Lobectomy in Bangkok

[derek744]

Returned from UK with dry cough and low grade fever - x-ray followed by CT scan showed

nodule plus "ground glass" in the lungs.

Tried brochoscopy plus CT guided needle aspiration to obtain biopsy without success.

Have now seen 2 thoracic surgeons - Samitivej and Bumrungrad - with differing views on

which procedure to use in order to remove the right middle lobe for biopsy which both

agree is now the only viable way to obtain enough material for pathology.

Samitivej goes for "vertical muscle sparing thoracotomy" whilst Bumrungrad goes for

VATS procedure.

Basically the first is more like "open" chest surgery with the possibility of cracked rib(s)

while the VATS is more endoscopic and should provide less days in hospital and quicker recovery.

My main concern with both is the record of the surgeons - how can I get data on numbers of

procedures performed and outcomes.

Or do I hotfoot it back to UK and pay someone I can get data on quite easily?

[bkkbudddy]

Unless it's an emergency, any major surgeries, I would go back to UK, and be admitted to a teaching hospital, STAT!

Edited July 11, 2013 by bkkbudddy

[Sheryl]

By asking them directly. And if they do not give you a clear answer, cross them off your list.

While it will not tell you the # they've done & outcomes, you can find a fair number of things about them using Mr. Google and their names. For example, whether they have published anything in a peer reviewed journal (and if so what), whether they hold a faculty appointment etc.

One thing I would share is that the "face" thing in Thai culture extends into medical practice as well and I find doctors here are often hesitant to mention or recommend anything they themselves cannot do. VATS requires special expertise and equipment to perform. It is possible -- just possible -- that the surgeon recommending open approach is not able to do the video-assisted. Have you asked him specifically why he recommends open approach over VATS? The only reason other than unavailability (not trained/don't have the equipment) that I can offhand think of would be if there is anticipation of a possible need, once they get a direct look, to do a more extensive excision than a simple biopsy would require.

Video-assisted procedures usually cost more than conventional surgical approaches owing to the need for specialized training and equipment.

[jrtmedic]

Are you still eligible for NHS care? If so then a return to the UK to seek treatment at any of the major cardio-thoracic centres (CTC) would, in my mind, be the option of choice. If covered by insurance a return to the UK would still be a good choice if you seek care at a private facility near one of the major CTC's. Take any scans/x-rays back to the UK with you , together with any other clinical data which if you do not already hold can be obtained on request.

From memory you will not find it easy to find comparative data on "lung" surgery in the UK and , whilst I stand to be corrected, almost impossible in Thailand.

[Sheryl]

BTW VATS was first introduced in Thailand >15 years ago so it should prove possible to find surgeons experienced though may take some searching.

http://www.ncbi.nlm.nih.gov/pubmed/8996986

[derek744]

Firstly no insurance for UK, only this region but if needs must I would pay for UK treatment.

I have googled and searched pretty extensively so far without producing much apart from training

- the VATS man has had some experience in the UK but I don't know if that included VATS.

The reason the other surgeon gave for not doing VATS was that he felt he didn't have enough depth of field

using the camera, especially with large blood vessels in a confined space.

He also said he was 68 years old and had lots of experience. A perfectly nice communicative man who had

plenty of time to discuss issues and put no pressure on me whatsoever.

This lobectomy, in my view, is an extreme way to get a biopsy but appears now to be the only way because of the

positions of the nodule and the "ground glass".

Which is why I initially chose the less invasive bronchoscopy and needle aspiration although they both come with

lower percentage (up to 50%) success rates,

My review of VATS outside Thailand is that it appears to be the procedure of choice in UK and USA even for bigger

lobectomies than my middle lobe,

Less time in hospital with much less recovery time and possible complications reduced as well.

The VATS surgeon suggested I took my scans to the UK on a then proposed vacation to see if the doctors

in UK "had any ideas". This vacation has been scuppered temporarily by a pneumothorax caused by the needle

aspiration but the suggestion was at the same time reasonable but also left me wondering why?

I guess I need to ask him directly about his "scoreboard".

I am also anxious to find out what's going on obviously so that I can get diagnosed and start any medication asap.

[jrtmedic]

You need a diagnosis ! The sooner that is achieved the better !

Sorry to learn about the pneumothorax (a recognised complication of needle biopsy ---It should resolve fairly quickly).

I understand your difficulty in "choosing" where to seek care and your approach in seeking comparative data is sound. In Thailand it is very unlikely you will find data and it will certainly not be published !

In the UK if asked a Surgeon is very likely to share his stats. even if they are not published ----and UK Cardio- Thoracic surgeons are world leaders in compiling and publishing their stats. relating to range of procedures.

If you choose to seek care in Thailand my best advise would be to seek a Surgeon who has received at least some Western Education/Training and someone with whom you can easily communicate and feel comfortable with.

Edit. 23:11

NB. In Thailand you also need to enquire about the proposed Anaesthetist ! - VATS involves the utilisation of very specialised anaesthetic techniques .

Edited July 11, 2013 by jrtmedic

[Sheryl]

I see no problem with asking a surgeon in Thailand how many procedures he has done and the success rate. If he is any good he'll have that information off the top of his head and no hesitation in telling you.

While VATS is preferred where available, even in Western countries not all facilities can offer it much less all surgeons do it. And much depends on the skill and experience of the surgeon.

Even if you go with VATS they will probably ask you to sign a consent form that includes an open approach and in the event that the surgeon is not able to get adequate visualization or otherwise excise a sample they will switch to open mid procedure.

[derek744]

Thank you for the comments - there's clearly some experienced clinical expertise on

this forum!

I will contact the VATS surgeon here again for a chat regarding his expertise with VATS

and also ask directly if the UK option would be best in his opinion.

I do feel VATS is the best procedure and I take the point that it could convert to open surgery

in the event of unforeseen operative complications.

From my research so far this appears rare (that research of course does not cover Thailand).

May I ask if you were in a position of needing a similar procedure where would you prefer to have

it done?

[geriatrickid]

If I understand you correctly the physician suspected "ground glass" syndrome?

Do you understand what that means? Have you had a follow up scan to determine if these nodules have grown or spread? . If you were referred to a surgeon, then someone, hopefully a radiologist, had reviewed your lung images and gave you the referral. Here's something to consider, if the recommendation was to have a biopsy, then the question you should ask, is which one of the proposed methods has the best chance of obtaining sufficient tissue of concern to allow the pathologist to make a reliable assessment? .

Please do not delay the biopsy. My personal bias is to avoid as much surgical intervention as possible as surgery does have complications. However, if the specialist you are seeing, says that the location of the nodes indicates a surgical investigation is more appropriate, then do it.

[derek744]

The "ground glass" refers to the appearance on the CT scans of the area of infection.

Additionally there is a small nodule in the right middle lobe.

I've now had 3 CT scans which show no change in appearance.

I agree with the least invasive approach and so I've already had 2 biopsy attempts as described

above without success, ie. pathology can't see any malignancy, TB etc. This does not mean these

are not present just that the biopsy techniques have limitations.

The lobectomy now seems the only option to get good biopsies and would cover both the nodule

and the "ground glass" areas in the middle lobe.

I'm still keen to take the least invasive route which is why I would prefer the VATS procedure which if

carried out well would provide far less discomfort and recovery time, especially avoiding cracked ribs

which can take a long and painful recovery period.

[Sheryl]

Thank you for the comments - there's clearly some experienced clinical expertise on

this forum!

I will contact the VATS surgeon here again for a chat regarding his expertise with VATS

and also ask directly if the UK option would be best in his opinion.

I do feel VATS is the best procedure and I take the point that it could convert to open surgery

in the event of unforeseen operative complications.

From my research so far this appears rare (that research of course does not cover Thailand).

May I ask if you were in a position of needing a similar procedure where would you prefer to have

it done?

A major consideration for me would be where I would plan to have whatever treatment might be indicated once the results are known, and that in turn would be influenced by financing considerations, presence of support persons and of course the level of care. While it is possible to get a biopsy in one place and treatment somewhere else it is optimal to have both done in the same place and by the same surgeon (assuming further surgery ends up being indicated). Generally when VATS is done for a nodule with ground glass appearance they do not just take the amount of tissue needed for biopsy but also, if at all possible, try to resect the nodule itself. Sometimes this can avoid the need for further surgery.

You should understand that "ground glass" refers to the appearance of the nodule and that nodules with a ground glass appearance have a higher chance of malignancy than others. So the situation is potentially quite serious.

Another consideration is how quickly you can get care in the UK, as others have mentioned given the risk of malignancy you need to see to this ASAP. If you would be under the NHS in the UK possible delays/wait listing needs to be factored in. Not an issue if you are self-pay.

All things considered the level and quality of care in the UK is above that in Thailand but there are doctors in Thailand of international caliber and there are mediocre (and worse) ones to be found in the UK so I don't think it is automatic that the UK is better. I suggest you plan based on worst case scenario: if the biopsy confirms malignancy where would you best get what may be a prolonged and costly course of treatment, taking all factors into account?

[derek744]

Some further clarification - the CT report describes the nodule (12x14mm) as calcified.

Several docs have said this is "probably" benign and may be the result of a previous unknown

TB infection which my immune system dealt with. This is not therefore 100% benign.

There has been no change in size over 3 CT scans.

I have had 2 biopsies already - the lobectomy is the 3rd attempt at getting biopsy/diagnosis.

The nodule in the RML plus some ground glass opacities will therefore be effectively resected

by the lobectomy. There are also ground glass opacities in RUL and LUL.

So the only way left it appears to get a diagnosis is to have the lobectomy which is at the centre of my

current treatment options.

Treatment in the UK would involve a large hit in the wallet but as a self payer that should be expeditious.

I have booked a telephone call with my VATS surgeon and hopefully he may get back today.