Department of Thoracic Surgery
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Department of Thoracic Surgery

01What we do

Norihito Okumura
Director
Norihito Okumura

This department was originally established in 1982. At the time, it was named the Department of Pulmonology; however we have now branched into two departments of thoracic surgery and respiratory medicine.

Our Key Principles

  1. To put the key principles and policies of this hospital into practice and maintain a high standard of care.
  2. To prioritize the safety and health of the patient while respecting individuality and confidentiality.
  3. To respect the rights of the patient and to provide safe and superior care through multidisciplinary treatment.
  4. To provide adequate care for patients suffering from multiple conditions, through referrals and ongoing follow-up.
  5. To give back to society with technical know-how, professionalism, proactive development and experience.

Points of care taken in practice

  • Keeping the time needed for appointments and testing to the minimum possible to avoid inconvenience to the patient.
  • Taking the upmost care in ensuring early treatment (especially surgery) and the smooth hospitalization, diagnosis and testing for patients with suspected malignant tumors.
  • Explaining the patient's condition with as much easily understood terminology as possible and deciding on treatment together.
  • The prompt and detailed relay of information to any referring institution.

02Conditions handled in this department

Diagnostic tests

We look after suspected conditions of the lungs, pleura, diaphragm, mediastinum and the chest wall. For conditions involving the mammary glands, esophagus, vessels of the heart and the thoracic spinal cord, we work together with other surgical departments (cardiovascular, orthopedic, etc.) Examples of this include the treatment of diaphragm conditions together with the general surgery and chest wall conditions with the plastic and reconstructive surgery and orthopedic surgery departments.

The main conditions we deal with include lung cancer, pneumothorax, mediastinal tumor and external chest trauma. Common cases include surgical intervention for palmar hyperhidrosis, foreign object aspiration in children and decreased lung capacity resulting from pulmonary emphysema. For inoperable lung cancer and pneumonia, pulmonary tuberculosis, bronchial asthma, pulmonary fibrosis, pneumoconiosis, hypersensitivity pneumonitis, bronchiectasis and chronic respiratory failure, treatment is undertaken by internists in respiratory medicine department.

Area of treatment

We treat patients from the west of Okayama Prefecture, centered in Kurashiki, with Niimi to the north, Kasaoka to the West and also Ibara and the eastern part of Hiroshima Prefecture.

Main treatment techniques
1. Thoracotomy

To preserve the chest muscles, we perform most thoracotomies with an anterior axillary incision. Skin incision size varies according to the purpose of surgery, but for lung cancer it averages at around 15 cm. Procedures of the chest wall and for pleural empyema involve a posterior incision. Surgery for mediastinal tumor and myasthenia gravis are approached with a median sternotomy. For the pain management of all posterior procedures, we use a combination of intercostal nerve block and epidural anesthesia.

2. Video-assisted thoracic surgery (VATS)

Minimally invasive and having little postoperative impact aesthetically, surgery with a thoracoscope has become the norm in this department. In addition to spontaneous pneumothorax and other benign conditions treated with the thoracoscope in the past, it is now widely used for lung cancer in this department, when circumstances deem this as the most effective and safe method. Surgery involves two to four incisions and on occasion, a minithoracotomy is performed. We use thoracoscopes with diameters of 3 mm, 5mm, 5.5mm and 10 mm, and also a flexible type.

3. Bronchoscopic treatment

Other than the removal of sputum and foreign objects from the respiratory tract, the bronchoscope is used for the removal of bronchial polyps and intrabronchial tumors, using a high-frequency snare. It is also used for cauterization with the YAG laser, with cauterization capable of achieving complete remission in cases of early stage cancer on the bronchial surface. For hemoptysis and for surgery, it is also used to achieve hemostasis. When required, we use a non-flexible bronchoscope rather than the conventional fiberscope, for stent placement in cases of stenosis and bronchial malacia.


Diagnostic tests
1. Bronchoscopy

This can be done either during admission or in the outpatient clinic. Local anesthetic is administered through either a spray or intravenous drip. The procedure itself lasts about 30 minutes, with the whole time spent at the hospital totaling around three hours.

2. Thoracoscopy

This is normally undertaken with anesthetic, with an incision made between two ribs and a thoracoscope of 3 mm to 5 mm in diameter inserted. The thoracic cavity is examined and samples of pleural fluid, pleura and any lesions can be taken for biopsy. Other than the main incision made for thoracoscope insertion, one or two other incisions are also necessary. The procedure takes a total of thirty minutes to one hour and generally requires hospital admission.

3. Mediastinoscopy

This is undertaken under general anesthetic. A horizontal incision of 3 cm is made directly above the sternum and the mediastinoscope is inserted in the area in front of the trachea. This is mainly done for biopsy of the mediastinal lymph nodes. The procedure itself takes 30 minutes to one hour and requires hospital admission.

4. Percutaneous needle biopsy

This is undertaken under local anesthesia. CT scan is used in biopsies of the chest wall, pleura, mediastinum and for legions within the lungs. This procedure is best suited for patients with strongly suspected lung cancer, in which all other diagnostic options have been exhausted. This generally requires hospital admission.


Conditions and surgical techniques
1. Lung cancer

In most cases this is approached with a resection of the lung lobe containing the lesion and dissection of the lymph nodes. Bronchoplasty and arterioplasty are first-line treatments and bilobectomy and pneumonectomy are undertaken as a last resort. In progressive cases, excision may need to be performed on the chest wall, diaphragm, superior vena cava, pericardium and the left atrium of the heart. Based on factors, including the size of the lesion, the presence of lymph node metastasis and the level of pulmonary function, we aim to perform the minimal amount of surgery required to achieve complete remission. VATS is a well utilized procedure both here and elsewhere, due to its minimal invasiveness. However, there are areas in which this procedure is not as effective as conventional thoracotomy. Given that VATS for mediastinal lymph node dissection yields clinically poorer results than conventional thoracotomy, we only utilize VATS for stage I cases with no radiological findings of lymph node metastatis. Furthermore, pathological analysis of resected lymph nodes is performed during surgery and if there are any findings of metastasis, the incision is extended to 7 or 8 cm and a thoracotomy and thorough dissection is performed. This results in effective surgery balanced with minimal invasiveness. As facilities for VATS spread nationally, there are many instances where incisions of up to 10 cm are made and the space between the ribs are excessively spread open, defeating the purpose of VATS as a minimally invasive procedure. In this department we make an incision for minithoractomy of 3 cm to 4cm, close to the armpit and another two 1.5 cm to 2 cm incisions which are used almost solely for the endoscopes. Widening of the ribs is kept to a minimum. If there are clinical indicators such as evidence of lymph node metastasis, the incisions may, however, need to be lengthened. Accidents and safety in endoscopic surgery have become a recent topic of discussion in the media. To address these issues, surgery planning and management here is rigorous, with only experienced surgeons being assigned for this surgery. Whether VATS is medically appropriate or not is also discussed and decided upon. Postoperative pain at the sites of incision is relatively minor compared to those of thoracotomy, as is impact on pulmonary function and quality of life. The general postoperative period until hospital discharge is five to seven days.


2. Pneumothorax

For spontaneous pneumothorax and secondary pneumothorax, thorascopic surgery is generally undertaken. Due to the young age of the patient demographic, we use a needle scope of 3 mm in diameter. Other than procedures for the insertion of a chest drain, this leaves few scars compared to the previous thoracoscope and is well accepted by patients due to its minimal aesthetic impact.

3. Tracheal tumor、airway narrowing

We perform resection and anastomosis for tracheal narrowing, tracheal tumors, and tracheal tumor invasion from the thyroid glands and esophagus. Sleeve resection and end-to-end anastomosis are the most frequent procedures and lateral wall resection is undertaken less frequently. For patients in which radical surgery is unsuitable, YAG laser cauterization and stent placement in the respiratory tract is performed.

4. Thymus-related conditions

Thymoma is the most frequent of these conditions; however we also see cases of thymic cancer, germinoma and thymic cyst. For malignant germinoma, preoperative chemotherapy is undertaken. VATS is generally utilized for the removal of cysts and median sternotomy is undertaken for all other surgical removal. For cases of invasion into adjacent organs, we perform multiple resection to completely remove all tumors. For myasthenia gravis, extended thymectomy is performed by median sternotomy.

5. Palmer and axillary hyperhidrosis

We have an unexpectedly large number of patients who are troubled by this. We determine the appropriate surgery based on the patient’s symptoms, account of the condition and their wishes. Endoscopic thoracic sympathectomy is performed for this using a 3 mm endoscope, resulting in minimal postoperative aesthetic impact. Compensatory sweating can occur postoperatively. The hospitalization period is usually three days and bed rest is required on returning home.

6. Foreign body aspiration in children

For adults and children alike, the aspiration of a foreign body in the trachea or bronchia is highly dangerous and requires diagnostic checks upon suspicion. A regular fiberscope is used for the removal of foreign objects in adults and for children a thin fiberscope is utilized, or a specialized non-flexible bronchoscope under general anesthetic if the latter is unsuccessful.

03Accreditations

Accredited Training Facility: The Japanese Board of General Thoracic Surgery
Accredited Specialist Facility: The Japanese Respiratory Society

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