Thoracic Surgery Description of Service 2007

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  • 1. Thoracic SurgeryDescription of Service 2007 Cardiothoracic Centre Swansea NHS Trust
  • 2. Executive Summary 4Contents Introduction 5 Background to the Swansea Service 6 Health Commission Wales (HCW) Aims and Objectives 7 For thoracic surgical services HCW aims 7 Descriptions of the relevant associated services within Swansea NHS Trust 8 Respiratory medicine 8 Video-Assisted Thoracic Surgery. 8 Endobronchial therapies 8 Cardiac surgery 8 Cardiothoracic anaesthesia and intensive care 9 Radiology 9 Plastic and Reconstructive surgery 9 Ear, Nose and Throat (ENT) surgery 10 Trauma services 10 Oesophageal disease 11 Radiotherapy & Chemotherapy 11 Palliative care 11 All Wales minimum standards 12 Description of the range of thoracic procedures offered by Swansea NHS Trust 13 Description of facilities for thoracic surgery 13 Description of MDT arrangements for lung cancer care in South West Wales 13 Moving towards a Managed Network 14 Activity Data 15 Thoracic Surgical procedures 2006-2007 15 Current activity compared with historical activity 16 Complications following thoracic surgery 16 Average and Median Length of stay 16 Mortality 16 Predicted future demand modelling 18 Assumptions 18 New scanning techniques 18 Theatre/bed capacity in cardiothoracic centre 19 Appointment of a second Consultant Thoracic Surgeon 20 Benefits of appointment 20 Conclusions 21 Thoracic Surgery Satisfaction Surveys 22 Glossary 25
  • 3. Executive Summary 1. Thoracic surgery based at Morriston Hospital ensures that high quality, best value spe- cialised treatment is provided close to patients’ homes. 2. Morriston Hospital is geographically placed in the centre of South Wales with travel times from the west (Haverfordwest) and east (Chepstow) being 80 minutes. This im- proves equity of access and allows the needs of patients, their families and friends to be at the forefront of the service. 3. Morriston Hospital has the key components of lung cancer services (i.e. respiratory physicians, thoracic surgeons, thoracic radiology, thoracic histo- pathologist, oncology, and palliative care) already established on one site. Patients and clinical staff are closer to the facilities and the multidisciplinary team. 4. Thoracic surgery and anaesthesia at Morriston Hospital provide support to Respiratory Physicians in their management of non-malignant chest diseases as well as procedures uniquely performed at Morriston Hospital such as endo- bronchial stenting, laser, diathermy and photodynamic therapies. 5. Thoracic surgery provides support to other local and regional specialist services within the Trust such as trauma, maxillofacial, oesophageal, plastic and ENT surgery and sup- ports the wider activities of the Swansea Cancer centre (e.g. diagnosis and staging of lym- phoma) 6. Education and training are important activities of the Trust and the School of Medicine, Swansea. Thoracic surgery is an important component of undergraduate and postgradu- ate training. Specialist Registrars in Respiratory medicine are uniquely placed to witness the management of complex respiratory problems by medical and surgical means. 4 Morriston Hospital, Swansea
  • 4. lung cancer compared to the UK, the rest of Europe and the USA. Surgery is the only known cure for lung cancer, suggesting that there is a lowIntroduction curative resection rate for lung cancer in Wales. Delays in diagnosis, staging and access to surgical resection may all contribute to this poor outcome.Thoracic Surgery is a specialty focusing onthe diagnosis and surgical treatment of disordersof the chest that encompasses a wide range of Thoracic surgeons also treat non-malignant condi-procedures pertaining to the chest, but exclud- tions that are referred by respiratory physiciansing the heart. It includes surgery to the lung, such as complications of pneumonia, treatmentmediastinum, chest wall (including reconstruc- of air leaks from the lungs into the chest cavity,tion) biopsies and excision of lung and pleura for drainage of fluid from the lung cavities, biopsy ofmalignant and non-malignant conditions together inflammed lung tissue, surgical repair of benignwith miscellaneous other non-cardiac procedures. narrowing of the windpipe and interruption ofIn the UK, 60% of these surgical procedures are specific nerves for severe sweating. Thoracicperformed by cardiothoracic surgeons (who also surgeons also treat non-malignant tumours of theperform operations on the heart) while 40% lungs and chest wall. In addition, congenital chestare conducted by standalone thoracic surgeons. wall abnormalities are very common in the UnitedAbout 50% of the work of a thoracic surgeon Kingdom. Pectus excavatum affects 1 in 500 ofis spent dealing with surgical resections of lung the population (i.e. in South Wales alone there arecancers and other malignant diseases of the chest. 4600 cases). Many of these require surgical cor- rection for symptomatic or psychological reasons.South Wales has a legacy of heavy industry andcoal mining, both of which contribute significantly Morriston Hospital in Swansea is the largest of theto lung disease. Lung cancer is the commonest acute hospitals in South West Wales and housescause of cancer death in many regional and specialised tertiaryWales. Tobacco smoking services. Morriston Hospital is locatedhas been shown to ac- just over 1 mile from junction 46 of thecount for about 80-90% M4 motorway and is thus very acces-of all cases in men and sible being positioned in the middle of50-80% in women. The South Wales and having travel times ofmedian overall survival only 80 minutes to Haverfordwest inin the UK is between 4 the west and Chepstow in the east.and 6 months with anoverall 5-year survivalof <10%. The 5-yearsurvival in those under-going curative resectionis 35-60% dependingon the histological type and stage of tumour. The 5population of Wales has a poor survival rate for
  • 5. Background to the Swansea Service The cardiothoracic surgeons began to offer tho- racic surgery on a “case-by-case” basis thereafter.During the commissioning of the Cardiac Centre Over subsequent years, as the volume of workin the mid 1990s, the chest physicians in South increased, it was clear that cardiac surgical capac-West Wales, through the Local Health Authori- ity was being compromised as a consequence ofties, approached the then Morriston Hospital thoracic surgical activity. Furthermore, lack ofNHS Trust seeking the development of a thoracic resources made it difficult to meet All Walessurgical service within the new Cardiac Centre. Minimum Standards for timely lung cancerFollowing a survey in 1996 to establish the need resection. Therefore, a decision was madefor the services that was conducted by Dr Kim to suspend the service temporarily (despiteHarrison and the Trust management, the Trust the demand) until it was resourced appropri-agreed with the Health Authorities to provide ately with provision of dedicated facilities.the service on a cost-per-case basis until properfacilities for thoracic surgery were established. A second review of thoracic surgical services was commissioned in 2002 but the report was notIn June 1997, Dr Gill Todd (Chief Executive of Bro published. After the input of dedicated funds byTaf Health Authority, representing all 3 Health Health Commission Wales, the thoracic surgicalAuthorities in South Wales) set up and chaired service recommenced in March 2004. Additionalthe thoracic strategy group for South Wales (first beds were ring-fenced on Morriston Hospital’sreview). This group had representatives from ward S and theatre space and high dependencyall stakeholders of the services including two beds arising out of the phase I (cardiac surgi-external advisors from the Society of Cardiot- cal) upsizing of the Cardiac Centre were al-horacic Surgeons of Great Britain and Ireland, located to the service. Three of the in-housenamely Professor Tom Treasure and Mr John cardiothoracic surgeons provided additionalDark. This group advised and concluded that the sessions to cover the Thoracic Surgical activity.service should be provided both in Cardiff andin Swansea and that Thoracic Surgery at Lland- In July 2005, the Thoracic beds were relocatedough Hospital should be moved to the University from Ward S into the main Cardiac Centre asHospital of Wales within the Cardiac Centre. a result of space vacated by the move of the cardiology day-case unit in the Cardiac Centre (Phase II of upsizing). Nursing care is now de- livered by cardiothoracic nursing staff based on Cyril Evans ward leading to economies of scale. 6
  • 6. Health Commission Wales (HCW) For thoracic surgical services HCW aimsAims and Objectives “To provide an integrated, audited, safe, highThe HCW website states: quality, sustainable thoracic surgery serv- ice to the residents of South Wales that:The primary objective of Health Commis- • Meets relevant national andsion Wales (Specialist Services) is to en- international standards;sure that Wales derives the maximum pos- • Has the potential and flexibil-sible benefit from the Specialist Services ity to meet all the present andCommissioning and, in particular to: future needs (including currently unmet needs) and requirements; 1) Secure an appropriate range • Is provided by skilled, account- of high quality, best value able professionals (working in specialised services for the MDTs) as close to the patient’s people of Wales within an home as possible. agreed budget • Is adequately resourced”. 2) Place the needs of patients, their families and friends and the public at the forefront of HCW(SS) business 3) Develop effective partner- ships with all key stakehold- ers 4) Ensure effective com- missioning processes are consistent with NHSWD targets, priorities and objec- tives and with LHB commis- sioning 5) Ensure equity of access 6) Ensure the customer focus of operational processes 7
  • 7. Descriptions of the relevant opened in 1997. It is used for the treatmentassociated services within of pneumothorax, pleural procedures includ-Swansea NHS Trust ing pleurodesis and surgical lung biopsies. VATS reduces morbidity (especially pain) and thusRespiratory medicine length of hospital stay leading to cost-efficiencies.The Department of Respiratory Medicine pro- Endobronchial therapiesvides clinical services at Morriston and SingletonHospitals. There are 2 consultant physicians based Morriston Hospital is the only centre in Walesat Morriston Hospital (Dr Kim Harrison and Dr to provide an extensive range of therapiesEmrys Evans) and 3 based at Singleton Hospi- such as endobronchial stenting, laser, dia-tal (Dr Phil Ebden, Dr Stuart Packham and Prof. thermy and photodynamic treatment. TheseJulian Hopkin). They diagnose and treat common are undertaken by the Respiratory Physiciansconditions such as lung cancer, asthma, bronchitis, at Morriston through on-site support of theemphysema and pneumonia as well as less com- cardiothoracic surgeons and anaesthetists.mon conditions such as tuberculosis, occupationallung diseases and sleep disordered breathing. TheRespiratory Physicians co-ordinate the multidisci-plinary team for treating patients with lung cancer.Diffuse parenchymal lung disease (DPLD) is oneof several disease groups that the Welsh Assembly Cardiac surgeryGovernment has identified as requiring guidelines Cardiac Surgery is based in the Cardiac Centrefor management through the Respiratory Imple- at Morriston Hospital. There are 2 dedicatedmentation Group. It recommended that patients cardiothoracic theatres, 8 Intensive care beds, 8with DPLDs should have access to Regional High Dependency beds and 20 ward beds. TheCentres where difficult cases can be discussed and unit undertakes all types of adult cardiac surgerythe requirement for surgical lung biopsy consid- including major surgery on the thoracic aorta butered (as demonstrated by a survey conducted does not undertake complex congenital heartby Dr Kim Harrison in 2002). This is likely to disease or transplant surgery. Annual activityincrease the number of surgical biopsies that are is 750 – 800 cardiac surgical procedures. Theundertaken in Wales by approximately two-fold. Cardiac Centre has some of the best outcomes in the UK for first-time coronary artery by-passVideo-Assisted Thoracic Surgery. surgery and aortic valve surgery over many years ( Video-assisted tho- racic surgery (VATS) All 5 consultant cardiothoracic surgeons in the is a minimally invasive unit are fully trained in both cardiac and thoracic 8 technique that has been used routinely by the cardiotho- surgery. All nursing and support staff are trained to manage thoracic surgical patients. The presence of thoracic surgery on-site has undoubtedly helped racic unit since it recruitment and retention of staff within the unit.
  • 8. Cardiothoracic anaesthesia and intensive care RadiologyThere are 5 Consultant Cardiothoracic Anaes- The Department ofthetists in the Cardiac Centre who provide Radiology houses a widetheatre sessions and cover for the 8-bed- range of imaging facili-ded Cardiothoracic Intensive Care unit. ties including spiral multi-array X-ray computedAdditional appointments are currently being made. tomography (CT), Magnetic Resonance Imaging, ultrasound, Digital Subtraction angiography andThe existing consultant cardiothoracic gamma camera imaging. Dr David Roberts, Dranaesthetists are fully trained in cardiac Liam McKnight and Dr Derrian Markham provideand thoracic anaesthesia. Many see the on-site expertise in chest radiology. Followingattraction of the post in the unit as the mix an agreed investigation and treatment strategy atof both cardiac and thoracic surgery. the MDT meeting, they undertake endoscopic-, CT- and ultrasound-guided fine needle aspira-In April 2007, the Car- tions and biopsies on behalf of the team. Thediac Intensive Care Unit Respiratory Physicians also undertake diagnosticwas re-accredited as a trans-bronchial needle aspiration based on CTPractice Development imaging. . In addition, a new 3 Tesla MRI scanner isUnit following review by the University of currently being commissioned at Singleton Hospi-Leeds. The reviewers met with a number of tal to increase imaging capacity within the Trust.patients and made the following comments: Plastic and Recon-“Patients on the unit spoke movingly and structive surgerypowerfully of the effect that the team hadhad upon their lives, and others were patient The Welsh Centrerepresentatives from the wider Trust who for Burns and Plastic Surgery was transferredclearly enjoyed working with the team.” from St. Lawrence Hospital Chepstow to Mor- riston in 1994 in order to be at the centre of“The range of presentations demonstrated the South Wales catchment area and to benefitclearly the multi-disciplinary nature of the from the presence of other services in Swansea.practice development unit and how effectively Plastic surgeons are able to carry out complexthe various disciplines worked together.” reconstructions of the chest wall for trauma andAll the presentations had patients, their experi- malignant disease (e.g. invasive breast cancers, softences and their outcomes as crucial components.” tissue sarcomata) in combination with thoracic surgery colleagues. The burns centre is expected“This is absolutely not a team that pays lip serv- to be awarded Su-ice to the notion of patient centredness.” pra-Regional Burns Centre Status in the“We were also pleased to hear of theclose and collaborative relationshipsthat the team have developed with col- near future and is ranked top against the UK standards 9leagues in the University of Swansea.” for burns care. One
  • 9. component of these standards was the pres- Lack of emergency thoracic input in specific casesence of other trauma services on site. The Welsh would inevitably put patients at increased risk.service can confidently receive burn patients There are approximately 40 cases of significantwith any type of associated trauma including thoracic trauma per year admitted to Morristonthoracic injury in the knowledge that all ap- Hospital. About 4 to 6 patients require emergencypropriate specialists are available in the Trust. thoracotomy, but the remainder require thoracic surgical consultation for advice requiring the man-Ear, Nose and Throat (ENT) surgery agement of their injuries, the placement, manage- ment and removal of intercostal chest drains.ENT surgery is based in Swansea. The tho-racic surgeons and ENT surgeons occasion- Clinical outcomes following trauma are collectedally undertake joint operations for example by the national Trauma and Research Networkbecause a surgical resection of the larynx re- (TARN) database. Details for Wales can be foundquires mobilisation of the bronchial tree or at a tracheal lesion such as a stricture or tu-mour extends from the chest into the neck. The figures released in August 2007 showed that Morriston Hospital has the highest number of trauma admissions in Wales. It was the only hospital in Wales where data on all injured pa- tients between January 2004 and December 2005 admitted to the Trust were submitted to the database. Trauma to the chest is one important component of these statistics. The Royal College of Surgeons and British Orthopaedic Association state in their guidelines on standards of care 13.3: “Examination of the chest is a fundamental com-Trauma services ponent of the cardiopulmonary assessment of the seriously injured and should be supervised by theMorriston Hospital has emerged as the Trauma most experienced clinician”. The TARN statisticsCentre for South West Wales. Previously, a small therefore identify the number of chest injuriesnumber of patients with severe chest injuries and the proportion assessed by consultants.would have been transferred to Cardiff for surgicalintervention. Clearly it is undesirable for patients The figures reveal that survival rates in Swan-with major injuries who may be critically ill to be sea are 2.1 per cent higher than expected, plac-moved when all facilities and expertise are on site. ing Morriston in the top 15 UK hospitals that In addition, they would took part in the research. Between 2003/4 and potentially be moved 2005/06, Morriston admitted 943 trauma pa- away from on-site tients. According to TARN, 847 of these patients 10 expertise in burns, plastic and recon- structive surgery and were expected to survive, but in fact, the figure was higher, at 869. Of the patients admitted with chest injuries, 49% were assessed by consultants maxillofacial surgery. (compared with the national average of 43%).
  • 10. The table below demonstrates the comparativedata for comparable centres closest to Wales. Morriston University Bristol Royal Royal University Wythenshawe Hospital, Hospital Infirmary and Devon and Hospital, Hospital, Manchester The Royal Liverpool Swansea of Wales, Frenchay Exeter Birmingham Manchester Royal Infirmary University Hospital Cardiff Hospital Additional survivors (per +2.1 0.0 No data -0.6 +0.6 -2.2 No data -1.6 100 treated) Number of 140 110 No data 133 23 81 No data 88 chest injuries Number seen 49% 25% No data 66% 26% 43% No data 28% by consultantOesophageal disease Radiotherapy & ChemotherapyOesophageal surgery is performed at Morris- The Swansea Cancer Centre is based at Single-ton Hospital by general surgeons with a specific ton Hospital, Swansea and has the benefit of aexpertise. Some surgery is performed with the newly appointed chair of Clinical Oncology (Prof.input of thoracic surgeons (e.g. trachea and Taylor). Radiotherapy is offered at the Regionalbronchus injury, empyema) and has been per- Cancer Centre based at Singleton Hospital, whichformed collaboratively since the opening of the has recently benefitted from an additional linearCardiac Centre in 1997. The thoracic surgeons accelerator to improve treatment access times. Aalso provide support for general surgeons when new CT simulator is expected to be operationaltheir patients develop pulmonary complications. during this financial year and the Trust has re- cently appointed an additional Consultant Clinical Oncologist to support lung cancer treatment. Improved chemotherapy regimes that successfully downsize lung tumours will increase the number of resectable cases. In addition, chemotherapy for mesothelioma (which will increase in inci- dence over the next 10-15 years) will render such tumours more amenable to surgical resection and modern chemothera- pies for other malig- nancies (e.g. bowel, malignant melanoma) will increase the number of resections 11 required for “solitary”
  • 11. The Swansea MDT Teamlung secondaries. These factors will increase the Communication with Primary Care teamsneed for thoracic surgery in the future. The Trustprovides clinical leadership for sarcoma in South General Practitioners generally refer patients veryWales and the sarcoma MDT works closely with promptly when there is a suspicion of lung cancer.the thoracic surgery team to ensure that biopsy The outcomes of the MDT meetings are com-or metastatectomy is offered where appropriate. municated back by fax to the GP within 24 hours.Palliative care All Wales minimum standardsThe hospital and commu- Swansea NHS Trust audits its lung cancernity palliative care teams are service annually against the “Lung Cancer Mini-based in Ty Olwen, within the mum standards”. During 2006/7, there were 46grounds of Morriston Hospital. MDT meetings that were well attended by vari- The Duchess of ous members of the MDT. At these meetings,Medical or nursing members of Gloucester visiting Ty 240 patients with a diagnosis of lung cancer werethe team attend the MDT meet- Olwen discussed. The lung cancer clinical nurse specialistings at Morriston Hospital. saw 214 of these patients. All general practition-Core membership of the lung cancer MDT in- ers were notified of a diagnosis of lung cancer cludes a consultant in (when made) within 24 hours following a patient’s palliative medicine who attendance at Morriston Hospital. Generally, 12 sees patients as neces- sary in the multi-profes- sional lung cancer clinic. each patient was provided copies of in-house and externally produced publications together with information on self-help and support groups.
  • 12. Description of the range of thoracic in Morriston Hospital, West Wales General Hos-procedures offered by pital and Prince Phillip Hospitals in Carmarthen-Swansea NHS Trust shire. The Cardiac Centre has purchased modern telemedicine facilities making the clinicians moreA wide range of invasive and minimally accessible to neighbouring hospitals within theinvasive thoracic surgical procedures are pro- network. Telemedicine conferences are heldvided at Morriston Hospital. A glossary of fortnightly with Bronglais Hospital in Aberyst-these procedures is provided in Appendix 2. • Bronchoscopy (rigid or flexible) • Mediastinoscopy, mediastinotomy and resection of mediastinal tumours (neurogenic tumours, bronchogenic cysts, tumours of the thymus) • VATS (Video-assisted thoracoscopic surgery) • Lung or pleural biopsy • Lung resection (segmentectomy, lobec- tomy. sleeve resection, pneumonectomy) Telemedicine facilities Mr Aprim Youhana • Chest wall resection and reconstruction wyth, weekly with West Wales General Hospital • Correction of congenital abnormalities of and Prince Phillip Hospital in Carmarthenshire the sternum (e.g. pectus excavatum) and weekly with Singleton Hospital in Swansea. • Metastatectomy • Pleurodesis, pleurectomy and decortication There is a full range of support services on- • Repair of diaphragmatic hernia site that includes a respiratory unit led by 2 • Tracheal surgery and reconstruction consultant chest physicians, complemented • Surgery for mesothelioma by consultant radiologists, histopatholo- • Pacing of the diaphragm gists and full lung function testing facilities. • Cervical sympathectomies for hyperhidrosis Description of MDT arrangements forDescription of facilities for thoracic surgery lung cancer care in South West WalesThere are 5 full-time Consultant Cardiothoracic The weekly Lung Cancer MDT and multi-profes-Surgeons based in the Cardiac Centre. Mr Mah- sional Lung Cancer Clinic are at the forefront ofmood Ashour took up his post as locum Con- modern clinical practice and were acknowledgedsultant Thoracic Surgeon at Morriston Hospital to be excellent by Dr Martin Muir and Professorin January 2006. He has 3 theatre sessions per John Dark when they visited Morriston Hospitalweek and 5 in-patient beds dedicated to thoracic in February 2004. Thepatients in addition to the other beds on Cyril clinic is attended byEvans ward that can be used flexibly. He is sup- consultant respiratoryported by Mr A Youhana who covers his annualand study leave utilising a combined waiting list.There are out-patient facilities within the Cardiac physicians, consult- ant radiologists, a consultant oncologist, 13Centre and weekly lung cancer MDT meetings a consultant cardi-
  • 13. othoracic surgeon and a palliative care doctor possible. It also allows the Chest Physicians ofor nurse. The Clinic is increasingly active as a West Wales greater access to, and interactionCentre for the West Wales Network. The physi- with, Consultant Thoracic Surgeons on a personalcal presence of a Consultant Thoracic Surgeon level. Such access invariably generates greateris of fundamental importance to its function. options for investigation and treatment of both malignant and non-malignant thoracic disease.The developing South West Wales LungCancer Network is the most advanced and sophis- The isochrone below indicates that Swanseaticated of the site-specific groups in South West is strategically placed in the centre of SouthWales. Local protocols have been adapted from Wales such that over two thirds of the popu-the NICE guidance for diagnosis and treatment lation of Wales are within 90 minutes of theand include key roles for thoracic surgery. It has Thoracic Unit at Morriston Hospital.been accepted by all clinicians in West Wales andprovides equity of access for patients.This network is now in a strongposition to work with other net-works in Wales to disseminate bestpractice and further improve equity.Moving towards aManaged NetworkThe “Option Appraisal” of 2004proposed a ”Managed Network” asone possible solution to the uncer-tainties regarding the development ofThoracic Surgical Services in SouthWales. The Thoracic Surgical Serviceat Morriston could sit comfortablywithin such a network by provid-ing local services for the populationof West Wales. This is in keepingwith the Welsh Assembly Govern-ment’s policy of providing healthcareas close to the patient’s home as 14
  • 14. Activity DataThoracic Surgical procedures 2006-2007Summary by operation type Summary By OPCS codePneumonectomy 14 Opcs Code Complex/extra Major/major/ NumberLobectomy 37 intermediate/minorBullectomy 15 E54.1 Complex 14Repair Of Diaphragmatic Hernia 1 E54.3 Complex 37Open Lung Biopsy 13 E57.2 Complex 15Pericardectomy 1 E59 Complex 13Open Pleurectomy 2 E55.1 Complex 6Thymectomy 3 E54.4 Complex 4Metastatectomy 4 E54.5 Complex 2Open Decortication 6 K67.1 Complex 1Bronchoscopy 57 G23.2 Extra Major 1Pericardial Biopsy 1 B18.1 Extra Major 3Mediastinal Mass/tumour 9 T09.2 Extra Major 14Thoracotomy 2 T07.2 Extra Major 2Open Pleural Biopsy 14 T02.1 Extra Major 3Mediastinoscopy 12 G23.2 Extra Major 1Repair Of Pectus (Pectoral Flaps) 3 T03.9 Major 2Repair Of Diaphragm & Chest Wall 1 E61.4 Major 3Partial Resection Of Lung 2 E61.1 Major 9Mediastinal Lymphalectomy 2 T85.3 Major 2Mediastinotomy 3 K71.1 Major 1Vats Biopsy & Pleurodesis 2 133Vats Lung Biopsy 1 E51.1 Intermediate 57Vats Pleural Biopsy 7 T11.9 Intermediate 2Debridement Of Wound 1 T11.9 Intermediate 7 213 T11.2 Intermediate 1 E63.1 Intermediate 12 S57.1 Intermediate 1 80 Total 213 15
  • 15. Current activity compared with historical activityData are presented for the financial years 1998 to 2001 and 2004-7 following resumption ofthe thoracic surgical service at Morriston Hospital. The data include all complex, major and in-termediate cases. Minor procedures (averaging about 50 per year) are not included.Procedures 1998-1999 1999-2000 2000-2001 2004-2005 2005-2006 2006-2007Major and intermediate 50 110 119 167 114 203(non-VATS)VATS 18 19 25 31 26 10TOTAL 68 129 144 198 140 213 BRIDGENDThoracic Surgery New CARMARTHENSHIRE CEREDIGIONOutpatient Referrals by GWYNEDD MONMOUTHSHIRELHB - 2006/2007 NEATH/PORT TALBOT NEWPORT OATS PEMBROKESHIRE POWYS RHONDDA, CYNON TAFF SWANSEA THE VALE OF GLAMORGAN TORFAENComplications following thoracic surgery MortalityCardiovascular = 3 (1 post-op MI, Over the last 5 financial years (2002-2007) there has2 re-operation for bleeding) been only one death complicating a lung resectionPulmonary = 8 (2 collapse/pneumotho- (pneumonectomy) which was caused by an embolusrax, 1 pneumothorax, 5 “other”) to the abdomen and leg. This equates to a mortal-Renal = 2 (1 H/F dialysis, 1 “other”) ity rate of ‹1%. The national average for mortalityInfective = 3 ( 1 Broncho pleural fis- after lobectomy is 2.6% and pneumonectomy 5-7%,tula, 1 wound infection,1 “other”) suggesting excellent early outcomes for patients.Neurological = 2 (confusion, peripheral nerve injury)Post op arrhythmias = 9 (all AF/Atrial flutter/SVT)Gastrointestinal = 1 (1 “other”) Average and median lengths of stay Average Median Lung Cancer 10.9 8 16 Mediastinoscopies VATS Bronchoscopies 1.5 7.2 Day case 1 5 Day case
  • 16. During 2006-2007, three patients died dur-ing their index hospital admission. It is reasonable to conclude that non of these deaths was related directly to thoracic surgery.One died in the Palliative care unit (Ty Ol- Although the Cardiothoracic Centre at Morristonwen) from metastatic squamous cell car- Hospital is a relatively new unit, more than 150cinoma of the lung that had been diag- lobectomies have been performed. Our results arenosed following surgical biopsy. consistent with an article published by Treasure et al (BMJ 2003 327: 73) relating to outcomesA second died following salvage surgery following lobectomy in the UK. Patients whofor mesothelioma of the pericardium. were operated on by one group of 49 surgeons with an annual volume of one to 15 lobectomies,A third patient died on the general in- compared well with patients who were operatedtensive unit. This patient had under- on by another group of just six surgeons doing 47gone surgery of her chest (closure of to 96 lobectomies a year. Across the groups ofmultiple diaphragmatic perforations) as part of surgeon activity, the mortality varied from 2.0%the treatment of a chyloperitoneum complicat- to 2.9%, with no evidence of relation to a laparotomy for intra-peritoneal bleeding.The Cardiac Centre Morriston Hospital 17
  • 17. Predicted future demand New scanning techniquesmodelling Tumour type and disease staging determineAssumptions whether surgical resection is feasible. The most accurate predictor of long-term survival in earlyAssuming that current estimates for the inci- lung cancer is the disease stage and those tu-dence of lung cancer in Wales is approximately mours that are more peripherally placed are2000 per annum and aiming for a resection rate easier to remove than those placed centrallyof 15%, there should be 1700 lung cancer casesin South Wales and therefore 250-300 resec- Positron Emission Tomography (PET)tions per annum for lung cancer alone. In addi-tion, there will be a requirement for other major Fluorodeoxyglucose (FDG) - PET scanning is athoracic surgical procedures such as resection sensitive method to distinguish spread of malignantof mediastinal, chest wall and tracheal tumours cells to lymph nodes from those where enlargedtogether with decortication for empyema. lymph nodes are reactive rather than infiltrated by tumour. Its use helps to guide physicians andThe most reliable figures for the incidence of surgeons in the selection of patients suitable orcancer in South West Wales relates to breast unsuitable for curative resection. For example,cancer. There are approximately 650 new cases it should reduce the number of cases of thoracicper annum. The incidence of breast cancer in surgery that are abandoned due to previouslythe UK is 40,000 per annum and broadly similar undetected lymph node involvement but increaseto that of lung cancer (38,000 per annum). As- resection rates in those who may otherwise besuming the network coverage has an incidence turned down because of apparent lymph node in-similar to the UK, it is estimated that the South volvement that represented reactive changes only.Wales Lung Cancer Network should be diagnos-ing and treating approximately 600 cases per Magnetic Resonance Imaging (MRI)annum by curative resection. Again a resectionrate of 15% would suggest 110-130 cases per an- MRI (as opposed to X-ray computed tomography)num for West Wales alone. further refines the identification of resectable thoracic tumours particularly with chest wall and mediastinal invasion. Imaging is immediately available to physi- cians and surgeons on site. 18 Contrast MRI
  • 18. Theatre/bed capacity incardiothoracic centreThe Cardiothoracic Unit has adopted modern 5 new beds (located in the former cardiologypractices to deliver high levels of cardiology and day case) to the surgical ward will enable thecardiothoracic surgical activity through the unit. thoracic activity to increase significantly with-The unit has only 62 beds of which 8 are coronary out any need for further capital beds, 8 are intensive care beds and 8 are high-dependency beds. The flexible use of these bedshas enabled the Centre to perform approximately2100 coronary angiograms, 1000 angioplasties, 350permanent pacemaker implantations and 750 car-diac surgical operations and more than 200 tho-racic surgical procedures annually. The addition of 19
  • 19. Appointment of a second The incidence of lung cancer in South West WalesConsultant Thoracic Surgeon combined with the challenging access targets for cancer treatment (maximum of 62 days fromBenefits of appointment referral with suspected cancer to definitive treat- ment) means that it is not possible for a singleService benefits thoracic surgeon to fulfil the surgical demands for lung cancer treatment. To consolidate theHistorically, thoracic surgery has been undertaken service, the Trust is planning to appoint a furtherby consultants with dual training in cardiac and substantive thoracic surgeon. This will ensurethoracic surgery. With the development of an continuity of the service as also provide an en-NSF for coronary artery disease, the adoption hanced infrastructure for teaching and training.of the European Working Time Directive and thenew amended Consultant Contract in Wales, it is Teaching and Trainingdifficult for cardiothoracic consultants to commitenergies to both disciplines. In addition, the need Specialist Registrars in Cardiothoracic Surgeryto achieve access targets for cardiac surgery has have regular academic teaching and practical train-meant that patients requiring thoracic surgery ing (in theatre) in all aspects of Thoracic Surgery.have been “competing” for similar resources. The consultants have a keen desire to teach and a strong track record in doing so. There is aThe appointment of a dedicated thoracic surgeon monthly training day for Morriston, UHW andhas enabled the service to be placed on a proper Bristol SpRs. The appointment of a dedicatedfoundation. Mr Ashour has been able to focus thoracic surgical consultant has enhanced traininghis energies to the delivery and expansion of an opportunities within the Trust. Morriston Hospitalalready existing high quality service for the resi- is the only hospital in Wales where SpRs in Tho-dents in South West Wales. There is a dedicated racic Medicine have the opportunity to observeout-patient clinic and 4 MDT meetings each week surgical procedures on site. Undergraduates(in Swansea and Carmarthen) and the accessibility based at the School of Medicine, Swansea have theof a standalone thoracic surgeon locally provides opportunity to follow from diagnosis to treat-support to the Respiratory Physicians and other ment in cases such as empyema and lung cancer.clinicians in the network. Mr Ashour has raisedawareness of thoracic services (e.g. lung resectionfor cancer) to primary and secondary care beyondtheir current levels. However, Mr Ashour has thebenefit of working in a Specialist CardiothoracicCentre with high quality facilities and receives sup- port from cardiac sur- gical colleagues who are trained in thoracic 20 surgery (e.g. for peri- ods of annual leave and for the on-call rota). Mr Ashour, Consultant Thoracic Surgeon
  • 20. Conclusions ered at primary and secondary care level and an integrated approach to the management of the patient pathway is required. Thoracic surgeryDespite 10 years of uncertainty, the enthusiasm complements other key services offered by theand drive to develop Thoracic Surgery at Mor- Trust such as the Trauma Centre, plastic surgeryriston Hospital continues unabated. For patients for major chest wall resection and reconstruction,with lung cancer, resection rates have increased oesophageal and maxillofacial surgery (and visit-significantly (from 5% to 15%) since the appoint- ing ENT surgery) for Tracheal surgery. Previousment of a dedicated thoracic surgeon. The surveys of chest physicians have highlighted thatprovision of locally-based thoracic surgical services the “existing level of provision of thoracic surgery”within a Managed Network is the best way to pro- in South Wales “did not meet their requirements”vide the appropriate quality of care that the popu- and they “would be prepared to refer thoraciclation of South Wales should expect to receive. cases to Morriston Hospital”. The Royal Col- lege of Surgeons state that cardiac and thoracicSwansea NHS Trust continues to view Thoracic surgery should be provided on the same site.Surgery as an important component of the port-folio of services that it offers to the populationof Swansea and South West Wales. Patients from There is overwhelming support for contin-West Wales have historically had poor access to ued and enhanced Thoracic Surgical Servicesthoracic surgical services in Llandough Hospital from the South West Wales Lung Cancer Net-and Bristol and the geographic distance to these work, all Chest Physicians and Cardiotho-centres makes it difficulty for them to receive racic Surgeons in South West Wales as wellsupport from their friends and families when they as the local population and media.need it most. Much of the patient’s care is deliv-Lung Function Suite Morriston Hospital 21
  • 21. Thoracic SurgerySatisfaction SurveysDuring the spring of 2007, the Thoracic Surgical Department arranged for a survey of the users of the tho-racic surgical service to be undertaken. Paper questionnaires were sent to the last 30 patients who hadused the service as well as 12 consultants who referred patients to the thoracic surgical service. 25 and11 anonymous replies were received respectively. The responses are detailed on the next two pages.In summary;Of the patients who have used the service, 96% rated their overall experi-ence of the thoracic surgical service at Swansea as being excellent or good.Of the consultants who have used the service, 90% rated the overall treat-ment that their patients received as being excellent or good. 22
  • 22. Patients who have used the serviceQ1 Are you? Q8 Were you given a likely date for your operation at the consultation? Male …………………………………..… 80.0% Yes ………………………………….88.0% Female …………………………………..20.0% No ……………………………....…..12.0%Q2 What age bracket are you in? Q9 How would you describe the care provided by: 18-30 years ……………………….……....4.0% Excellent Good Fair Poor Thoracic Surgical 88.0% 12.0% 0.0% 0.0% 31-50 years …………………….…….….20.0% Consultant 51-70 years ……………………….……..48.0% Medical Staff 80.0% 16.0% 0.0% 0.0% Over 71 years …………………….……..28.0% Nurses 80.0% 20.0% 0.0% 0.0% Physiotherapist 48.0% 28.0% 4.0% 4.0%Q3 Who referred you to the Thoracic Surgery Unit in Swansea? Other 48.0% 12.0% 0.0% 4.0% Your hospital consultant……………….96.0% Your GP ………………………………….0.0% Other …………………………………….4.0%Q4 How long did you wait before being seen in the Q10 How would you rate the follow up and after care you Thoracic Surgical Clinic at Swansea? Received from the Thoracic Surgical Service in Swansea? I was seen within 1-2 weeks ……..……..12.0% Excellent…………………………….……………..60.0% I was seen within 2-3 weeks ………..…..60.0% Good ………………………………….……………36.0% I waited over 4 weeks ……………….…..28.0% Fair ………………………………….………………0.0%Q5 Were you given any written information before or during your consultation at the Thoracic Poor …………………………….…………………..4.0% Surgical Clinic ? Yes ………………………………….52.0% Q11 Overall, how would you rate the experience at the Thoracic Surgical Service at Swansea? No ……………………………....…..44.0% Excellent…………………………….……………..60.0%Q6 Did you have the opportunity to ask questions Good ………………………………….……………36.0% Before or during your consultation at the Thoracic Surgical Clinic? Fair ………………………………….………………4.0% Yes ………………………………….92.0% Poor …………………………….…………………..0.0% No ……………………………....…..4.0%Q7 What was your first impression of the Q12 Do you have any suggestions or other comments to Thoracic Surgical Service provided in Swansea? Improve the Thoracic Surgical Service at Swansea? Excellent……………………..……..76.0% Yes ………………………………….24.0% Good ………………………….……20.00% Fair …………………………….…….4.0% No ……………………………....…..76.0% Poor …………………………….…...0.0%Free text comments to Q12 “Do you have any suggestions or othercomments to improve the Thoracic Surgical Service at Swansea?” “Quality of food after operation could be improved” “More Nurses” “Post operative care excellent in HDU” “Low staffing levels on ward” “Lack of toilet facilities and proper functioning showers” “Expression of thanks to Staff” “More written information” “Follow-up treatment could be improved” 23
  • 23. Referrers to the Swansea Thoracic Surgical Service About you Q4 How would you rate the overall treatment your patient received?Q1 Are you? Excellent …………………….80.0% Referring Consultant…………………….… 100.0% Good …………………………10.0% G.P. ………………………………………..…0.0% Fair …………………………..10.0% Other ……………………………………..…...0.0% Poor ……………………………0.0% 0.0%Q2 Why did you refer the patient to the Swansea Thoracic Surgical Service? (tick all that apply) Q5 Did you receive timely information following your patient’s discharge from hospital? Professional recommendation ……….…60.0% Yes ……………………………..80.0% Good reputation ………………………….80.0% No. …………………………..…20.0% Nearest referral centre ………..………100.0% Satisfied with previous service ……...…70.0% Q6 When you received this information would you categorise it as? Good quality care …………………..……70.0% Excellent ………………………...80.0% Good communication ………………...….70.0% Good ……………………………..20.0% Good patient outcomes ………………….70.0% Fair …………………………………0.0% Good patient satisfaction …………….….60.0% Poor ………………………………..0.0% Other (please state) …………………..…20.0%Q3 How did you find the response to your referral in Q7 Do you have any suggestions to improve thethe Swansea Thoracic Surgical Service? service? Excellent …………………………………….80.0% Yes ………………………………..70.0% Good …………………………………………10.0% No………………………………….30.0% Fair ……………………………………… …10.0% Poor ……………………………………… ….0.0%BRIEF OVERVIEW OF SURVEY COMMENTS FROM REFERS TO THESERVICEFree text comments to Q7 “Do you have any suggestions to improve theService?” “Mr Ashour requires support to cover leave” “Patients should be able to see the Surgeon more quickly” “More operating time required” “Service excellent” “Increase number of Surgeons” “Increase number of theatre sessions”
  • 24. Glossary wall may need to be reconstructed to maintain a rigid thoracic cage. This usually requires a sand- wich of polypropylene mesh and methyl meth-Bronchoscopy acrylate glue. This is constructed and allowedRigid bronchoscopy: A rigid bronchoscope is a to solidify outside the body and then suturedstraight, hollow, metal tube. Rigid bronchos- into place or it may be formed within the defectcopy is performed less often now that flex- to be reconstructed. Large defects may also beible bronchoscopy is routinely available, but it repaired with muscle or myocutaneous flaps.remains the procedure of choice for removing Muscles that can be used are the pectoralis major,foreign material and for several other treat- serratus, latissimus dorsi or the rectus muscle.ments. Rigid bronchoscopy also becomes useful They may then be covered by skin grafts, if re-when bleeding interferes with seeing the area. quired. These procedures require the skills and expertise of plastic and reconstructive surgeons.Flexible bronchoscopy: A flexible bronchoscopeis a long thin tube that contains small clear fibres Endobronchial therapiesthat transmit light images as the tube bends. Its Endobronchial therapies, including, brachytherapy,flexibility allows this instrument to reach the stenting, laser therapy, cryotherapy, and dia-farthest points in an airway. The procedure can be thermy. Stents are used to keep compromisedperformed easily and safely under local anaesthesia. large airways open in a variety of malignant and benign conditions. Diathermy resection is per-Bullectomy formed via a rigid bronchoscope and diathermyBullae are formed in the lung when alveoli is used to resect and cauterise intraluminal tu-rupture and combine with other alveoli to mours to relieve breathlessness and haemoptysis.form one alveolus. This causes a reduc-tion in respiratory capacity and they can be Lobectomyresected via a thoracotomy approach. The lungs are divided into separate sections or “lobes.” The left lung has two lobes and the rightChest wall resection lung has three lobes. During a lobectomy a sur-Major resection of the chest wall is occasionally geon will remove an entire lobe of a patient’s lung.necessary in the treatment of malignant disease.Small resections are usually tolerated without Lung volume reduction surgeryrequiring the reconstruction of the rigid tho- Lung volume reduction surgery is a surgical proce-racic cage. The extent of the resection and what dure where the worst areas of damaged lung tis-it involves will be dependent on the severity of sue (usually due to emphysema) are removed. Thisthe disease. It is usually performed via a thora- surgery can be performed by either median ster- cotomy incision. notomy or video-assisted thoracoscopic technique. Chest wall re- The goal of the surgery, with either operative 25 construction If a major chest wall resection has been technique, is to remove up to 30 % of the lung volume and therefore make the lungs smaller. performed, the chest
  • 25. Median Sternotomy ameliorated by the technique of diaphragmaticThis is an incision in which the sternum (or breast- pacing. A pacemaker device is implanted underbone) is divided down the middle from top to bot- the skin and electrodes attached to the phrenictom and is routinely used to access the heart and nerve (the nerve supply to the diaphragm).mediastinum but is also very useful for bilateral Pancoast tumour and Grunwald procedurelung procedures such as lung volume reduction This is a tumour of the extreme apex of thesurgery or combined cardiac and lung operations. lung. It may involve invasion of the parietal pleura, brachial plexus, chest wall, fascia at theMediastinoscopy root of the neck, subclavian vein and arteryThis is a procedure in which a tube is inserted and the sympathetic chain. The Grunwald pro-into the chest to view the organs in the area cedure refers to the extensive neck incision,between the lungs and nearby lymph nodes. with or without a thoracotomy that may beThe tube is inserted through an incision above required to access and resect the tumour.the breastbone. This procedure is usually per-formed to get a tissue sample from the lymph Pleurectomynodes on the right side of the chest and is Pleurectomy is the surgical procedure to removevery important for staging of lung cancer. the parietal pleura, the outermost lining around the lungs. This procedure is performed for aMediastinotomy variety of disorders including pleural effusion,This is a procedure in which an incision is malignant pleural mesothelioma, and trauma.made on one side of the breastbone so thephysician can view organs of the mediastinum Pleurodesisthat cannot be seen by mediastinoscopy Pleurodesis is the artificial obliteration of the pleural space. It is done to prevent re-Metastatectomy currence of pneumothorax or pleural effu-This is the excision of metastatic nodules from sion. It can be done chemically or surgically.areas of the lung. It can involve a small numberof nodules or can be multiple. It is performed Pneumonectomyvia a thoracotomy if one side is affected or a This is the removal of an entire lung,sternotomy for bilateral metastatectomy. for cancer, lung abscesses, bronchiecta- sis, or extensive tuberculosis.Open lung biopsyOpen lung biopsy is a test in which a small piece Rib resectionof the lung tissue is removed through a surgical This is the removal of part or the whole rib forincision in the chest. The sample is then ex- disease or to obtain access to a specific area ofamined for cancer, infection, or lung diseases. lung. It can also be done to obtain ribPacing of the diaphragm for bone grafting.Patients who have sustained injuries to the highspinal cord that affects the nerve supply to thediaphragm may develop respiratory distress ow- Segmentectomy This is performed 26ing to paralysis of the diaphragm. This can be to resect small tu-
  • 26. mours in a segment of a lobe. It is preferred to Tracheal resectiona lobectomy in patients with borderline pulmo- Trauma, tracheostomy and prolonged endotra-nary status to preserve some lung function. cheal intubation are the usual causes of benign strictures of the trachea that may require resec-Sleeve resection tion. Also, malignant tumours of the tracheaThis is usually performed when an upper lobe is may cause obstruction and require resection.removed with a circumferential cuff of the parentbronchus. Continuity to the remaining lobe or Video Assisted Thoracoscopic Surgery (VATS)lobes is restored by an end-to-end anastamosis. This is an advanced, minimally invasive surgi- cal procedure used for both diagnosis andSternal deformity correction treatment of lung cancer. Instead of mak-(e.g. pectus excavatum) ing a large incision through the chest wall, thePectus Excavatum is a congenital deformity that surgeon makes two or three small incisionscauses the sternum to be depressed into the chest through which a tiny camera and surgical instru-causing a “caved-in” look. It causes decreased ments are introduced, and tissue removed.lung capacity and often chest and back pain. Thiscondition occurs once in every 500 children,normally in males. The condition often becomesworse during the teenage years. Surgical cor-rection can be undertaken to improve cosmeticappearance and to improve respiratory function.ThoracotomyThoracotomy is a surgical incision into the chest.It is performed by a surgeon to gain access tothe thoracic organs most commonly the heart,the lungs, the oesophagus, or the thoracic aorta.ThymectomyA thymectomy is an operation to re-move the thymus gland. It usually resultsin remission of myasthenia gravis with thehelp of medication including steroids 27