From video-assisted thoracic surgery to laparoscopic procedures and sleeve lobectomies, the Thoracic Surgery Division at Stanford has an overriding goal of imparting a cure with the least invasive procedure available. Patients who come to Stanford have surgical
options that are not widely available in the community, or even at many other academic centers, according to Joseph Shrager, MD, Chief of the division.

With Shrager’s recruitment just over a year ago, Stanford renewed its focus on thoracic surgery, creating what Shrager feels is rapidly becoming “the premier clinical and research thoracic surgery program in the West.” Previously Chief of Thoracic Surgery at the University of Pennsylvania, Shrager joined highly reputed Stanford faculty member Richard Whyte, MD, and immediately brought on two additional thoracic surgeons– Chuong Hoang, MD, and Robert Merritt, MD – to round out the department.

“With the additional surgical staff, all super-specialized in non-cardiac thoracic surgery, we are able to do a number of things that haven’t been done at Stanford before in any consistent way,” he says.

A focus on minimally invasive procedures

Stanford thoracic surgeons have a high level of experience with minimally invasive techniques, and a philosophy to use them whenever possible. These techniques include: video-assisted thoracic surgery (VATS) lobectomy, laparoscopic Nissen fundoplication, transcervical thymectomy and VATS sympathectomy – to name a few.

VATS lobectomy, usually done for lung cancer, allows surgeons to carry out the same operation as by thoracotomy, but through three to four small incisions rather than the large incision with rib
spreading that a thoracotomy entails. Similarly, transcervical thymectomy allows removal of the thymus gland through one small incision rather than the breastbone-splitting median sternotomy that is otherwise used. This is appropriate for patients with Myasthenia Gravis as well as some small thymic tumors,
and it can be done as an outpatient procedure. Using thoracoscopic (VATS) sympathectomy, surgeons can provide a long-term cure for hyperhydrosis, severe sweating of hands. Through two, 2 mm incisions, surgeons pass a tiny video camera and a single dissecting instrument into the chest. The incisions are so small that this procedure is sometimes called "needlescopic surgery" – it creates almost no pain. With this minimally invasive approach, more patients are taking advantage of a surgical cure for their hyperhydrosis.

Esophageal diseases such as reflux and hiatal hernia can be treated laparascopically, giving patients the same benefits
of shorter hospital stays and quicker recoveries. Dr. Robert Merritt has extensive experience with these esophageal diseases.

Lung sparing treatment for lung cancer

In addition to its focus on minimally invasive techniques, Dr. Shrager points out that Stanford has a philosophy of avoiding
pneumonectomy if at all possible when managing lung cancer. In addition to performing the standard lung cancer resections such as lobectomy, pneumonectomy, segmentectomy and wedge
resection, Stanford surgeons also perform the more complex sleeve lobectomy, which allows complete removal of the tumor, without complete removal of the lung, in cases where most surgeons would carry out a pneumonectomy.

“This approach provides the same chance of cure as pneumonectomy, with far lower operative complications and
better post-operative quality of life,” says Shrager. Stanford is one of the few centers in the country with extensive experience
performing this procedure.

“Several studies show that patients do better when complex lung and esophageal resections are performed by physicians who do large volumes of these resections,” cites Shrager. “There are not only fewer complications at high volume centers like Stanford; it has even been shown that there are greater long term survival rates from the cancer.”

Stanford also takes on the challenge of treating patients with more aggressive lung cancers such as Pancoast tumors or Stage 3A lung cancers that involve mediastinal lymph nodes. “These
are more complicated surgeries that involve chemotherapy or chemoradiation treatment before surgery,” says Shrager. “Some institutions consider stage 3A tumors inoperable. We believe the evidence is strong that many 3A patients benefit from aggressive, multi-modality therapy including surgery, as long as that surgery is done by individuals experienced in managing these difficult cases.”

Clinical trials provide next generation treatment

Stanford’s Division of Thoracic Surgery is also involved in testing new treatments and surgical techniques by participating in national and international trials through its Clinical Trials program. For example, in the “MAGE-A3 Vaccine Trial,” the surgeons are evaluating the effectiveness of a vaccine that harnesses a patient’s own immune system to attack microscopic cancer cells and prevent a recurrence. In a national surgical trial evaluating “sublobar” resections, they are determining if a technique that removes less than an entire lobe of the lung can
offer patients with smaller tumors the same cure rate as a full lobectomy.

Working with referring providers

Stanford’s thoracic surgeons work closely with referring physicians to ensure that patients receive the most appropriate
pre- and post-operative care. “I am an extremely strong believer in
maintaining close communication with referring physicians,” explains Shrager, who sends a letter to the patient’s primary
and referring specialists within 5 days of any patient visit. Stanford thoracic surgeons also, as a routine, call referring physicians on the day of surgery, and send them a fax at the time of discharge
briefly summarizing the patient’s hospital course and any other information the local doctor may need in caring for the patient post-operatively.

“Some of our referring doctors may think we communicate too much,” Shrager adds. “But all of my frequent referrers have my cell phone number and know they can reach me at any time. I know the same is true of my partners.”