Lung Cancer Gets a Sharper Look in the Hybrid OR

New Innovative Methods for Cardiothoracic Surgery

Kathleen Raven |  May 25, 2017

Mahesh Ramchandani, a cardiothoracic surgeon at Houston Methodist Hospital in Texas, USA, has devoted his career to searching for innovative methods for cardiothoracic surgery. Earlier this year, he asked his friend and colleague, Alan Lumsden, chair of the department, about the possibility of localizing a nodule or tumor in the lung with what Lumsden used every day: a CT-like angiography system in the hybrid operating room.

Photos: Thomas Steuer

Trading toolboxes
By trading advice, “we get the opportunity to see what each other is doing – to sort of look into each other’s toolkit,” Ramchandani says. He is a specialist in operating on patients’ lungs. At the slightest puncture, the lung can collapse from an airy structure to something like a compact sponge. If possible, Ramchandani follows a minimally invasive approach called video-assisted thoracoscopic surgery or VATS, which consists of inserting a video camera along with special surgery tools through small incisions – forgoing the need to open up the whole chest. Because the surgeon works through small ports VATS provides less complications, less pain, a shorter recovery time and a better cosmetic outcome. However, the method has trade-offs, because the surgeon has limited sight and loses tactile contact to the surgery site.

About five years ago, Houston Methodist purchased a robotic-assisted angiography system, the Siemens Artis zeego1, which delivers 3D CT-like images owing to a detector rotating around the patient in a flexible C-arm. Originally, the system was used mainly for cardiovascular procedures. Lumsden and his colleagues focused on the implantation of coronary stent grafts, trans-catheter valves and image-guided interventions on aneurysms of the aorta, for example. “We began using the system to place coils inside an aneurysm by going in with a needle through the back to treat endoleaks. In that situation it’s important that you are accurate,” Lumsden says. He quickly became an expert in navigating the system, while Ramchandani was an expert at VATS. Thus, the two colleagues made common cause.

Adopting a precision approach
With the VATS approach, nodules that are visible on the surface of the lung can be removed with relative ease. Since this approach does not allow one to palpate the lung, deeper nodules need to be localized in advance. By combining the 3D imaging system and VATS, the physicians found they could pinpoint and remove such pulmonary nodules or tumor tissue with extreme accuracy using small chest incisions. The duos have already successfully performed the technique on a several patients. To understand how this method might improve lung cancer surgery, it helps to know what happens during a traditional VATS procedure, Ramchandani explains. On the day of surgery, a patient might arrive to the hospital at 7 o’clock in the morning. He or she then checks in at the radiology department, where a CT scan is performed. The radiologist localizes the tumor or nodule, for example by injecting blue dye to the targeted area based on CT images..

By 8 o’clock, the patient enters the pre-operating area, by about 9 or later, the surgery eventually starts. “The patient ends up being shuttled from one part of the hospital to another, which is inconvenient,” Ramchandani says. During this time, the blue dye, if it is used, can dissipate from the targeted area. Further, CT scans taken in the radiology department do not always match the position of the patient on the operating table, Lumsden points out. Another important disadvantage of the traditional workflow is the risk of a pneumothorax during the needle procedure in the CT room. Such complications could be handled much safer in an OR environment. With the new method, a patient enters the operating room without a visit to the radiologist. “With the ability to look at the scan right in the OR, we can see the nodules ourselves, and immediately proceed to a resection,” Ramchandani says. Artis zeego, which delivers images with spatial resolution in the submillimeter range, has a virtual guidance system to apply a localization needle to the nodule or place a solid marker. Then, the surgeon can make small incisions to introduce his video camera and instruments and securely navigate to the targeted area under fluoroscopic control for removal of as little lung tissue as possible.

Improving procedures while lowering costs
Lumsden estimates that this precision technique might shorten a patient’s procedure by an average of four hours from start-to-finish. While he and Ramchandani are still gathering data, it is possible that patients will also have shorter recovery times, because of the quicker procedure and the lesser interventional trauma. The team plans to publish a cost-savings analysis that outlines the details of their protocol, Lumsden says. For example, the billing process might be more simplified. “Normally you would get a billing from the radiology department, and a separate bill from the surgical side,” Ramchandani explains. “Theoretically, the cost of the procedure should also be lower to the patient and to the insurance company.”

This type of lung cancer surgery could become popular for removing pulmonary nodules that are caught early through low-dose CT screening. Screening has recently proven to help reduce mortality in heavy smokers, and is endorsed by new U.S. guidelines on screening and reimbursement. As the guidelines gain traction, then surgeons may find themselves in even greater demand for imageguided biopsies as well as for minimally invasive resection of small pulmonary nodules. Of course, hospitals will need to invest in hybrid ORs first, Lumsden points out. Typically, hybrid operating rooms have been considered necessary for cardiac or endovascular procedures, but not for thoracic ones. That could change. “People will start thinking about the possibility that CT-like scanning in the OR could help,” Ramchandani agrees. “Only by using it can one learn the possible applications of this important technology.”

About the Author

Kathleen Raven has covered lung cancer clinical trials for Biopharm Insight, consumer health for Reuters Health and biomedical news for Nature Medicine. She is a freelance writer in New Haven, Connecticut, USA.

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1This article refers to an installation of Artis zeego. Artis zeego is no longer available and is replaced by ARTIS pheno.

The statements by Siemens’ customers described herein are based on results that were achieved in the customer's unique setting. Since there is no "typical" hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption) there can be no guarantee that other customers will achieve the same results.