Thoracic Surgery

  • Lung cancer surgery
  • Carina surgery, mediastinum tumor and cyst surgery
  • Bronchoplastic and angioplastic surgery (sleeve and double sleeve resection)
  • Reimplantation technique
  • Thoracic surgery with CBP and ECMO
  • Chest wall reconstruction
  • Thoracoplasty
  • Operations of diaphragm and pleura (mesothelioma)
  • Lung hydatid cyst removal, VAT and robotic surgery
  • Cardiac operations (CABG and valve replacement)
  • VRS (Volume Reduction Surgery)
  • Combined operations of lungs, mediastinum and heart thoracic surgery for both neonates and children

Athens Medical Center

Dr. Jubrail Dahabreh, MD PhD, FETCS

  • Director of the Thoracic Surgery Department
  • Has participated in more than 130 peer-reviewed articles in journals.
  • Trained by Professor Sir Magdi Yacoub
  • Member of European Society of Thoracic Surgeons (ESTS)

Related Articles

15.08.16
Smoking and lung cancer

Written by Dahabreh Jubrail MD,PhD Thoracic Surgeon, Director of Thoracic Surgery Department, Athens Medical Center

The relationship of smoking to lung cancer, just as with other fatal diseases, is a serious social and economic problem. 

It is estimated that 80% of deaths from lung cancer in women are due to smoking, while this percentage reaches 90% in men, and this relationship is linear with the number of smokable cigarettes and duration of smoking in years.

Besides smoking, the appearance of lung cancer may be attributed also to other factors such as radon, exposure to asbestos, uranium and coal, as well to contamination of the atmosphere.

Lung cancer is responsible for 28% of cancer deaths, and causes more deaths than the total of deaths caused by cancers of the colon, breast and pancreas.       

The effects of lung cancer concern the patient, their family members, society, personal finances as well as the national economy. As regards the patient this is related to the duration of hospitalization, high cost of diagnostic tests, and treatments, which are often done at regular intervals.

Equally important is the social cost that is unbearable, as patients often suffer dramatic consequences in their personal as well as family and professional lives. Many times, patients are treated with compassion, others suffer rejection, lose professional development opportunities and all these create an additional intolerable psychic load.

It is important to implement programs for the prevention and early diagnosis and treatment for people with a family history, those at a high risk due to smoking, profession and those suffering from pulmonary emphysema and chronic obstructive pulmonary disease.

At the Athens Medical Center in Maroussi, the Thoracic Surgery Department  operating since 2001 has treated a large number of patients suffering from lung cancer, many of whom underwent successful surgical treatment, with long-term survival. Patients undergo the required surgery after prior extensive clinical laboratory tests. The decision to carry out any treatment must be individualized and made once the perioperative risk is deemed acceptable, and in accordance with the guidelines of the European Society of Thoracic Surgeons (ESTS), European Society for Medical Oncology (ESMO), as well as the American Association for Thoracic Surgery (AATS) and American National Comprehensive Cancer network (NCCN).

It is worth mentioning that the decision to conduct the surgery is made after assessment of the whole of the patient by the responsible Thoracic Surgeon (Jubrail Dahabreh ), in collaboration with the Pulmonologist, Oncologist, Radiotherapist, Doctor of the CT and Cardiologist. Finally, the picture of the patient is also assessed by the Anesthesiologist, who has extensive experience in the administration of Anesthesia and in the treatment of postoperative pain. It must be noted that older age (80 and above), diabetes mellitus, renal failure, possible coronary heart disease, and prior Bypass surgery are not in themselves contraindications to perform the surgical treatment. An assessment of all these risk factors is done and based on the result, the final decision to perform or not the surgery is taken.

Patients with lung cancer comprise a specific group of thoracic surgery patients, that need proper evaluation by an experienced team of experts since surgical treatment is the treatment of choice offering long-term survival. It should be emphasized that major and specialized thoracic surgical procedures must only be performed by qualified, experienced Thoracic Surgeons and should be done in specialized Nursing Units. There are many patients who undergo successful surgical treatment after correct assessment by the specialized team of the Athens Medical Center in Maroussi,  though initially they had been excluded from surgical treatment when the assessment was done at non-specialized centers. Patients with limited respiratory reserve can undergo surgical treatment with the performance of specialized surgical techniques, such as bronchoplasty,  with or without angioplasty,  that aim at maintaining as much functional pulmonary tissue as possible. Likewise patients with locally advanced cancer may be subjected to surgical treatment after successful preoperative chemotherapy or chemo-radiotherapy. Furthermore, patients with advanced lung cancer that has spread to adjacent anatomical structures, such as the ribs, diaphragm, pericardium, or the superior vena cava, but also those with monera metastasis in the brain, can be treated surgically with a very low post-operative risk. The execution of this type of surgery is very demanding and requires skill and extensive experience.

Surgery in the above groups of patients not only increases survival but also offers a better quality of life. Thanks to the significant advances in surgical techniques, the use of more modern technical support measures, the progress of anesthesia and also the support of Intensive Care Units, perioperative risk has been significantly reduced, even for the most complicated surgeries.

Until we reach the point where we have the perfect therapy with the desired results, young people must be properly informed on the risks of smoking and the provision of this information is more effective when done at schools. Finally, an important role in early diagnosis of lung cancer is played by a CT scan of the chest, with a low radiation dose, which should be done annually, in heavy smokers, aged over 55 years and in those who have first-degree relatives who had lung cancer, but also to those exposed to various risk factors, such as exposure to asbestos and contamination of the atmosphere. 

06.12.15
Myasthenia Gravis (MG): The Role of Surgery

Written by Dahabreh Jubrail MD,PhD Thoracic Surgeon, Director of Thoracic Surgery Department, Athens Medical Center

The term Myasthenia Gravis concerns an autoimmune disease of the nervous tissue, resulting in weakness and fatigue of muscles and it has an incidence on the population of 2,5 to 20 cases per 100.000 people per year.

Women are affected more often in the 2nd - 3rd decades of life, while men in the 6th decade of life. Myasthenia is not inherited under the laws of Mendel, but members of a family with a myasthenic person are 1000 times more likely to develop myasthenia, compared to the general population.

Cause

The appearance of symptoms of myasthenia are attributed to impaired function of the neuromuscular junction, that is the point of transfer of the neuromuscular stimulation and this is attributable to the occupation of acetylcholine receptors by autoimmune antibodies. Acetylcholine is the substance that causes muscle contraction. The amount of acetylcholine secretion is normal, while the number of receptors is reduced and in addition these receptors are occupied by autoimmune antibodies. 12%-17% of patients with general myasthenia do not have antibodies against acetylcholine receptors.

Symptoms

The most common symptoms are blepharoptosis and diplopia, difficulty in chewing, swallowing and speech articulation. A percentage of 10% have weakness of the lower extremities. Muscle weakness is mild in the morning, with progressive deterioration throughout the day. Also, opthalmic symptoms worsen while reading, when watching television for many hours and while driving in direct sunlight.

Value of the Thymus gland in Myasthenia

The relationship of the thymus with myasthenia has been known for many year,s without being completely clarified yet. 10% -20% of patients with MG have a thymus tumor, 20% -30% of patients have myasthenia and 70% of patients have hyperplasia of the thymus gland. Anatomically, the thymus gland is located in the upper anterior mediastinum and during adulthood, it regresses is completely replaced by fat. Islets of thymic tissue are found scattered within the pro-pericardial fat at a percentage of 72%, while in the anterior cervical region this percentage reaches 32%. This knowledge is crucial in deciding the surgical technique to be applied in the case of thymectomy and this is directly related to the effectiveness of thymectomy.

Treatment of Myasthenia Gravis

Treatment of MG includes administration of drugs against acetylcholinesterases, administration of immunosuppressive drugs, plasmapheresis, administration of immunoglobulin, administration of new drugs and thymectomy. The goals of treatment are individualized, taking into account the severity of the disease, the patient's age, the incidence of the disease in daily activity as well as the likelihood and degree of compliance with treatment. Patients with myasthenia, without a tumor or hyperplasia of the thymus gland, are a special category of patients and thymectomy in these patients is indicated under certain conditions. According to the American Academy of Neurology, thymectomy in patients without thymoma is proposed as an option, with the aim to increase the possibility of complete remission of symptoms or improvement thereof.

Thymectomy

The thymectomy is performed at centers specialized in the treatment of myasthenia. According to the classification of the Myasthenia Gravis Foundation of America, the best prognostic factors, for thymectomy are myasthenia gravis and the short duration of the occurence of the disease before thymectomy. A patient with Myasthenia undergoing thymectomy doubles the probability of achieving remission of the disease without the use of medication, has 1,6 times the possibility of being asymptomatic and 1,7 times the possibility of improving his symptoms.

There are several studies supporting the efficacy of thymectomy in pure opthalmic myasthenia and thymectomy has the major advantage of providing rapid and sustained remission of symptoms, often without the need for administration of drugs.

Surgical techniques

The surgical techniques of thymectomy are transcervical, intrasternal, thoracoscopic and robotic techniques. Today, there is an increased use of minimally invasive surgical techniques, as these have fewer complications, less pain and a lower probability of causing a myasthenic crisis. Moreover, these techniques have better cosmetic results and a shorter duration of hospitalization.

Thymectomy is contraindicated in patients who are negative for antibodies to acetylcholine receptors and at the same time do not have a thymus tumor and hyperplasia of the thymus. Likewise, it is contraindicated in any patient where the extent of penetration is such that it makes the tumor unresectable and when there is unresectable metastatic disease. Finally, it is not indicated as the first treatment of myasthenic crisis.

Myasthenia and pregnancy

The evolution of myasthenia during pregnancy is unpredictable. 11% of myasthenic pregnancies present a remission of symptoms, 39% present elation while 50% have unchanged symptoms. The percentage of newborns exhibiting transient myasthenia reaches 21%.

Results of thymectomy

The recent study of the Mount Sinai hospital of New York, announced at the American Annual Congress of Thoracic Surgery in April 2015, included 1.000 patients, where 19% presented a complete remission of symptoms for at least a year after thymectomy, 58% had a stable clinical condition, while 7% of the patients noted deterioration of the disease. In view of the international data, transcervical and alternative thoracoscopy, robotics or intrasternal thymectomy are recommended for patients with myasthenia without thymoma or with thymoma of up to 3,5 cm. In myasthenia with thymoma> 3,5 cm and less than 5 cm, robotics or thoracoscopy and alternative intrasternal thymectomy are recommended. Finally, when there is a sizable thymoma or thymic carcinoma with penetration of adjacent tissues with or without myasthenia intrasternal thymectomy is proposed.

The role of thymectomy is especially significant in the treatment of myasthenia, even when it concerns myasthenia without existence of a thymoma. Thymectomy holds a position in the treatment of opthalmic myasthenia and is indicated in the treatment of myasthenia after recurrence of symptoms. The progress of science will lead to improvement of the quality of life of patients with MG and reduce the need for thymectomy.