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Through our Information Line and Online Survivors Community, we have heard many questions asked about thoracic surgery. William R. Burfeind, Jr., MD, Director of the Lung Cancer Program and Thoracic Surgery at St. Luke's Health Network in Bethlehem, PA answers them below.
Some patients, especially those who had a spread of their cancer to lymph nodes, may benefit from chemotherapy after complete removal of the tumor. Fewer patients will need postoperative radiation therapy. If either were needed, then they would ideally begin 4-10 weeks after surgery. The most important factor determining the start date of postoperative therapy is your recovery from surgery. In order to tolerate chemotherapy, you must be completely recovered from your operation. If your surgery can be done in a minimally invasive fashion, this will speed your recovery and improve your ability to tolerate chemotherapy.
The number of follow up visits is dependent upon how well you tolerate surgery and whether there are any complication. Usually, you are seen about two weeks post-discharge and then again 4 weeks later. If all were going well, you would then enter a period of close follow-up for 5 years to make sure the cancer does not recur. If any other issues arose, you would see your surgeon more often.
You should ask your specific surgeon for their incision – care instructions. Typically, though, when you go home you can take showers and should use soap and water right on top of your incision. Avoid soaking in tubs or swimming until cleared by your surgeon (this usually relates to complete healing of your chest tube incisions).
There are several factors that determine the procedure most appropriate to remove your lung cancer. These include 1) your over-all medical condition and lung function; you must be in reasonable medical condition and have adequate lung reserve to tolerate larger lung resections 2) the size of your tumor 3) the location of your tumor; in the outer third versus central and 4) whether there is any sign of spread to lymph nodes.
Surgery, whether performed using VATS or thoracotomy is done with you completely asleep / unconscious. Lobectomy performed via either technique takes a similar amount of time, in the operating room, to perform. Lobectomies performed using VATS are associated with a shorter hospital stay, less pain, fewer complications, earlier return to full activity, and, if needed, better tolerance of postoperative chemotherapy.
Most patients can drive two weeks after a VATS lobectomy and approximately 4 weeks after a lobectomy performed via thoracotomy. Prior to driving, one should no longer be taking narcotic pain medicines during the day.
Initially, after surgery, the best form of exercise is walking. You should begin this as soon as possible. Usually, the day after surgery nurses and physical therapists will help you start to move around your room and for short trips out in the hall. By the time you are discharged from the hospital you should be taking short walks around the hospital ward 3-4 times per day. At home, you should dedicate 30-40 minutes per day for walking. As far as weight lifting or vigorous upper body exercises go, these can usually be started 4-6 weeks after surgery.
Everybody needs some support after lung surgery. The amount of support will depend on how functional you were before your operation and how well you tolerated surgery. Normally, you can ride in a car, do minimal cooking and perform basic shower / toiletry activities. For a few weeks, these activities may take you longer than normal to perform. Initially, you will not be able to drive or lift heavy loads. Having someone to assist with shopping and some of your daily activities is usually all that is needed until you are driving again.
Removal of whole or part of a lung does decrease your lung function, but most patients are able to resume an active life after lobectomy or pneumonectomy. Before surgery, your surgeon will measure you lung function (Pulmonary Function Tests) to make sure that you have adequate lung reserve. Obviously, the more lung that is removed, the more you are affected. Pneumonectomy patients tend to notice the most shortness of breath, especially while walking up hills or doing vigorous exercise.
Before surgery, you should do everything you can to improve your lung function. This includes quitting smoking (longer than a month, if possible), eating well, and exercising (walking for 30 minutes to an hour per day). After surgery you should continue to abstain from smoking so that your lung function does not continue to deteriorate. A regular exercise program will help you return to “normal” life.
Your surgeon and / or pulmonologist will be able to determine whether pulmonary rehabilitation would be helpful either before or after surgery. The decision is usually based on your lung function tests, functional status (how far you can walk before getting short of breath) and your blood oxygen saturation.
Formal Pulmonary Rehabilitation consists of professionally monitored sessions, occurring 3-4 days per week for 1-2 hours per day. During these sessions you receive education as well as perform exercises that help you do activities with less shortness of breath and improve your stamina. For patients with particularly impaired lung function, a 6-week period of pulmonary rehabilitation before surgery may improve your ability to tolerate the surgery.
There is an increasing amount of scientific information that your surgeon is an important factor in determining not only the likelihood of having an uncomplicated surgery but also your chances of being alive and cancer-free 5 years after your operation. If possible, you should seek a board-certified cardiothoracic surgeon who practices predominantly general thoracic surgery in a lung cancer multidisciplinary team. A multidisciplinary team is usually composed of surgeons, pulmonologists, medical oncologist, radiation oncologists, radiologists, pathologists as well as other support staff. Patients cared for in this setting receive the benefit of all the member of the team reviewing their case and helping to develop the most effective plan of care. Surgeons who practice in these settings often do between 30 and 100 lobectomies per year as well as many other lung cancer related surgeries.
Yes, surgery after chemotherapy and / or radiation therapy is typically more difficult for the surgeon due to scar tissue that forms in your chest. Although more difficult, experienced surgeons do this kind of surgery with outcomes that are similar to those obtained in patients that did not have chemotherapy before surgery. In experienced centers, preoperative therapy is not a contraindication to performing these operations in a minimally invasive fashion. If possible, seek a surgeon who practices predominately general thoracic surgery, as they have the most experience with this kind of surgery.