BPKMCH | ANNUAL REPORT - 2018

DEPARTMENT OF SURGICAL ONCOLOGY

THORACIC UNIT

Introduction

Thoracic Surgery at BP Koirala Memorial Cancer Hospital deals with non-cardiac thoracic diseases. The

main emphasis is on diagnosis and treatment of thoracic lesions, which are suspected or diagnosed

malignant neoplasms. Thoracic Unit has three operating days per week. Thoracic unit as a separate

division was established on 4, Dec 2006. A separate Thoracic ward was opened in year 2009.

The Thoracic Surgery Unit and its faculty provides operative, perioperative, and critical care for all diseases

of the thorax, including:

Early and locally advanced lung cancer

Pretreatment staging of thoracic neoplasms

Minimally invasive surgery (MIS) including VATS and advanced laparoscopic surgery

Esophageal carcinoma

Gastroesophageal Junction tumors

Management of complex esophageal diseases (complications of gastroesophageal reflux,

neuromotor diseases, etc.)

Tracheal tumors and airway management

Malignant pleural and pericardial effusions

Mesothelioma and other malignant pleural diseases

Chest wall tumors

Pulmonary metastases

Mediastinal tumors

Complex GI/ hepatopancreaticobiliary tumors requiring vascular reconstruction

Others.

Besides, the Thoracic Unit is actively involved in the advanced laparoscopic surgery of various malignancies

of GI tract, mostly upper GI tract.

Routine activities

OPD patients

Male: 4311, Female: 4334, Total: 8645

Inpatients admissions

Total beds: 20

Total admissions: 517, Male: 264, Female: 253

In-hospital mortality: 7 (1.3%)

DOPR: 12 (2.3%)

Mean Hospital stay: 10 days

Mean post-operative stay: 9 days

The Lung, Esophageal/ GE Junction and Gastric cancers were the most common malignancies for which

the patients were admitted.

BPKMCH | ANNUAL REPORT - 2018

Table 1. Frequency of diseases in admited cases

Disease

Ca lung

15.5

Ca esophagus/ GE Junct on

19.0

Pleural effusion

7.0

Hepatobiliary ca

7.0

Ca stomach

10.6

Ca pancrease/periampullary ca

7.5

Colorectal ca

7.4

Anterior Mediast nal mass

2.5

Chest wall tumor

3.0

Hydat dosis of lung/ + liver

0.4

Sof t ssue sarcoma

1.0

Retroperitoneal sarcoma

0.8

Others

18.3

Minor Surgical Procedures

Various biopsies, debridement, drainage, tube thoracostomy, etc: 480

Major surgical procedures

N = 521, Mean age: 51 yrs (2-90 yrs)

Male: 255 (48.9%)

Female - 266 (51.1%)

The major surgical procedures performed have been shown in table 2.

Table 2. Operative procedures.

Procedures

Pulmonary

15.5

Mediast num

1.4

Sternotomy and

excision

Lobectomy

3.6

0.8

mediast nal mass

Bilobectomy

0.4

VATS thymectomy

0.4

VATS Wedge resect on

0.4

Retrosternal thyroidectomy (Sternoto-

0.2

my)

VATS lung/ med node biopsy

3.8

Esophageal / GE junct on diseases

14.2

VATS hydat d cystectomy

0.6

McKewon’s esophagectomy

0.8

USG guided trucut biopsy

6.7

Transhiatal esophagectomy

2.8

Pleural diseases

8.8

Extended total gastrectomy

2.3

Pleurectomy/ decort cat on

0.8

Feeding jejunostomy

4.4

Tube thoracostomy/ pleurodesis

1.7

VATS-3-incision esophagectomy

3.3

VATS pleural biopsy/ pleurodesis

6.1

Laparoscopic cardiomyotomy

0.4

VATS decort cat on

0.2

Laparoscopic Nissen’s Fundoplicat on

0.2

BPKMCH | ANNUAL REPORT - 2018

Procedures

Gastric tumors

4.8

Laparoscopic cholecystectomy

2.9

D2-Subtotal gastrectomy

1.7

Extended cholecystectomy

1.5

Gastojejunostomy

1.7

T-tube hepat costomy

0.4

Diagnost c laparoscopy

1.4

Segmentectomy

0.2

Colorectal tumors

7.1

Cholecystectomy + CBD explorat on

0.6

LAR

2.1

Pancreat c surgery

4.0

Ultra-low LAR

0.4

Whipple’s procedure

3.0

Right hemicolectomy

1.5

Biliary-enteric (tripple) bypass

1.0

APR

1.1

Central Chemoport insert on

3.4

Transanal excision of rectal cancer

0.4

Breast

3.5

Total proctocolectomy

0.2

Appendicectomy

0.8

MRM

3.3

Ileo/ colostomy closure

0.6

BCS

0.2

Wide local excision for sof t ssue

Miscellaneous

117

22.4

8.3

tumors

Discharge on request: 0.5%, In-hospital mortality: 2%

Laparaoscopic Adrenalectomy

0.6

Mean hospital stay: 9 days, Mean stay in post operative

ward: 1.7 days

Chest wall resect on and reconstruct on

0.4

Hepatobiliary

5.6

New services in year 2018

The major breakthrough in year 2018 was the consolidat on of minimally invasive approach, mainly for Upper

GI tract malignancies. We changed our approach of lateral posit on VATS to semi prone-posit on 3 port VATS

technique for esophagectomy. To the best of our knowledge, for the first t me in Nepal we performed totally

minimally invasive esophagectomy in prone posit on (April 12, 2012).

We have a unique approach for the laparoscopic ports for the gastric mobilizat on and upper abdominal nodal

dissect on. We use four 5 mm working ports and one 10 mm opt cal port in “V” fashion. During the thoracic

phase (VATS), we ut lize one 10 mm opt cal port and two 5 mm ports (prone posit on). To the best of our

knowledge, VATS lobectomy for lung cancer and VATS thymectomy for thymoma were performed for the first

t me in Nepal by our team in our hospital (Started in year 2011). Our team is trying to use more and more

minimally invasive approach for various thoracic lesions. For undiagnosed pleural effusion, we have adopted

the policy of diagnost c thoracoscopy (preferably under Local anesthesia and IV sedat on) with excellent

results. Since year 2014, we have adopted the policy of SMA (superior mesenteric artery) first approach

during Whipple’s procedure. The primary aim of the above approach was to perform portal vein resect on

and reconstruct on if needed.

To the best of our knowledge, for the first t me in Nepal, we started Fluoreoscence Guided Cancer Surgery

(January 19, 2018). We rout nely use Indocyanine green dye to assess vascular perfusion of gastric conduit

before gastroesophageal anastomosis in neck. Besides, we are planning to use the same dye to see the

completeness of nodal dissect on. In year 2018, our unit has started insert on of central chemo port under

USG guidance.

BPKMCH | ANNUAL REPORT - 2018

Figure 1. Shows the minimally invasive surgeries (MIS)

Figure 2. Overall trend of OPD Admission & Major Operat ons

performed in year 2018.

Academic activities (Conferences/ Published articles)

1. Approach to gastric cancer. Panel discussion (panelist). MASICON 2018. Mumbai, India. Jan 25-28,

2018.

2. Breast and Esophageal Conclave. Difficult case presentat on on Esophageal cancer. Medicity Hospital,

Nepal. July 30-Aug 1, 2018.

3. VATS esophagectomy for esophageal leiomyosarcoma

(Video presentat on). XIV Internat onal

Conference of Society of Surgeons of Nepal. Kathmandu, Nepal. Nov 29 - Dec 1, 2018.

4. Is there any role of surgery in mult disciplinary treatment of esophageal cancer

(Guest lecture). XIV

Internat onal Conference of Society of Surgeons of Nepal. Kathmandu, Nepal. Nov 29 - Dec 1, 2018.

5. Surgical results of non-small cell lung cancer in Nepal. XIV Internat onal Conference of Society of

Surgeons of Nepal. Kathmandu, Nepal. Nov 29 - Dec 1, 2018.

Research Activities

We are act vely part cipat ng in a Lung cancer research programme in collaborat on with researchers from

USA. Besides, the following clinical trials are being carried out:

1. Two field Vs. three field nodal dissect on for cancer of esophagus

2. Minimally invasive esophagectomy vs. open esophagectomy for cancer of esophagus.

3. Outcome of VATS lobectomy for lung cancer

4. NOTES (Natural orifice transluminal endoscopic surgery) esophagectomy

5. SMA first approach and feasibility of portal vein resect on for Pancreat coduodenectomy

6. Fluorescence guided cancer surgery

7. Use of Ultrasound in Thoracic surgery

Human Resources

Dr Binay Thakur, Senior Consultant and Chief, Thoracic Surgery.

Dr Li Aiming, Visiting Consultant Thoracic Surgeon from People’s Republic of China

Dr Mukti Devkota, Junior Consultant

Dr Manish Chaudhary, Medical Officer

Total Nursing staff (Thoracic ward); 16

Nursing Incharge (Thoracic ward): Janaki Upreti

Future Plans

Afer successful surgical workshop on minimally invasive esophagectomy during 4^th Internat onal SFO-N

Cancer Conference, we are planning to start a Fellowship program in Minimally Invasive Surgery of Upper

GI Tract. We are planning to perform sent nel lymph node biopsy using blue dye for upper GI tract tumors

and assess its sensit vity and specificity in our populat on. We are planning to come up with our early results

of Fluorescence guided surgery for complete nodal dissect on and assessment of vascular perfusion of

anastomot c margins.

As our hospital is on the way of purchasing Endobronchial Ultrasound and Endoscopic Ultrasound, our unit

will definitely be able to stage thoracic malignancies with a great precision.