The heart may get the most play, but there are other very important structures in the chest cavity that require surgical treatment.

Stay with us as we talk with thoracic surgeon Doctor Mansoor M Shah about new techniques in thoracic surgery.

Next on Kentucky.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.

>> When we think of the organs in the thoracic cavity, we often, and rightly so, begin and end with the heart and lungs.

However, there are several other important structures, and these include the esophagus, the pleura, and the thymus, just to name a few.

Common conditions affecting these structures include cancer, noncancerous, tumors and masses, chronic and acute infections, and congenital anomalies.

Many of these conditions are consequence of smoking, environmental pollutants, infectious agents, and inherited disorders.

Fortunately, the thoracic cavity is readily accessible for both diagnostic and therapeutic interventions.

Many of these procedures can now be done through minimally invasive approaches, and this has resulted in improved survivals, fewer complications, and improved functional outcomes.

To give us a better look into newer techniques in thoracic surgery, how they are done and when they are indicated.

We have as our guest today, Doctor Mansi Shah.

Doctor Shah is a graduate of the Boston University School of Medicine, and she completed her general surgery residency at the University of North Carolina Health Systems and her fellowship in cardiothoracic surgery at the University of Kentucky.

Doctor Shah is now an assistant professor of thoracic surgery at the University of Kentucky Health Care and Markey Cancer Center doctor Shah Mansi.

Thanks for being with us today.

>> Thank you for having me.

>> What got you into thoracic surgery?

>> I was fortunate to have a mentor while I was in general surgery residency.

That just was the coolest, smartest person I thought I'd ever met.

And I just wanted to be like him when I grew up.

That's really.

That's what started me on the journey.

>> That's what got you.

What is the best thing about being a thoracic?

What?

So if that a ten year old young lady is sitting there going, I want to do what she does, but what is the one thing that excites you the most about this?

>> It's funny, I think one of the most satisfying things when when we're operating in the chest, oftentimes we have to deflate the lung to create working space or to be able to operate on the lung.

And my favorite part of surgery is when that lung reinflates.

It's such a satisfying thing to just see that air fill the lung and see the watch the lung come back to life.

>> That's really got to be a fascinating thing.

It's great.

All right.

So when we you mentioned the lung, but what else is in the thoracic cavity.

What are the what is the structures here.

What are we talking about.

>> Yeah.

So as thoracic surgeons, really what we think about and talk to patients about is we deal with everything besides the heart that's in the chest and the upper belly.

So the lungs are a lot of what we take care of.

But there's other structures like the esophagus or food pipe that connects food from your mouth down to your stomach.

There's the diaphragm.

We deal with some of the upper parts of the stomach, especially when the stomach can come up into the chest, a type of hernia.

There's other organs like the thymus, like you mentioned, the lining of the chest wall, the pleura, the diaphragm muscle that helps us breathe.

So there's a lot there in the chest besides the heart.

>> These are very sensitive organs.

What role do the ribs play in all this?

>> The ribs are basically the protective cavity that keeps all of that.

Protected.

Really?

>> Yeah.

So that keeps it from being injured.

So there's an integral part.

But you don't operate on that stuff though.

>> No.

That's a, that's a part of the that thoracic surgeons wheelhouse as well.

So you know rib fractures cancers of the chest wall ribs sternum things like that.

So all of that part of the thoracic cavity.

>> Wow.

That's impressive.

What are some of the conditions.

Now again we talk about you do everything but the heart so we know we have heart attacks and all this.

But what are some of these other problems that can occur in the chest cavity?

>> Yeah, I think a lot of what we see in, in work with, especially here in the state, is lung cancer.

Really.

We have in Kentucky the highest rate of lung cancer in the United States.

So that is a lot of what we see patients for and operate on for esophageal cancer is is also a pretty serious condition and something that we see a lot of here in Kentucky and across the United States.

And that's a lot of what we operate on as well.

Lung infections is another thing that we'll see.

But then also you think about what's in the thoracic cavity, but then what could move into the thoracic cavity that shouldn't be there.

So like I was mentioning before hernias what we call hiatal hernias.

So things from the belly that are coming up into the chest where they're not supposed to be, that requires surgery to get them back down where they're supposed to be.

So that's part of it.

>> Wait, wait, wait.

>> Are you telling me that your stomach can come up into your chest cavity?

>> Oh, yeah.

>> Yeah, we see that quite often.

>> Why?

>> How so?

The.

The hiatus is a natural opening between the chest and the belly.

Because there's things be able to get from the chest down into the belly.

So things like your esophagus, blood vessels that carry blood flow from the heart down to the belly, in blood vessels that carry blood flow from the belly back up to the chest, into the heart.

So there's a natural opening there.

And if that opening stretches over time for a number of different reasons, well, stuff then can slide from the belly up into the chest.

>> Gotcha, gotcha.

We hear about and you talked about the thymus.

What is it and what's the big deal?

I mean, I've heard of people eating thymus.

I assume that's not what you're doing.

>> In there.

>> No, not so much.

>> Okay.

>> The thymus is an organ that lives in in front of the heart, behind the breastbone.

When we're kids, it it plays a role in immunologic function.

So it helps to prevent infection, create antibodies.

But as adults other organs take over that that function.

So the thymic tissue really just becomes fatty tissue and doesn't really do much for us.

So it's kind of like the appendix.

It's there.

It doesn't really do much, but it can cause trouble.

And where it can cause trouble is if things grow in that thymic tissue.

>> Gotcha.

>> So you can get masses and cancers and cysts and all sorts of things that can grow in there that can cause trouble.

>> Let's go back to something you said about lung cancer.

You mentioned that we're number one.

So what are some of the things besides not smoking that we can do to decrease our risk of getting it and dying from lung cancer?

>> Yeah.

I mean, smoking is definitely the biggest thing.

I think if you can stop smoking or stop being exposed to smoking, that's one of the biggest things that that people can do to to protect their health.

Secondhand smoke is another big risk factor for for lung cancer.

So even if you're not smoking yourself but you're around it, that can be a problem.

Radon exposure is another big risk factor for lung cancer.

So testing your house to make sure that the house is is safe.

And there's not radon levels that are that are high where where you're living.

And then other, you know, work related risk factors.

So people that work in the coal mines, which is a big part of the Appalachian region, chemical plants working around pesticides, working with asbestos and other things that can be breathed in and can cause damage to the lungs.

Those are all risk factors.

And some things are in our control, right?

Some things aren't.

You got to work to be able to live and and survive.

But whatever we can do that's in our control, I think is is is the best thing.

>> What about screening for lung cancer?

>> Yeah, I think that's one of the biggest things that I would like patients to be aware of.

And people in this region to be aware of lung cancer screening helps save lives.

If we can catch lung cancer early while it's small and it hasn't spread, that's our best chance at curing lung cancer.

And so I highly encourage anyone out there that has a smoking history or has been exposed to, to smoke in the past to to talk to your doctor about getting screened for lung cancer.

It's just like any other preventive health care maintenance, like women getting mammograms, men getting their prostate levels checked, getting your colonoscopies, as you know.

So lung cancer screening should really be part of that routine health care maintenance.

Anyone that has smoked what we call 20 pack years or more pack year is considered.

If you smoke one pack a day for 20 years, that's 20 pack years.

If you smoke half a pack a day for 40 years, that's 20 pack years.

So if you have a 20 pack year smoking history or more if you're an active smoker, or if you've quit smoking.

But for less than 15 years.

And if you're between the ages of 50 and 80, you qualify for lung cancer screening.

So that's a lot of people in this.

>> Region.

>> If I'm not mistaken, here in Kentucky, it's a free service, isn't it?

>> Yeah.

>> What do you do?

You have to call a place like the Markey Cancer Center.

>> Or you can talk to your primary care physician, or you can call over to the Markey Cancer Center to get connected.

But there's definitely options to to make sure lung cancer screening is happening.

Right now, only about 10% of people in the state are getting screened for lung cancer.

That should be screened.

So a lot of room for improvement.

>> So they can call folks.

If you're living in Owensboro, if you're living in Louisville, just call your local hospital.

Talk to your local doctor.

That's an important point.

You mentioned esophageal cancer.

What are the risk factors for this?

I mean, we hear about this sometimes in Asian populations, but what's going on here as.

>> Far as this.

Yeah.

>> So a lot of there's definitely overlap in risk factors.

Smoking is also a risk factor for esophageal cancer.

Alcohol abuse is a risk factor as well.

There's you can get esophagus cancer in different portions of the esophagus.

So we think about the upper part of the esophagus middle part of the esophagus and lower part of the esophagus.

The lower part of the esophagus is more commonly related to reflux.

So people that have long standing heartburn and acid reflux, that is a risk factor for esophageal.

>> Cancer, just got a lot.

>> Of people's attention with that.

>> By the way.

Okay.

>> What about up in the upper parts of the.

>> Esophagus so that we see a lot with with smoking, alcohol abuse, certain forms of diet and things like that.

>> When you talked about the reflux, is.

That Barrett's esophageal problems.

>> That's in the spectrum.

So what can start as mild heartburn and reflux over time can progress to chronic inflammation in the esophagus, which can lead to Barrett's esophagus, which is a risk factor for esophageal.

>> Cancer as well.

>> Not to scare people, but I'm going to assume that a lot of people have problems with some kind of reflux Gerd, gastrointestinal reflux disease.

Judging by all the products we see on the shelves at the pharmacies.

So if we're having irritation, is this something we should therefore see someone about?

>> I think if you have long standing heartburn and acid reflux, it's worth talking to your doctor about their specific reasons that you would need to get what's called an endoscopy, or a camera that goes down the esophagus or the food pipe.

So I'd have to make sure, you know, see if you fit into those those reasons.

But definitely if you have history of reflux and then develop trouble with your swallowing, that should be a red flag.

>> Okay.

>> I want to change gears a little bit.

Back when I was a surgical resident, back in the medieval times, you know, we still use leeches and things.

We would make a large incision for something called what, open thoracic surgery.

So what, you made this?

Do you still do that anymore?

And what's going on when you're using an open surgical technique?

>> Yeah.

>> So the.

>> Open incision is called a thoracotomy.

So it's basically a cut between the ribs a long cut usually.

You know back when we first started doing this it would be probably about this big.

>> Yeah.

>> But that allows the ribs to be spread so that there's direct access into the chest space.

So we start with thoracotomy, you know, like this.

And over time we've been able to slowly make that smaller and smaller, which is what's great for patients.

And I think important for people to hear about because by allowing technology to help us and get these cuts smaller and smaller, it allows us to offer surgery to a lot more people that may not have been candidates for surgery in the.

>> Past.

>> So you don't have to make that big.

I imagine you had more pain issues and other functional problems after that.

>> Yeah, there's a much higher risk of complications and chronic pain with the bigger incision.

The bigger the incision, the more pain.

It just, you know, makes.

>> Kind.

Of goes hand in hand.

Common sense.

>> All right.

And the trouble too is that there's nerves that run between the ribs.

And so the bigger the cut, the more likely there is damage to those nerves, which can be a cause of, of long term pain.

>> All right.

So this leads us to minimally invasive surgery.

>> Yeah.

>> What does that really mean.

>> Basically it means we do surgery through as small of a cut as possible.

And that's really the standard of care right now.

We try to avoid doing open surgery as much as possible.

There's still some reasons that we need to do it, especially in the cancer world for, you know, very large tumors or tumors that are next to delicate structures like blood vessels and things like that.

But the vast majority of surgery that we do now is through smaller cuts.

>> So it started off as something, I guess, laparoscopic because it was going through the belly.

But I guess endoscopic procedures.

What is this?

This you have these sticks that you're poking into people.

So you're not doing a you're not a bullfighter with the picador or something.

But tell me what's going on with this type.

>> Of surgery.

>> So minimally invasive started as what we call fiat surgery or video assisted thoracic surgery.

>> Okay.

>> That's sort of the the complement to laparoscopic surgery in the belly.

So those are straight stick instruments and a camera.

What we've been able to advance to is much more delicate instruments that have a higher range of motion really.

And that's the the term robotic surgery.

So that surgery is still great.

It's still through small incisions, robotic surgery also through small cuts, but with a broader range of instruments.

So we can do a lot more.

>> But you got.

>> This big piece of equipment.

Where's the patient?

I mean, you're are you actually at the patient thing or are you sitting behind this console doing all this stuff?

>> Yeah, I am not at home.

>> Okay.

>> Patients do ask me that.

I am there in the operating room, not sipping coffee at.

>> Home, but.

>> But, yeah, the robotic technology, there's basically the robot that connects to the patient that we put instruments through.

But then I'm sitting still in the operating room at a console, controlling those instruments to allow, basically allow me to do a lot of work on the inside through small cuts so that I don't have to make a bigger cut to actually use my hands.

>> Now, originally the instruments were straight and you had to do a lot of manipulation by.

So with the robot, is it is it like your.

So tell me, is it is the instrument like your hand?

And when you're manipulating things, is it mimicking your movements.

>> Yeah.

With robotic instruments we actually call them wristed instruments because they have more joints than with the straight stick instruments.

So it is kind of like you're moving your own hands.

You get very, very fine degree of motion.

So it's been it's been great.

It allows us to do a lot more through smaller cuts.

And the technology is just advancing over time.

The camera is is very precise.

So it's really great to to be able to do more and more for our patients.

>> Now, I got to admit, I'm an older guy who came along with open surgery, but you're seeing actually better.

The view is better than just looking down at things.

>> Yeah, yeah, we can we can zoom in and really magnify and really see very, very clearly with these, these cameras.

And the nice thing now, what's really exciting in the world of thoracic surgery is we're now advancing the technology even further within robotic surgery.

So rather than multiple small cuts, we're now trying to do surgery through a single cut on the side of the chest, what we call single port robotic surgery.

So we can do the same work on the inside through one cut about this big.

>> Why?

>> Why?

>> I mean.

>> Yeah, I mean, it's really it's all about the patients.

What we're trying to do is get patients better, faster.

And a big part of that is if they feel less pain, then they can get up, move around, breathe better, get to get home faster, get back to work faster, get back to their lives faster.

And when the cut is smaller and people can get up and moving, there's less complications.

So less risk of pneumonia, less risk of blood clots.

And so all of those things matter.

But the big thing with the single port and the single incision is that we're trying to make patients pain better, especially here in the state and in the Appalachian region.

We're really trying to minimize or, you know, keep the narcotic use as low as possible.

I think a lot of people have experienced or know somebody that has struggled with, with opiates, and that can be a barrier or a reason that patients don't want to have surgery.

And so if we can make the pain after surgery better and less, I think it's just better for patients.

>> Is this still the same operation that you would have done?

Open versus minimally invasive, or are we having to make compromises in any.

>> Way same same surgeries as we get more and more comfortable with the technology.

Right now, the single port technology is very new.

It was just recently approved for use in the United States.

For the thoracic world, it's been used in ear, nose and throat cancer or ear, nose and throat surgery and urology surgery.

But it's new in the thoracic space.

But the goal is to be able to use that for the same surgeries that we are doing robotically.

Vats and open.

>> Now, you mentioned a key part is that patients are up moving.

So I guess you have more or less risk of clot formation.

Patient is less pain.

So therefore you're cutting back on the medications.

Has this pushed some of your indications to do some procedures or treatments for patients earlier than what you may have done in the past, because of all the complications associated with those treatments?

>> I think the indications for surgery are the same, but we can offer surgery to a broader population.

>> Of people.

>> People that previously wouldn't have tolerated a big open surgery could be candidates for minimally invasive surgery or single port surgery.

So it allows us to take care of more people.

And I think that's another benefit of doing this.

>> Wow.

>> So in terms of diagnostics, are you able to get a better idea of what you're getting yourself into or what the patient has because of some of these?

Can you use them for diagnostic purposes?

>> Yeah, there's use different technology for the diagnostic portion of of the process.

But we've been able to use robotic technology and endoscopic technology to, to help with more accurate diagnosis as well.

So there's a different robotic platform called the ion that we use at the University of Kentucky.

>> Ion ion.

>> Was that what that stands for?

>> I don't think it's an acronym.

I think it's.

>> Just a.

>> That's it.

>> Okay.

>> Just the name, but it's allowed us to to diagnose smaller and smaller lung nodules, really, so that we can pick up lung cancer earlier and earlier.

And it's been great for accuracy and and its diagnostic capabilities and you know, low risk for complications as well.

So definitely technology in different arenas of of the overall process.

But it's helped us tremendously to be able to help patients.

>> Who's making the decision as to what type of surgery, I should say what type of surgery.

But the modality of what you're going to go about is this a discussion that you and you alone as the thoracic surgeon superior, or is this a discussion that you're having with the patient and or your care team?

>> A little bit of all of that.

We do have what we call multidisciplinary conference, meaning that we have a weekly meeting with, you know, physicians of different specialties.

So it's a meeting of the minds.

You might say.

Gotcha.

So radiologists, pathologists, the medical oncologist, radiation doctors, the surgeons.

So we really try not to operate in a silo because we're human, right.

We want to make sure that we're not missing something.

And so we try to have these weekly meetings to make sure we're taking the best care of patients as possible.

But then a lot of it is surgeon preference.

I think the standard of care really is minimally invasive surgery.

But within minimally invasive surgery, you know, it's what surgeons feel most comfortable with.

And these newer technologies that takes expertise, it takes training, it takes perseverance.

And so right now this the single port robotic technology University of Kentucky is the only place in the state that's offering that for thoracic surgery.

So it you know, it it matters.

>> Are you trying to start trouble?

>> Nah.

>> My my husband would probably say yes.

>> Okay.

>> We know AI and how it's affecting diagnostic things.

Does it come in?

Since you're talking about a robot, does that come into play with surgery?

>> Not as of now.

Where we have been using AI is more in lung nodule detection.

So where people are getting CT scans for other reasons.

If there's lung nodules that are being picked up, what we call incidentally, which is not on not meaning to look for it, we're using AI to help capture those so that we can make sure those patients get the follow up.

They need to make sure those lung nodules aren't lung cancer.

>> We have about a minute to go.

What are two take home points that you want us to keep to try to keep us alive in your realm?

>> I would say if you're smoking, try to quit or seek help to quit.

And lung cancer screening, because the earlier that we can detect and diagnose lung cancer, the more chance that we have to cure you of your lung cancer.

And we have a lot of great technology to be able to treat you safely and with a speedier recovery.

>> So we can find a lung cancer early.

You can cure.

What about esophageal cancer?

>> Esophageal cancer too.

We use minimally invasive surgery now to treat esophageal cancer.

So again surgery through small cuts.

It is a big operation to operate on the esophagus.

But we can still do that through small cuts.

And again, the earlier that we can diagnose it, the more likely we are to cure it.

>> That's interesting.

I would have thought that a person with your small hands and delicate fingers making you still would have to make a big cut.

But nonetheless, the robot is here and you're using it.

And I'm glad that you're here in Kentucky doing all these wonderful things.

Thank you very much, Doctor Shaw, for being with us today.

>> It's my pleasure.

>> I'd like to thank you for being with us today.

Hope that you now have a better understanding of the various diseases in the thoracic cavity, and the advantages and indications for the surgical treatments.

If you wish to watch this show again, or watch an archived version of past shows, please go to ket.org.

If you have a question or comment about this or other shows, we can be reached at Chi health at ket.org.

I look forward to seeing you again on the next Kentucky Health.

But in the meantime, if you were a smoker, please get screened for lung cancer.

It's easy and it's as we talked about already.

It is free of charge for you.

If you have complaints of burning in the esophagus, see somebody about that.

Otherwise, we want to look forward to seeing you again next week on Kentucky Health.

And thank you very much.

I hope that wasn't.

>> Too bad.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.