Trachea Surgery

Years ago, while explaining tracheal surgery at a congress, the legendary C. Pearson told the following origin story: Toronto General Hospital, which can be considered the temple of thoracic surgery, has its own intensive care unit.

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In modern medicine, the easiest treatment for diseases is to prevent them from occurring. Modern city life, industrialization and, of course, cigarettes have a very important place in this regard, but since this will be the subject of another article, it will not be discussed in detail in this section.

Benign or malignant tumors of the lung, unlike other organs, appear with very late symptoms. Both lungs are quite large organs in the way they function. A tumor that begins to grow inside them grows silently until it begins to affect important structures inside or outside the lung. For this reason, by the time the disease is diagnosed around the world, the disease has reached a stage that is too advanced for surgery in most patients. In this case, an important weapon such as surgery becomes unusable.

How did lung cancer surgery begin?

According to a story told, the surgical treatment of lung cancer emerged as follows: In the 1930s, a dentist was diagnosed with lung cancer. Since the dentist is not completely unfamiliar with the subject, he understands the gravity of the situation and prepares himself for the inevitable end. So much so that he even bought his grave. They somehow suggest that he see the successful doctor of that region, and he accepts. He goes to see Graham. The doctor suggests a surgical intervention, and the desperate man accepts. There's nothing to lose anyway. After a successful surgery, the dentist begins to visit the doctor for check-ups at regular intervals. Years follow each other and the doctor-patient relationship turns into a friendship. More than 20 years pass and the doctor who performed the surgery passes away. At a medical congress in the late 50s, people wondered whether cancer had been diagnosed by mistake at that time, and all documents were re-examined. No! The diagnosis was correct and the treatment was extremely successful. The dentist lives for about another 30 years after the surgery before he too is lost.

Based on this story, which actually contains some magazine elements, as well as nearly a century of experience, it must be said that surgery plays a key role in the treatment of this disease. Thousands of studies have been published investigating how cancer surgery should be performed and what type of surgery is beneficial in which situations, and today the standards of this intervention have been largely revealed. It should be noted that early stage lung cancer, which can be operated on with reasonable risks, must be operated on.

Surgical Techniques (Thoracoscopic / Robotic)

Over a period of more than 30 years, as the author has personally witnessed, the standardization of surgical techniques and all factors affecting the surgical process has greatly improved surgical success. Surgeons not only select the right patient, but also benefit from many opportunities to ensure the success of their procedure. Since such surgeries are performed frequently, it is now possible to create a standard approach. Patient preparation, anesthesia process and subsequent support opportunities have made great differences even during this period.

Discussing these technical differences is of course not the subject of this article, but we should not pass without mentioning thoracoscopic and robotic surgery, which are popularly referred to as "closed" surgery. Thoracoscopic surgery, which first started in 1991, or rather its use, especially in cancer patients, was viewed with suspicion until the 2000s. It must be admitted that it would not be easy to replace a proven procedure, developed by thoracic surgeons over the past decades, with a new-fangled approach. Certain centers took these initiatives, and the whole world followed the results. However, after this first 10 years, it was seen and shown that thoracoscopic surgery was as successful as open surgery and even made an additional contribution to the lifespan of patients. Additional contribution; Performing the intervention with less damage is an indirect contribution as it leads to better protection of the general condition of the patients. This finding exploded thoracoscopic surgery all over the world. As experience was gained, the limits of closed surgery were expanded and it was seen each time that if a procedure could be performed thoracoscopically, it should be done that way.

In parallel with this development, robotic surgery began to be used in the early 2000s. Robotic surgeries, which had great hopes at the beginning, have not reached the desired level over time. Because, despite the passage of time, it was understood that robot technology could not provide sufficient development and that no additional benefit was seen despite the excess cost. As such, some clinics abandoned the use of robots and returned to thoracoscopy. While emphasizing this, it should also be said that; Some surgeons continue to perform surgeries robotically. This is the use of a completely conventional technique. It does not provide any additional benefit to the patient.

Here it is necessary to make an evaluation based on the concept of "closed surgery". By definition, closed surgery; It is a procedure performed without opening the ribs. Regardless of the size and number of incisions, closed surgery is considered when the procedure is performed between the ribs. The technique that is effective on life expectancy is closed surgery. This surgery is thoracoscopic; It does not make a difference whether it is performed roboticly or with a single incision or multiple incisions.

Surgical interventions and consecutive treatments

As we mentioned above, surgical treatment is undoubtedly the most important treatment weapon in early stage lung cancer. The opposite of this approach is naturally also true; Surgical treatment has no place in advanced stage disease. However, daily practice does not work with such a black/white approach. There is a large gray area in between, and most debates occur in this area. Because it is not possible for patients in this field to be treated by a single discipline. Depending on the treatment approach, surgeons, medical oncologists and radiation oncologists participate in the treatment sequentially. Participation of different disciplines in treatment together requires a common approach, perspective and way of practicing the medical profession.

These differences sometimes create endless debates in determining the most appropriate treatment. As someone who comes from a surgical perspective and discipline, I know that there will be many colleagues who will not agree with the views and opinions I will write. It may be appropriate to start from this point: We make a clinical staging with all examinations and tissue samples of the patients. This is referred to as cTNM in clinical practice. Clinically, it means the stage of the disease. What we also have after surgery is a pTNM. This is the pathological stage of the disease. In pathological examination, it is understood through tissue samples which tissues the disease has affected and which stations it has spread to, and the stage of the disease is unequivocally revealed. It is quite natural to see incompatibilities between cTNM and pTNM. Since none of the diagnostic methods are 100% successful, this incompatibility is inevitable. It is possible to see the extent of this incompatibility only in patients who underwent surgical intervention. Because detailed pathological examination can only be performed when the disease is removed by surgery, the stage of patients without surgery can only be revealed clinically. In the end, since the decision can only be made in the surgical group, the mistake is always in the surgeons' patient selection. Since there is no pTNM, the disease remains cTNM, so there will be no error(!). However, just as it is a big mistake to perform unnecessary surgery on a patient, it is also a big mistake not to perform surgery on a patient who can undergo surgery. Because this decision significantly affects the patient's chance of survival. In this context, physicians who contribute to the treatment of patients are conscientiously and ethically responsible not only for the decisions made, but also for the decisions not made.

In sequential treatment approaches, all disciplines must also assume responsibility for keeping the patient's general condition at a good level during treatment. For example, if drug treatment is to be performed first and then surgery, the general condition of the patient should be kept at the highest level at the end of the drug treatment, that is, before the surgical treatment. Because this level greatly affects the success of the surgery. The success of the closed surgery I mentioned above gains importance in this sense. Therefore, the contributions of all disciplines to treatment with world-class success rates should be known. However, when the results of the clinic are revealed, the risk of the procedure can be compared with the benefit. The success rates of the largest centers in the USA cannot be given to patients by saying that the risk of this surgery is this much. Because the patient is not there, he is being operated on here. As a result, all disciplines are responsible as well as partners in success. Success can only be achieved by doing the best at all stages.

Lung transplantation in lung cancer

Organ transplantation is generally not considered in a patient who has had cancer. Because the medications used after the transplant may also cause some problems. Especially in lung cancer, this situation should not be considered except in very special cases. However, in a series of 29 cases published in the USA in 2012, the 5-year survival rate was 57%. Such a transaction was first reported from China in 2012. Of course, we need to evaluate the issue within the conditions specific to our country, not with memorized information. Among the things I wrote about 'Lung Transplantation', this issue should be evaluated together with the way we used lung donors, at least in those years. In summary, my opinion is that we should first do what the world does, and when we reach that level, we will not do what the world does not do.

About 5 years ago, I had a patient who had surgery to remove part of his lung. The cell type was a special type of lung cancer that progresses best in the lung and does not spread throughout the body. These types of tumors are generally known to have a very good course, but the downside is that there is a possibility of recurrence from different foci in the lung tissue. In this patient, the disease recurred in both lungs within a few years, and despite all efforts and treatments, the disease could not be stopped. As the tumor progressed within the lung tissue, functional lung tissue decreased and the patient began to experience respiratory distress. The patients' relatives had left no doctor they didn't visit, no door they didn't knock on, and they also came to me many times. Baba kept asking me, "Isn't there anything to do, Master?" saying. Every time I said "No". He asked again and again, "Isn't there anything to do?"

Actually there was something. The more I asked that question, the more I felt swell, and in order not to give unnecessary hope, I always gave the same answer. But could we attempt something like reaching behind Mount Qaf? I was constantly preoccupied with this issue and wondered, "I wonder?" I said to myself. Because I had left Koşuyolu in those days, there were many medical, administrative and legal issues such as the team there accepting this job, inviting me for surgery, etc. But once the 'I wonder' fire was lit. How could it go out?

Another day, we were sitting in my hospital room with the patient's father and brother. I went to all the doctors you can think of and then they came to my room and discussed what was said to me. During such a conversation, the father asked again with tears in his eyes: "Is there nothing to do, Master?" That time I just said "Yes". "Lung transplantation can be done". A storm broke out in my room. They stood up and said, "Let's do it." I told them one by one the difficulties and the problems we had to overcome. After the work, I talked about how the community would target us and blame us, and how much trouble it could cause us. When I explained each obstacle, they said, "We can handle it." I concluded the long story like this. "I can perform this surgery from a surgical standpoint, and then I can deal with all the gossip and pressure that will come out."

They left. I knew that they would go around everyone again and ask for my opinion. And so it was. The oncologists they visited generally said, "What a transplant?" and some surgeons said, "If he says he can do it, he can do it." They fell somewhere in between. They wanted it wholeheartedly, but with these conversations, they could not fully believe and trust what I said. Meanwhile, we had applied for a license and were waiting for permission from the ministry. If we couldn't do it, we had to convince the Koşuyolu team. The team with whom I had been involved in transplantation for years said, "If he is available, we will get into this business." We were just having a hard time deciding. "Let's ask someone who knows about this, and if possible, let's call him for surgery," I said. Who knows this? W Klepetko. He is one of the world's leading surgeons in this field, making Vienna one of the top 5 centers in the world for lung transplantation. "Go and talk to him," I said. They arranged Vienna tickets and a doctor's appointment almost within hours.

Klepetko is not an easy person to relate to. But he knows me by name because of my patients. Minutes before the appointment time, I sent Klepetko a Whatsapp message. "You will be meeting with the relatives of a Turkish patient shortly. Can we have a chance to talk before that?" About 15 minutes later my phone rang: "I'm Walter, Walter Klepetko."

My point was this: Klepetko was starting to get old. I wanted him to come to Turkey, to undergo surgery with him, and to create the opportunity to do a lot of work and research on this subject thanks to him. We would put a lot of facts and energy in addition to a great experience and a great vision. He would direct us and we would work in that direction with all our strength. I didn't know how much energy I had myself, but we were going to motivate and train our young doctors on this path. Maybe we, as a country, could raise lung transplantation to very high levels in a short time. Of course I didn't tell him about these. "We can operate on the patient here, I will arrange and organize everything as you wish until you arrive," I said. "If you want, come back immediately after the surgery, if you want, we can stay with you in Istanbul for a few days," I said. "Let me see the patient's relatives, then let's talk," he said.

Klepetko said that transfer was an option and that he could join an organization along the lines I said. Then he called me again. We talked about the legal process of the transplant and how he could participate in this work. "Will you accept that the entire legal process will be your responsibility?" asked. And I said, "I can only accept this for you." "Just for me?" he said, "Just for you", we laughed together.

The plan was actually simple. We would make all kinds of organizations in advance. As soon as the organ was removed, a private plane would depart from Istanbul and go to Vienna, pick it up and return. During this time, depending on the arrival of the organ, we would either wait or start the surgery as he wanted. He would join us as soon as he arrived. At the end of the process, the same plane would take him back. Of course, the goal wasn't for him to have the transplant. We could do that too. The aim was to open such a path and enable him to contribute to the lung transplantation process in our country.

However, the plan did not go as we wanted. Despite all our efforts, we could not obtain a license. But after talking to him, the patient's relatives were completely convinced. It was decided that the transplant would be done in Koşuyolu. During this period, the patient got worse and worse. The Koşuyolu team put the patient on the transplant list and we started waiting. During this period, the patient was no longer able to get out of bed. One night, his condition worsened and he was connected to an ECMO device. This was the last stage of support that could be provided and time was now of the essence. 3 days after this procedure, I was driving in front of the plazas in Levent in the evening. The patient's brother called and said, "Sir, David has an organ." "I don't know, no one called me," I said. About half an hour later, a friend of mine from the Koşuyolu team called. "Brother, are we doing a transplant?" asked. This was a way of speaking that we inherited from our coordinator. We wouldn't say "there is an organ" or "there is a transplant" to each other. "Can we do a transfer tonight?" or “Is it a good evening for a transplant?” We used to talk like. The answer to this question has never been "No" for me.

The surgery was to begin in the morning. Davut was transferred from our hospital to Koşuyolu that night. I don't know the details, but their journey was very troublesome. I left home around 05:00. It was raining like crazy. Those familiar rains of Istanbul. So much so that I lost track of my usual route and took a long road to reach the hospital. The surgery started and the chest was opened. Since there would be some technical difficulties on the right side, where I had previously operated, we started working on that side first. We finished the right side without any problems. Then we moved to the left side. The team could move on from there like we always do. Coincidentally, at that time, the team accepted another organ, and another patient was prepared for another transplant in the adjacent operating room. When I came out of surgery, that patient's chest was being opened. They said, "Brother, you must have missed it. Come and take a look at this and let's finish it quickly." Without hesitation, I underwent that surgery and performed another unilateral transplant. Everything went smoothly. Both patients were taken to intensive care.

I left the hospital in the evening. It was dark and it was still raining. As I crossed the bridge under the lights and rain, I looked at My Dear Istanbul. The past 24 hours flashed before my eyes. I was neither very happy nor very unhappy. I just thought that if I lived a thousand years, I would want to do surgery for a thousand years.


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