Orange County Thoracic and Cardiovascular Surgeons

A bronchoscopy is a test performed to view and diagnose problems in the bronchial tubes or related to lung disease. The procedure is performed using a bronchoscope, a device used to see the interior of the lungs. The doctor inserts this long tube through the nose or mouth, into the trachea and then into the patient's lungs. A bronchoscopy is usually recommended when the patient shows signs of lung disease. Reasons for Bronchoscopy A bronchoscopy is performed when an abnormality is observed on an X-ray or other diagnostic imaging test and may be performed on patients who have one or more of the following symptoms: Unexplained lung growth, lymph node changes or atelectasis Suspected interstitial lung disease Hemoptysis Obstruction of a bronchial tube Unexplained cough for more than 3 months Prolonged or puzzling infections in the respiratory tract Inhaled toxin Lung rejection after transplant Goals of a Bronchoscopy A bronchoscopy may result not only in diagnosis, but in the treatment of a condition. During a bronchoscopy, the doctor is able take a biopsy of tissue in the lung or airways when cancer is suspected, or to: Remove fluid or mucus from the airways Remove a foreign object from the airways Dilate an airway that is blocked or narrowed Drain an abscess Treat cancer by radiating a tumor directly Stop bleeding in the airways Put in a stent to open constricted air passages Cleanse an airway, known as therapeutic lavage Types of Bronchoscopy When bronchoscopy is performed for diagnostic purposes, biopsies to determine the presence of lung or lymph node cancers can be taken. Therapeutic uses include the removal of a foreign object from the airways, dilation of an airway that is blocked or narrowed, draining an abscess and placing a stent to keep an airway open. Electromagnetic Navigational Bronchoscopy Electromagnetic navigational bronchoscopy, or ENB, is a form of diagnostic bronchoscopy. ENB is used to detect and help treat peripheral lung lesions, and can detect lung disease even before symptoms are present, improving the patient's prognosis. The procedure is performed under anesthesia, using CT imaging to create a 3D picture of the lungs. The bronchoscope is inserted through the patient's mouth and into the airways of lungs, and catheters are placed into the bronchoscope channel. Biopsy tools are then used to collect tissue samples for diagnosis and testing. Because ENB is minimally invasive, it reduces the potential for complications that are more likely to result from an invasive surgical procedure. Unlike traditional bronchoscopy, ENB can reach lesions deep within the lungs, and it is an effective alternative to needle biopsy. The procedure usually takes 30 minutes to complete. Endoscopic Bronchial Ultrasound Endoscopic bronchial ultrasound, or EBUS, is a technique that combines ultrasound and bronchoscope technology to diagnose and evaluate the stages of lung and bronchial cancers. Performed while the patient is under sedation, EBUS involves the insertion of a flexible endoscope with a small ultrasound tool attached through the patient's mouth and trachea. This provides the doctor with a detailed view of the lungs in order to diagnose lung disease and determine the severity of the condition. The entire procedure generally takes about 30 minutes to complete, and patients can usually return home the next day. Bronchial Thermoplasty Bronchial thermoplasty, or BT, is a therapeutic form of bronchoscopy, primarily used to treat severe cases of asthma. Using a catheter inside a flexible bronchoscope, the procedure is performed to deliver controlled amounts of thermal energy through the patient's nose or mouth and into their lungs, helping minimize airway constriction. The patient will be monitored closely following the procedure, and can usually return home the next day. BT typically requires multiple treatment sessions, which are generally scheduled approximately three weeks apart. Risks of a Bronchoscopy Bronchoscopy is relatively safe, but there are possible risks associated with any medical procedure of this type. These may include: Excessive bleeding Pneumothorax or collapsed lung Infection Spasms in the airway Cardiac complications Adverse reaction to anesthesia Breathing difficulty Recovery from Bronchoscopy After a bronchoscopy, a follow-up visit is scheduled for the patient to discuss the results of the procedure with the doctor. If a biopsy was taken, it will take a few days for the lab results to become available. The recovery from the procedure itself is usually short and uneventful, although the patient may experience a sore throat or hoarseness for a day or two.

Chest tube placement is a surgical procedure in which a tube is inserted into the chest to act as a drain. The chest tube drains blood, fluid or air from the pleural space, the area between the inner and outer linings of the lung, allowing the lungs to fully expand. It can be performed either as a independent procedure or in conjunction with heart surgery. Reasons for Chest Tube Placement Chest tube placement, also called thoracostomy, is used to treat conditions that cause a lung to collapse. These conditions include: Surgical complication Traumatic injury to the chest Pneumothorax, air leakage from the lung into the chest Fluid buildup in the chest or pleural effusion Hemothorax, an accumulation of blood in the pleural space Infection or abscess Heart failure Emphysema or other disease Cancer Symptoms That May Require Chest Tube Placement Symptoms of lung collapse include the following: Sharp chest pain made worse by deep breath or cough Shortness of breath Chest tightness Fatigue after slight exertion Rapid heart rate Nasal flaring Cyanosis, or bluish skin color Procedure of Chest Tube Placement It is possible for a small pneumothorax to resolve on its own with rest and the administration of oxygen. It is also possible for a doctor to re-inflate the lung by extracting air from the area around the lung using a needle. In more serious cases, however, a chest tube placement will be necessary. This procedure involves: General Anesthesia The patient will be under general anesthesia for the procedure. Before the administration of the general anesthesia, the patient may also be given a sedative to relieve presurgical anxiety. Placement of a Chest Tube The chest tube is surgically inserted between the ribs into the space between the inner and outer linings of the lung, known as the pleura, to help drain the air and allow the lung to re-expand. On occasion, the patient may be able to go home with a small chest tube. If a larger chest tube is needed, the patient will be required to stay in the hospital for the duration of this treatment. Extra Oxygen In many cases, the patient requires extra oxygen during or after the procedure. Lung Surgery In some cases, there may be a need for lung surgery to prevent further episodes of lung collapse. Sometimes, a special chemical will be surgically placed on the weakened in order to cause a scar to form as a patch. This procedure is called pleurodesis. Complications of Chest Tube Placement While they rarely occur, there are possible risks associated with the placement of a chest tube. These may include: Recurrence of lung collapse Shock Adverse reactions to anesthesia or medications Post-surgical infection Damage to adjacent organs Damage to the lung which may result in breathing problems Recovery From Chest Tube Placement After a chest tube placement, patients usually remain in the hospital until the lungs have properly drained and the chest tube has been removed. The patient will have to cough and breathe deeply to help the lung re-expand. Antibiotics may be prescribed during recovery to prevent infections. Once the patient has fully recovered, steps will be taking to avoid a recurrence of the problem. Only a small scar will result from this procedure.

Coronary artery disease is a condition in which the arteries that supply blood and oxygen to the heart become narrowed and hardened. Typically, this condition is caused by the build up of plaque and fat on artery walls, which narrows the vessels that connect to the heart. This narrowing of the arteries restricts blood from reaching the heart, and proper circulation of blood and oxygen is not provided to the heart and its surrounding tissue. Blood clots can also form and completely block the artery. Coronary artery disease develops gradually and can eventually lead to a heart attack or heart failure. Coronary artery disease is often initially treated with medication, and in some cases, angioplasty and stenting are performed. For many types of blockages however, coronary bypass surgery is the best option for treatment. The coronary artery bypass procedure creates new pathways for oxygen-rich blood to flow into the heart and bypass the blocked arteries. During the coronary artery bypass procedure, one or more blocked coronary arteries are bypassed using a blood vessel grafted from another part of the body, restoring normal blood flow to the heart. The blood vessel grafts come from the patient‘s own arteries and veins in either the chest, leg, or arm. The Coronary Artery Bypass Procedure General anesthesia is administered to the patient during coronary bypass surgery. The surgery can be performed "on-pump" with the use of a heart-lung bypass machine or as an "off-pump" procedure also known as "beating heart" surgery. The type of method that is used depends upon the patient‘s age, health and an evaluation of the patient‘s heart and arteries. During surgery the sternum is divided and the heart is temporally stopped. Based on the prior evaluation, the patient‘s vital functions may become fully supported by a cardiopulmonary bypass pump which takes over the function of the heart and lungs, blood circulation and oxygen content of the body. Healthy blood vessels are taken, often from inside the chest wall or from the lower leg, and attached to the the ends above and below the blocked artery so that blood flow is diverted, or bypassed around the narrowed portion of the clogged artery. The coronary artery bypass procedure generally takes about 3-5 hours to perform, depending on the number of arteries that are being bypassed. On average, two to four coronary arteries are repaired during this procedure. A minimally invasive form of coronary artery bypass surgery may also be performed. In this procedure, the coronary bypass is performed through a smaller incision in the chest, often with the assistance of robotics and video imaging that help the surgeon operate in a small area. Recovery from Coronary Artery Bypass Surgery After coronary artery bypass surgery, most patients spend 1 to 2 days in the cardiac intensive care unit for monitoring. Monitoring includes continuous heart function, blood pressure and oxygen monitoring and frequent vital sign checks. Overall, the patient is hospitalized for about 1 week. Medications such as statins and cholesterol-lowering medicine are often prescribed after surgery. Most patients will take part in a cardiac rehabilitation program as a part of their recovery. Most people can return to work within 4 to 6 weeks and full recovery usually takes about 10 weeks. Risks of Coronary Artery Bypass Surgery As with any invasive procedure there are risks associated with coronary artery bypass surgery. Risks include: Bleeding Infection Heart arrhythmias Heart attack Stroke The risk of developing these complications depends on the overall health of the patent prior to surgery. Any concerns should be discussed with a doctor prior to undergoing surgery. Although bypass surgery improves blood supply to the heart, it does not cure underlying coronary artery disease. Medication and healthy lifestyle changes are strongly recommended to reduce the risk of recurring heart disease, and the need for additional heart surgery in the future.

The diaphragm is the muscle that stretches along the bottom of the rib cage and plays a crucial role in respiration. When the diaphragm is damaged, it must be immediately repaired. There are several ways in which the diaphragm may be injured, all eventually involving hiatal herniation. Congenital Defect In a rare birth defect, an infant is born with a hole in the diaphragm which requires immediate repair. Since the diaphragm separates the chest cavity from the abdominal area, when there is a hole, or hernia, present the abdominal organs may invade the chest cavity, interfering with breathing and normal lung development. Until the surgical correction surgery is performed, the infant almost always needs a breathing device to assist in respiration. Once the surgery is performed and the hole is closed, the infant is able to breathe normally. Severe Hiatal Herniation Hiatal herniation, in which the abdominal organs protrude into the chest cavity, may also result from the aging process. Its symptoms may remain mild and respond well to dietary changes and medication, but when a hiatal hernia causes severe symptoms, particularly when it causes respiratory difficulties, surgical intervention may be necessary. Physical Trauma Blunt force trauma or penetrating trauma can actually rupture the diaphragm. Such trauma may occur through accident or as a result of deliberate attack. Since the pressure in the abdomen is higher than the pressure in the chest, physical trauma to the diaphragm region will also almost certainly result in hiatal herniation and require immediate surgical repair. Symptoms of a Diaphragm Injury There are several signs of diaphragm rupture that may include the following. Diminished breathing signs on the affected side Chest pain Abdominal pain Acid reflux Breathlessness (dyspnea) Coughing Sepsis, in severe cases Bowel sounds in the chest Symptoms of bowel obstruction Tachycardia or rapid heart beat A bluish skin color (cyanosis) Diagnosis of a Diaphragm Injury An injury to the diaphragm is often difficult to diagnose since the symptoms may be similar to those found in other conditions. Diagnostic tests including X-ray, CT scan or ultrasound may be employed to pin down the cause of symptoms. Under certain circumstances, an exploratory laparotomy, a surgical procedure in which a large incision is made in the abdomen, may be performed to make an accurate diagnosis and immediate repair. The Diaphragm Repair Procedure This procedure may be done as open surgery, but is most often performed laparoscopically. The latter requires only small incisions and results in less pain, less scarring, and a shorter recovery time. Sometimes the surgical repair is performed by suturing the patient's own tissue only. Other times, surgical mesh is employed to repair the diaphragm. Risks of a Diaphragm Repair With any surgery risks are present, including the following: Excessive bleeding Blood clots Adverse reactions to anesthesia or medications Post-surgical infection Damage to adjacent organs Breathing problems In the case of diaphragm repair, breathing problems are particularly dangerous and include the risk of the following: Collapsed lung or pneumothorax Lung problems that do not resolve Respiratory failure Recovery from a Diaphragm Repair After a repair of the diaphragm, the patient can usually return home in a day or two. The patient will be given pain medication and be instructed to limit physical activity and heavy lifting for about a month. The following symptoms after surgery should be reported to the doctor immediately: Severe pain at the surgical site High fever Difficulty breathing or swallowing Swelling, redness or odor at the incision site Absence of bowel movement for 3 days

A lung biopsy is a procedure in which a small piece of tissue is removed from the lung to be examined microscopically in order to determine the presence or absence of damage or disease. There are several types of lung biopsies, each useful depending on medical circumstances. Bronchoscopic and needle biopsies are usually done under mild sedation whereas open biopsies, VATS, or mediastinoscopy, since these require incisions, are performed under general anesthesia. Reasons for Lung Biopsy Lung biopsies are done for several reasons as follows: To diagnose lung cancer or to establish the stage of malignancy To diagnose other lung conditions, such as sarcoidosis or mesothelioma To further investigate abnormalities seen on other diagnostic tests, such as chest X-rays To investigate the cause of unexplained fluid collection in the lung Procedure of Lung Biopsy There are several methods used in performing lung biopsies, depending on where the sample will be taken from and the overall health of the patient: Bronchoscopic Biopsy During this type of biopsy a lighted instrument called a bronchoscope is inserted through the mouth or nose and into the bronchial passage to remove a lung tissue sample. This method may be used if an infectious disease is suspected, if the abnormal lung tissue is located next to the bronchial tubes, or as a preliminary procedure before trying more invasive methods. Needle Biopsy In a needle biopsy a long needle is inserted through the chest wall to remove a sample of lung tissue. This method is used if the abnormal lung tissue is located close to the chest wall. During a needle biopsy, a CT scan, ultrasound or fluoroscopy is commonly employed to guide the surgeon's needle with precision to the abnormal tissue. Open Biopsy In an open biopsy, the surgeon makes an incision between the ribs to remove a sample of lung tissue. An open biopsy is usually done when the other methods of lung biopsy have not been successful or cannot be used, or when a larger piece of lung tissue is required for diagnosis. Video-assisted Thoracoscopic Surgery (VATS) In VATS the surgeon uses a thoracoscope which is passed through a small incision in the chest to remove a sample of lung tissue. Mediastinoscopy In mediastinoscopy, the surgeon examines the space behind the breastbone in the middle of the chest. This area, which separates the two lungs, is known as the mediastinum, and contains lymph nodes, as well as the heart and other organs. During this procedure, using a special type of endoscope, the physician is able to locate and take a biopsy of one or more of the affected lymph nodes for microscopic examination. Risks of a Lung Biopsy Lung biopsies are generally safe procedures. There are, however, some risks associated with all types of lung biopsies. These should be discussed with the pulmonologist beforehand. Death resulting from a lung biopsy is an extremely rare occurrence, but lung biopsies should never be undertaken lightly. The most serious risk during a lung biopsy is the collapse of the lung, known as a pneumothorax. There is a 15 percent chance of lung collapse occurring during a lung biopsy. If pneumothorax occurs, the doctor may need to place a tube in the chest to keep the lung inflated while the biopsy site heals. Other risks of a lung biopsy may include: Excessive bleeding or hemorrhage Infection Bronchial spasms Heart arrhythmias Allergic reactions to anesthesia or medications Blood clots Risks of a Lung Biopsy Recovery varies depending on the type of procedure performed and the type of anesthesia or sedation used. The patient will usually be discharged as soon as blood pressure, pulse, and breathing are stabilized. A chest X-ray may be performed immediately after the biopsy and repeated in a few hours. The patient should expect the following symptoms during the recovery period, depending on the type of biopsy performed: Dry mouth resulting from the use of the bronchoscope Blood tinged saliva or other secretions Tenderness for several days after a needle biopsy Fatigue and possible aches Pain relievers should be taken as recommended or prescribed by the physician. Aspirin and similar medications should be avoided since they may cause excessive bleeding. The patient is usually cautioned to avoid strenuous activities for a few days following the lung biopsy, and to report any of the following to the doctor: Shortness of breath Chest pain Difficulty or pain associated with breathing Coughing up blood Fever and/or chills Redness, swelling, bleeding or other drainage from the biopsy site

Lung resection is a surgical procedure to remove all or a portion of a diseased lung. There are several reasons for this surgical intervention, but the most common is as a treatment for lung cancer. When lung resection is performed in the presence of early-stage lung cancer, the prognosis is much better than if the disease has progressed. The type of lung resection performed depends on the severity of the condition. Reasons for Lung Resection Although lung resection is often performed on patients with lung cancer, other common reasons for surgical resection of a lung include: Congenital lung malformation in children Benign growths in the lung Infectious lung lesions Tuberculosis Atelectasis (partial collapse of the lung) Emphysema The majority of lung cancers in adults, 85 to 90 percent, are attributable to smoking tobacco. Other factors that may cause patients to develop lung cancer are secondhand smoke, predisposing genetic factors, air pollution and exposure to asbestos and radon gas. Types of Lung Resection Lung resections, like many other operations traditionally performed as open surgery, are now often performed using minimally invasive laparoscopic techniques. Video-assisted thoracoscopic surgery, or VATS, provides several advantages over open surgery, including smaller incisions, less pain and scarring, shorter hospital stays, less risk of infection, and a shorter recovery period. There are several types of lung resection which may be done laparoscopically or as open surgery, including: Lobectomy A lobectomy is a surgical procedure in which one lobe of the lung is removed, usually to excise a cancerous tumor. If it is necessary to remove two lobes of the lung, the procedure is called a bilobectomy. Sleeve Lobectomy During a sleeve lobectomy, the part of the bronchial tube that attaches to the diseased lobe of the lung is also removed. In this procedure, the resectioning involves reattaching the remaining lobe or lobes of the lung to the remaining segment of the bronchial tube. Wedge Resection A wedge resection is the surgical removal of a small, wedge-shaped portion of the lung containing the malignant tissue. In this procedure, some healthy surrounding tissue is also removed for diagnostic testing. This surgery is performed to remove a small tumor or to diagnose lung cancer. A wedge resection can be performed by minimally invasive video-assisted thoracoscopic surgery, VATS, or as a thoracotomy, an open chest surgery. Segment Resection or Segmentectomy During a segment resection of the lung, the surgeon does not remove the entire lobe, but does remove a larger portion of the lobe than during a wedge resection. Pneumonectomy A pneumonectomy is the removal of the whole lung. Risks of Lung Resection All surgery involves some risks, which may include: Excessive bleeding Blood clots Adverse reactions to anesthesia or medications Post-surgical infection Damage to adjacent organs Breathing problems Hernia at the incision site Beyond general surgical risks, lung resection is associated with other, more specific, risks. While rare, these may include: Residual air leakage from the lung Damaged blood vessels or nerves in the chest Ongoing post-surgical chest pain. Recovery from Lung Resection Length of recovery from lung resection depends on the patient's overall physical condition before the surgery and which type of surgery was performed. The usual hospital stay, if there are no complications, is about a week to 10 days. There are several aspects to recovery, both in the hospital and at home, which include: Pain Management Because lung resection involves incisions into the chest, the spreading apart of the ribs and the possible removal of a small portion of a rib, the patient will experience pain for weeks to months after surgery. Pain medication will be prescribed immediately after surgery and may be continued and then tapered down during the following weeks. Depending on the type of surgery performed, the pain may persist and the patient may require medication for a few months. Chest-tube Placement After lung resection, one or more chest tubes are used to drain fluid and blood from the chest cavity. These tubes help the lungs inflate. The tubes are attached to a suction machine that helps fluids to drain and measures the amount of drainage. Once there is no air leaking from the incision site and the affected lung is fully expanded, the drainage tubes will be removed. This usually occurs within 2 to 3 days after surgery. In some cases, air leakage may persist for a period of weeks and the chest tubes will have to remain in place longer.

A thoracotomy is an incision into the pleural space, the space between the membranes surrounding the lungs and chest cavity. It is performed to correct a problem within one of the lungs. A thoracotomy allows the surgeon to see the affected area, and to determine exactly how extensive a repair or tissue removal needs to be. If the thoracotomy is performed to treat lung cancer, nearby lymph nodes may also be removed to determine if the malignancy has spread. A thoracotomy may be performed laparoscopically or as open surgery, depending on the extent of the problem and the condition of the patient. Reasons for a Thoracotomy A thoracotomy, which requires general anesthesia, may be performed for a variety of reasons, including: Removal of a lobe of the lung (lobectomy) Removal of an entire lung (pneumonectomy) Treatment of a collapsed lung (pneumothorax) Removal of tissue damaged by infection or disease Treatment of the buildup of fluid in the lungs (pleural effusion) Tissue biopsy Treatment of a pulmonary embolism Lung transplant Risks of a Thoracotomy A thoracotomy, whether done laparoscopically or as an open procedure, is serious surgery. It involves the same risks as other major surgery, including: Excessive bleeding Blood clots Adverse reactions to anesthesia or medications Post-surgical infection Damage to adjacent organs Breathing problems Hernia at the incision site Risks of a thoracotomy in particular may include: Pneumonia Leakage of air through the lung wall Worsening of any preexisting heart problems Buildup of fluid in the chest cavity Recovery from a Thoracotomy The thoracotomy procedure takes between 2 and 6 hours. After the procedure, the patient will remain in the hospital for 5 to 7 days. Recovery time varies from several weeks to a few months, depending on the overall condition of the patient and on the method of the surgery performed. After a thoracotomy, the patient will temporarily have a drainage tube implanted to remove waste fluids from the chest. To prevent blood clots in the legs, the patient will wear special stockings and receive injections of blood-thinning medication. The patient will also receive intravenous medication to control pain. It will be essential for the patient to learn and practice deep-breathing exercises after a thoracotomy to inflate the lungs and prevent pneumonia or other infection.