it could restrict the function of the musculature of the airways, worsening the breathing difficulties experienced by the patient. Resection of the most severely over-inflated sections which brings about lung volume reduction restores the functions of the respiratory musculature.
  • Lymphadenectomy – the removal of the lymph nodes.
  • Metastatectomy --   removal of one or more metastases (tumours formed from cells that have spread from a primary tumour).
  • Pleurectomy – excision or removal of part of the pleura.
  • Segmentectomy – the removal of a segment of the lung.
  • Sleeve resection -- surgery to remove a tumour in a lobe of the lung and a part of the main bronchus (airway). The ends of the bronchus are rejoined and any remaining lobes are re-attached to the bronchus.

This surgery is done to save part of the lung.

  • Talcum pleurodesis -- a talcum-based powder preparation is introduced into the pleural space to fuse the pleural layers together to prevent the collection of air or fluid in this space.
  • Thymectomy -- the removal of the diseased thymus (that helps control immune cell growth).

(* Names of patients have been changed to protect identity)

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