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Posts Tagged ‘lung surgery’

Mexicali, Baja California (Mexico)

Dr. Carlos Cesar Ochoa Gaxiola, Thoracic Surgeon

We’ve back in the city of Mexicali on the California – Mexico border to interview Dr. Carlos Cesar Ochoa Gaxiola as part of the first of a planned series of video casts.   You may remember Dr. Ochoa from our first encounter back in November 2011.  He’s the personable, friendly thoracic surgeon for this city of approximately 900,000 residents.  At that time, we talked with Dr. Ochoa about his love for thoracic surgery, and what he’s seen in his local practice since moving to Mexicali after finishing his training just over a year & a half ago.

Now we’ve returned to spend more time with Dr. Ochoa; to see his practice and more of his day-to-day life in Mexicali as the sole thoracic surgeon.  We’re also planning to talk to Dr. Ochoa about medical tourism, and what potential patients need to know before coming to Mexicali. He greets me with the standard kiss on the cheek and a smile, before saying “Listo?  Let’s go!”  We’re off and running for the rest of the afternoon and far into the night.  Our first stop is to see several patients at Hospital Alamater, and then the operating room for a VATS procedure.

He is joined in the operating room by Dr. Cuauhtemoc Vasquez, the newest and only full-time cardiac surgeon in Mexicali.  They frequently work together during cases.  In fact, that morning, Dr. Ochoa assisted in two cases with Dr. Vasquez, a combined coronary bypass/ mitral valve replacement case and a an aortic valve replacement.

Of course, I took the opportunity to speak with Dr. Vasquez at length as well, as he was a bit of a captive audience.  At 32, he is just beginning his career as a cardiac surgeon, here in Mexicali.  He is experiencing his first frustrations as well; working in the first full-time cardiac surgery program in the city, which is still in its infancy, and at times there is a shortage of cases[1].  This doesn’t curb his enthusiasm for surgery, however and we spend several minutes discussing several current issues in cardiology and cardiac surgery.  He is well informed and a good conversationalist[2] as we debate recent developments such as TAVI, carotid stenting and other quasi-surgical procedures and long-term outcomes.

We also discuss the costs of health care in Mexicali in comparison to care just a few short kilometers north, in California.   He estimates that the total cost of bypass surgery (including hospital stay) in Mexicali is just $4500 – 5000 (US dollars).  As readers know, the total cost of an uncomplicated bypass surgery in the USA often exceeds $100,000.

Hmm.. Looks like I may have to investigate Dr. Vasquez’s operating room on a subsequent visit – so I can report back to readers here.  But for now, we return to the case at hand, and Dr. Ochoa.

The Hospital Alamater is the most exclusive private hospital in the city, and it shows.   Sparkling marble tile greets visitors, and patients enjoy attractive- appearing (and quiet!) private rooms.  The entire hospital is very clean, and nursing staff wears the formal pressed white scrub uniforms, with the supervisory nurse wearing the nursing cap of yesteryear with special modifications to comply with sanitary requirements of today.

The operating rooms are modern and well-lit.  Anesthesia equipment is new, and fully functional.  The anesthesiologist is in attendance at all times[3].  The hemodynamic monitors are visible to the surgeon at all times, and none of the essential alarms have been silenced or altered.  The anesthesiologist demonstrates ease and skill at using a double lumen ETT for intubation, which in my experience as an observer, is in itself, impressive.  (You would be surprised by how often problems with dual lumen ETT intubation delays surgery.)

Surgical staff complete comprehensive surgical scrubs and surgical sterility is maintained during the case.  The patient is well-scrubbed in preparation for surgery with a betadine solution after being positioned safely and correctly to prevent intra-operative injury or tissue damage.  Then the patient is draped appropriately.

The anesthesiologist places a thoracic epidural prior to the initiation of the case for post-operative pain control[4].  The video equipment for the case is modern with a large viewing screen.  All the ports are complete, and the thoracoscope is new and fully functioning.

Dr. Ochoa demonstrates excellent surgical skill and the case (VATS with wedge resection and pleural biopsy) proceeds easily, without incident.  The patient is hemodynamically stable during the entire case with minimal blood loss.

Following surgery, the patient is transferred to the PACU (previously called the recovery room) for a post-operative chest radiograph.  Dr. Ochoa re-evaluates the patient in the PACU before we leave the hospital and proceed to our next stop.

Recommended.  Surgical Apgar: 8


[1] There is another cardiac surgeon from Tijuana who sees patients in her clinic in Mexicali prior to sending patients to Tijuana, a larger city in the state of Baja California.  As the Mexicali surgery program is just a few months old, many potential patients are unaware of its existence.

[2] ‘Bypass surgery’ is an abbreviation for coronary artery bypass grafting (CABG) aka ‘open-heart surgery.’  A ‘triple’ or ‘quadruple’ bypass refers to the number of bypass grafts placed during the procedure.

[3] If you have read any of my previous publications, you will know that this is NOT always the case, and I have witnessed several cases (at other locations) of unattended anesthesia during surgery, or the use poorly functioning out-dated equipment.

[4] During a later visit with the patient, the patient reported excellent analgesia (pain relief) with the epidural and minimal adjuvant anti-inflammatories.

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As most readers know, Thoracic surgery is my absolute passion – and it’s a big part of my day-to-day life, too.. So, it was a great pleasure to spend this morning talking to Dr. Carlos Cesar Ochoa Gaxiola, here in Mexicali.

Dr. Ochoa is one of those surgeons that make this project so worthwhile.  He is enthusiastic, and enjoys what he does.  Talking with young surgeons like Dr. Ochoa seems to restore my faith in the future – which is desperately needed sometimes after reading (and reporting) all of the negative headlines regarding the health care crisis; shortages of vital medications (and surgeons!), escalating and out-of-control costs, fraudulent practices and patient mistreatment.

For more on this morning’s interview, see my sister site, www.cirugiadetorax.org

He kindly extended an invitation to visit the operating room, and see more about his practice – so I’ll give a full report on my next visit to this city.

In the meantime, I am enjoying the mild (and sunny) winter weather.

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In previous posts, we’ve talked about prevention and management of respiratory complications of lung surgery. However, one of the more common complications of lung surgery, is atrial fibrillation, or an abnormal heart rate and rhythm.

Developing atrial fibrillation is problematic for patients because it increases length of stay (while we attempt to treat it) and increases the risk of other problems (such as stroke – particularly if we can’t get the heart rhythm to return to normal).

‘The Cootie Factor’
Length of stay is important for more than cost and convenience. One of the things I try to explain to my patients – is that hospitals are full of sick people, and in general, my surgery patients are not sick – they’ve had surgery..
But surgery increases their chance and susceptibility to contracting infections from other patients, and visitors. I call this ‘the cootie factor’. (Everyone laughs when you say cooties – but everyone knows exactly what you mean.) So the reason I am rushing my patients out the door is more than just for patient convenience and the comforts of home – it’s to prevent infection, and other serious complications that come from being hospitalized, in close quarters, with people who have may have some very bad cooties indeed (MRSA, resistant Klebsiella, VRE, Tuberculosis and other nasties.)

But besides, length of stay – atrial fibrillation, or a very rapid quivering of the atrial of the heart (250+ times per minute) increases the chance of clots forming within the atrial of the heart, and then being ejected by the ventricles straight up into central circulation – towards the brain – causing an embolic stroke.. Now that’s pretty nasty too..

But there are some easy things we can do to reduce the chance of this happening..
One of the easiest ways to prevent / reduce the incidence of post-operative atrial fibrillation – is to slow down the heart rate. We know that just by slowing down the heart by 10 – 15 beats per minute, we can prevent abnormal heart rhythms.

Most of the time we do this by pre-operative beta blockade, which is a fancy term for using a certain class of drugs, beta blockers (such as metoprolol, carvedilol, atenolol) to slow the heart rate, just a little bit before, during and after surgery.

In fact, this is so important – national/ and international criteria uses heart rate (and whether patients received these medications prior to surgery) as part of the ‘grading’ criteria for rating surgery/ surgeons/ and surgery programs. It’s part of both NSQIPs and the Surgical Apgar Scale – both of which are important tools for preventing intra-operative and post-operative problems..

The good thing is, most of these drugs are cheap (on the $4 plan), very safe, and easily tolerated by patients. Also, most patients only need to be on these medications for a few days before and after surgery – not forever.

Now, if you do develop atrial fibrillation (a. fib) after surgery – we will have to give you stronger (more expensive, more side effects) drugs such as amiodarone, or even digoxin (old, but effective) to try to control or convert your heart rhythm back to normal.

If you heart rhythm does not go back to normal in a day or two – we will have to start you on a blood thinner like warfarin to prevent the blood clots we talked about previously. (Then you may have to have another procedure – cardioversion, and more medicines, if it continues, so you can start to see why it’s so important to try to prevent it in the first place.

Research has also looked at statin drugs to prevent atrial fibrillation after surgery – results haven’t been encouraging, but if you are already on cholesterol medications prior to surgery, there are plenty of other reasons for us to continue them during and after surgery.. (Now, since the literature is mixed on whether statins help prevent a. fib – I wouldn’t start them on patients having lung surgery, but that’s a different matter.)

Now Dr. Shu S. Lin, and some of the other cardiac surgeons did some studies down at Duke looking at pre-operative vitamin C (along with quite a few others) and the results have been interesting.. That doesn’t mean patients should go crazy with the supplements.. anything, even Vitamin C can harm you, if taken willy-nilly (though the risk is minimal).

In fact, the evidence was strong enough (and risk of adverse effects was low enough) that we always prescribed it to our pre-operative patients for both heart and lung surgery.  (Heart patients are at high risk of atrial fibrillation too.)  We prescribed 500mg twice a day for a week before surgery, until discharge – which is similar to several studies.
I’ve included some of these studies before – please note most of them focus on atrial fibrillation after heart surgery.
Vitamin C with beta blockers to prevent A. Fib
This is probably my favorite free text about Vitamin C and Atrial fib – it’s my sort of writing style..

Another article on Vitamin C – for pharmacists (note – article is sponsored by Ester C supplements.)
Contrary to popular belief, performing a VATS procedure (versus open surgery) does not eliminate the risk of post-operative atrial fibrillation.

Now Dr. Onaitis, D’Amico and Harpole published some interesting results last year (and of course, as Duke Thoracic surgeons, I am partial) – but I can’t repost hre since it’s limited access articles..

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Not all conditions are curable, and not all treatments are curative. Some treatments are based on improving quality of life, and alleviating symptoms. This is a hallmark of patient centered care – doing what we can to make the patient feel better even when we can’t ‘fix’ or cure the underlying disease. No where is this more evident than in the treatment of malignant effusions.

By definition, a Malignant Effusion is the development of fluid in the space next to the lungs related to an underlying (and sometimes previously undiagnosed) malignancy. Malignant effusions can be seen with several different kinds of cancers, most commonly lung and breast cancers. The development of a malignant effusion is a poor prognostic sign as it is an indicator of metastasis to the pleural tissue/ space.

The development of a malignant effusion usually presents with symptoms of shortness of breath. While the treatment of the underlying cancer may vary, the primary goal of treatment of an effusion is palliative (or symptom relief). The best way to relieve symptoms is by removing the fluid.

This can be done several ways – but each has its own drawbacks.

Thoracentesis:
The fluid can be drawn out with a needle (thoracentesis) either bedside or under fluoroscopy. The potential drawbacks with this treatment strategy are two-fold:

1. There is a chance that during the procedure, the needle will ‘poke’ or ‘pop’ the lung, causing a pneumothorax (or collapse of the lung). This then requires a chest tube to be placed so the lung can re-expand while it heals. However, if the procedure is performed uneventfully, (like it usually does) the patient can go home the same day.

2. The other complication – is rapid re – accumulation – since you haven’t treated the underlying cause, but have only removed the fluid. This also happens when the cause of the effusion (nonmalignant) is from congestive heart failure. This means the fluid (and symptoms of shortness of breath) may return quickly, requiring the patient to return to the hospital – which is hard of the patient and their family.

Video- Assisted Thoracoscopy:
Malignant effusions can also be treated by VATS – this is a good option if we are uncertain of the etiology (or the reason) for the effusion. While all fluid removed is routinely sent for cytopathology (when removed during surgery, thoracentesis or chest tube placement) – for cytopathology can be nortoriously inaccurate with false negative reports, because the diagnosis is dependent on the pathologist actually seeing cancer cells in the fluid). I have had cases in the operating room (VATS) where the surgeon actually sees the tumor(s)** with the camera but the fluid comes back as negative.

** in these cases, we send biopsies of the tumor tissue – which is much more accurate and definitive.

But a VATS procedure requires an operation, chest tube placement and several days in the hospital.

Chest tube placement:
Another option is chest tube placement – which also requires several days in the hospital..

During both chest tube placement and VATS, a procedure called pleurodesis can be performed to try to prevent the fluid from re-accumulating.

But what if we know it’s a malignant effusion? What are the other options for treatment?

Catheter based treatments:
(note: catheter means a small tube – a foley catheter is the type used to drain urine, but other types are used for many things – even an IV is a catheter.)
One of the options used in our practice was pleur X (brand) catheter placement. This catheter was a small flexible tube that could be placed under local anesthesia – either in the office or the operating room – as an ambulatory procedure. After some patient teaching, including a short video, most family members felt comfortable emptying the catheter every two or three days at home, to prevent fluid  re -accumulation (and allowing the patient to continue normal activities, at home.)

Sometimes a visiting nurse would go out and empty the catheter, and in several cases, patients would come to the office, where I would do the same thing – it was a nice way to relieve the patient’s symptoms without requiring hospitalization, and several studies have shown that repeated drainage often caused spontaneous pleurodesis (fluid no longer accumulated.) We would then take the catheter out in the office.. Now, like any procedure, there is a chance for problems with this therapy as well, infection, catheter can clog, etc..

But here’s another study, showing that even frail patients benefit from home-based therapy – which is important when we go back and consider our original treatment goals:
-Improving quality of life
-Relieving symptoms

In the article, the authors used talc with the catheters and then applied a heimlich valve, which is another technique very similar to pleurX catheter placement.  (Sterile talc is used for the pleurodesis procedure – which we will talk about in more detail in the future.)

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As many of you know, this site was originally developed to help promote my first book, and to talk about medical tourism. But since the completion of this book – we’ve begun posting articles, and discussions on different medical topics, some related to medical tourism, some not. I’ve tried to include pertinent medical research, and we’ve talked about popular medical topics in the mainstream press. I hope that these discussions have been informative, and helpful.
Much of it has been cardiac surgery and cardiology related, since that is my background. But my other true interest is lung surgery, and the treatment of lung diseases.

The responses I’ve gotten from readers have been great. So, I would like to ask that readers participate in some of my new polls, so I know where your interests lie, and what you want to hear about, if and what your questions are.

I also want to know, is there a need or an interest in a new Lung surgery portal – to focus on and talk about topics related to Lung Surgery; from new and emerging research and procedures, to pre & post operative care, and all points in between. So either drop me a comment or participate in the new polls to let me know what you think.

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It’s been shaping up to be a bit of a weird week – as everyone that’s been following on Bogota Surgery knows – it was a rapid change of gears from neurosurgery to thoracics this week.. (and everyone knows how much I enjoy interviewing surgeons from my home specialty). But during this week – the same name keeps cropping up in conversations – Dr. Edgard Eduardo Gutierrez, and that’s when I realized that while we’ve mentioned him from time to time on the Bogota blog – he’s never really gotten proper face time, here at home at Cartagena Surgery.

Of course, my loyal readers of Hidden Gem already know Dr. Gutierrez – since he’s profiled in my book, but let me introduce him to the rest of the world** – since it seems all of Bogota is talking about him.. (okay, to be fair – the Bogota thoracic surgery community).

** since this is long overdue **

First off, I have to say that Dr. Edgard Eduardo Gutierrez Puente has got to be one of the most easy-going, good-natured people I’ve ever met – Which explains why I ended up following him on his rounds through out the hospitals of Cartagena one sunny day.. (or how he ended up hosting some gringa nurse who spoke really bad Spanish). He’d been nice enough to review cases with me – and have me in the OR one day at Medi-help after I’d practically accosted him in the hallway.. Then as we were leaving the operating room, he turned at me with a long stream of spanish over his shoulder ending in “aqui o vamos conmigo?” I missed the whole preceeding paragraph, but caught “or go with me?”

That was it – he was stuck with me. And it was definitely out of the goodness of his heart – and no other motive because, frankly, I don’t think Dr. Gutierrez:
a.) has time to think about medical tourism, or care about being in some first-time author’s book or b.) even knew why I was there..
So there he was, driving around with me, asking him questions the entire time, in my fractured, barely comprehensible, mish-moshed Spanish. But he’d patiently answer, and then wait for me to figure out what he’d said – and then we’d start all over again.

At the time, (he was one of my first interviews), I probably took his graciousness for granted – it’s only now after meeting, and interviewing, interviewing and interviewing my way through my second book, that I realize how kind he was to that naïve little nurse, wandering around a strange city, in a foreign country, writing a book that very few people are actually interested in.

But all of this, doesn’t really matter.. What matters is all the other things; all the qualities and skills I saw during the time I followed him around Cartagena, and its’ operating rooms.

It didn’t matter if we were in the upscale Medi-help clinic or the aged, struggling Universitario de Cartagena; he was kind, gentle and empathetic with all of his patients.

There are a lot of things I could say, and have said in my book about Dr. Gutierrez, his operating style, adherence to surgical protocols and overall dedication to his profession. But to me; his kindness and compassion said it all.

Update: 20 April 2011

Here are the top search terms for the blog this week:

Top Searches

doctor edgardo gutierrez puente, cartagena  colombia  real stste, what is overstenting, colombia cartagena edgar eduardo gutierrez puente, tourist attractions in colombia

– so I am glad to see Dr. Gutierrez get some well deserved recognition for all his hard work..  The blog was also one the featured daily blogs for wordpress yesterday – congratulations, Dr. Gutierrez!

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It’s been a busy week in the operating rooms here in Bogota.  I spent time with several surgeons from different specialties including Bariatric surgery with Dr. Rami Mikler, Dr. Diana Gomez and Dr. Eduardo Silva, Thoracic Surgery with Dr. Juan Carlos Garzon, and Plastic surgery with Dr. Luis Pavajeau, the self-proclaimed “best plastic surgeon in the world.”

Didn’t get to the OR but met with several others from Orthopedics, ENT and more plastic surgeons.. (Seems all my readers love plastic surgeons!)

If you want to follow my progress more closely, be sure to look under the “Bogota Updates” tab.

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