This guide will help you get ready for your thoracic surgery at MSK. It will also help you know what to expect during your recovery.
You will get efficient and thoughtful service from Ezisurg.
Use this guide as a source of information in the days leading up to your surgery. Bring it with you on the day of your surgery. You and your care team will use it as you learn more about your recovery.
The word “thoracic” refers to your thorax, which is your chest (see Figure 1). Your thorax contains your:
There are many types of thoracic surgeries. Your surgeon will talk with you about which type you’ll have. Examples of some surgeries are described in this section. Your surgeon may also use the lines and pictures in this section to describe your surgery.
Your surgeon may reconstruct your diaphragm and pericardium during your surgery.
Some conditions can be treated with a procedure that does not remove your lung or pleura. Three common procedures are listed below.
There are different ways thoracic surgery can be done. Your surgeon will tell you which type of incision you’ll have.
How long you stay in the hospital will depend on which type of surgery you have. Your doctor will talk with you about this before your surgery.
This section will help you get ready for your surgery. Read it when your surgery is scheduled. Refer to it as your surgery gets closer. It has important information about what to do to get ready.
As you read this section, write down questions to ask your healthcare provider.
You and your care team will work together to get ready for your surgery. Help us keep you safe by telling us if any of these things apply to you, even if you’re not sure.
It’s important to talk with your healthcare providers about how much alcohol you drink. This will help us plan your care.
If you drink alcohol regularly, you may be at risk for problems during and after your surgery. These include bleeding, infections, heart problems, and a longer hospital stay.
If you drink alcohol regularly and stop suddenly, it can cause seizures, delirium, and death. If we know you’re at risk for these problems, we can prescribe medicine to help prevent them.
Here are things you can do before your surgery to keep from having problems.
These are early signs of alcohol withdrawal and can be treated.
If you smoke, you need to stop smoking 2 weeks before your surgery. This includes e-cigarettes, vaporizers, and other types of electronic nicotine delivery systems (ENDS).
Quitting smoking will help you recover better after your surgery. Quitting will:
If you smoke, tell the nurse who works with your surgeon. They will refer to you our Tobacco Treatment Program. You can also reach the program by calling 212-610-.
If you have quit smoking, tell the nurse the date you quit and how much you smoked before you quit. They can refer you to our Tobacco Treatment Program to help you avoid starting again.
Our Tobacco Treatment Program has a team of Tobacco Treatment Specialists (TTS). They can help you create a plan to quit smoking or stay quit. A TTS will call you to talk with you about the benefits of quitting smoking, especially before surgery.
The TTS may suggest nicotine replacement therapy (such as a nicotine patch, gum, lozenge, or inhaler) or other cessation medicines.
These medicines:
The TTS will also teach you practical skills to cope with your urges to smoke. They’ll also help you find ways to manage nicotine withdrawal symptoms.
Sleep apnea is a common breathing problem. If you have sleep apnea, you stop breathing for short lengths of time while you’re asleep. The most common type is obstructive sleep apnea (OSA). With OSA, your airway becomes fully blocked during sleep.
OSA can cause serious problems during and after surgery. Tell us if you have or think you might have sleep apnea. If you use a breathing device, such as a CPAP machine, bring it on the day of your surgery.
BPH is when your prostate gland is enlarged (bigger than normal). If you’re male, age 50 or older, and have a history of BPH, your surgeon will give you a prescription for tamsulosin (Flomax®). Taking tamsulosin before your surgery can help prevent problems with urination (peeing) after your procedure.
Start taking the tamsulosin 3 days before your surgery.
MSK MyChart (mskmychart.mskcc.org) is MSK’s patient portal. You can use it to send and read messages from your care team, view your test results, see your appointment dates and times, and more. You can also invite your caregiver to make their own account so they can see information about your care.
If you do not have an MSK MyChart account, you can sign up at mskmychart.mskcc.org. You can also ask a member of your care team to send you an invitation.
If you need help with your account, call the MSK MyChart Help Desk at 646-227-. They are available Monday through Friday between and (Eastern time).
ERAS is a program to help you get better faster after your surgery. It’s important to do certain things before and after your surgery as part of the ERAS program.
Before your surgery, make sure you’re ready by:
After your surgery, help yourself recover more quickly by:
You’ll have a PST appointment before your surgery. You’ll get a reminder from your surgeon’s office with the appointment date, time, and location. Visit www.msk.org/parking for parking information and directions to all MSK locations.
You can eat and take your usual medicines the day of your PST appointment.
It’s helpful to bring these things to your appointment:
You’ll meet with an advance practice provider (APP) during your PST appointment. They work closely with MSK’s anesthesiology (A-nes-THEE-zee-AH-loh-jee) staff. These are doctors with special training in using anesthesia during a surgery or procedure.
Your APP will review your medical and surgical history with you. You may have tests to plan your care, such as:
Your APP may recommend you see other healthcare providers. They’ll also talk with you about which medicine(s) to take the morning of your surgery.
Your caregiver has an important role in your care. Before your surgery, you and your caregiver will learn about your surgery from your healthcare providers. After your surgery, your caregiver will take you home when you’re discharged. They’ll also help you care for yourself at home.
Caring for a person going through cancer treatment comes with many responsibilities. We offer resources and support to help you manage them. Visit www.msk.org/caregivers or read A Guide for Caregivers to learn more.
If you have not already filled out a Health Care Proxy form, we recommend you do now. If you already filled one out or have any other advance directives, bring them to your next appointment.
A health care proxy is a legal document. It says who will speak for you if you cannot communicate for yourself. This person is called your health care agent.
Talk with a member of your care team if you have questions about filling out a Health Care Proxy form.
Practice taking deep breaths and coughing before your surgery. Your healthcare provider will give you an incentive spirometer to help expand your lungs. To learn more, read How To Use Your Incentive Spirometer.
Doing physical activity will help your body get into its best condition for your surgery. It will also make your recovery faster and easier.
Try to do physical activity every day. Any activity that makes your heart beat faster, such as walking, swimming, or biking, is a good choice. If it’s cold outside, use stairs in your home or go to a mall or shopping center.
Follow a well-balanced, healthy diet before your surgery. If you need help with your diet, talk with your healthcare provider about meeting with a clinical dietitian nutritionist.
4% CHG solution is a skin cleanser that kills germs for 24 hours after you use it. Showering with it before your surgery will help lower your risk of infection after surgery. You can buy a 4% CHG solution antiseptic skin cleanser at your local pharmacy without a prescription.
Aspirin can cause bleeding. If you take aspirin or a medicine that has aspirin, you may need to change your dose or stop taking it 7 days before your surgery. Follow your healthcare provider’s instructions. Do not stop taking aspirin unless they tell you to.
To learn more, read How To Check if a Medicine or Supplement Has Aspirin, Other NSAIDs, Vitamin E, or Fish Oil.
Vitamin E, multivitamins, herbal remedies, and other dietary supplements can cause bleeding. Stop taking them 7 days before your surgery. If your healthcare provider gives you other instructions, follow those instead.
To learn more, read Herbal Remedies and Cancer Treatment.
If your healthcare provider gave you a prescription for tamsulosin, start taking it 3 days before your surgery. For more information, read the “About benign prostate hyperplasia (BPH)” section of this guide.
NSAIDs, such as ibuprofen (Advil® and Motrin®) and naproxen (Aleve®), can cause bleeding. Stop taking them 2 days before your surgery. If your healthcare provider gives you other instructions, follow those instead.
To learn more, read How To Check if a Medicine or Supplement Has Aspirin, Other NSAIDs, Vitamin E, or Fish Oil.
A staff member will call you after the day before your surgery. If your surgery is scheduled for a Monday, they’ll call you the Friday before. If you do not get a call by , call 212-639-.
The staff member will tell you what time to get to the hospital for your surgery. They’ll also remind you where to go.
This will be:
The Presurgical Center (PSC) at Memorial Hospital
York Ave. (between East 67th and East 68th streets)
New York, NY
Take the B elevator to the 6th floor.
Visit www.msk.org/parking for parking information and directions to all MSK locations.
Shower with a 4% CHG solution antiseptic skin cleanser before you go to bed the night before your surgery.
Do not put on any lotion, cream, deodorant, makeup, powder, perfume, or cologne after your shower.
Stop eating at midnight (12 a.m.) the night before your surgery. This includes hard candy and gum.
Your healthcare provider may have given you different instructions for when to stop eating. If so, follow their instructions. Some people need to fast (not eat) for longer before their surgery.
Between midnight (12 a.m.) and 2 hours before your arrival time, only drink the liquids on the list below. Do not eat or drink anything else. Stop drinking 2 hours before your arrival time.
If you have diabetes, pay attention to the amount of sugar in your drinks. It will be easier to control your blood sugar levels if you include sugar-free, low-sugar, or no added sugar versions of these drinks.
It’s helpful to stay hydrated before surgery, so drink if you are thirsty. Do not drink more than you need. You will get intravenous (IV) fluids during your surgery.
Stop drinking 2 hours before your arrival time. This includes water.
Your healthcare provider may have given you different instructions for when to stop drinking. If so, follow their instructions.
A member of your care team will tell you which medicines to take the morning of your surgery. Take only those medicines with a sip of water. Depending on what you usually take, this may be all, some, or none of your usual morning medicines.
Shower with a 4% CHG solution antiseptic skin cleanser before you leave for the hospital. Use it the same way you did the night before.
Do not put on any lotion, cream, deodorant, makeup, powder, perfume, or cologne after your shower.
When you get to the hospital, take the B elevator to the 6th floor. Check in at the desk in the PSC waiting room.
Many staff members will ask you to say and spell your name and birth date. This is for your safety. People with the same or a similar name may be having surgery on the same day.
When it’s time to change for surgery, you’ll get a hospital gown, robe, and nonskid socks to wear.
Read Information for Family and Friends for the Day of Surgery to help you know what to expect on the day of your loved one’s surgery.
You’ll meet with a nurse before surgery. Tell them the dose of any medicines you took after midnight (12 a.m.) and the time you took them. Make sure to include prescription and over-the-counter medicines, patches, and creams.
Your nurse may place an intravenous (IV) line in one of your veins, usually in your arm or hand. If your nurse does not place the IV, your anesthesiologist (A-nes-THEE-zee-AH-loh-jist) will do it in the operating room.
You’ll also meet with an anesthesiologist before surgery. They will:
Your doctor or anesthesiologist may also talk with you about placing an epidural catheter (thin, flexible tube) in your spine (back). An epidural catheter is another way to give you pain medicine after your surgery.
When it’s time for your surgery, you’ll take off your eyeglasses, hearing aids, dentures, prosthetic devices, wig, and religious articles.
You’ll either walk into the operating room or a staff member will bring you there on a stretcher. A member of the operating room team will help you onto the operating bed. They’ll put compression boots on your lower legs. These gently inflate and deflate to help blood flow in your legs.
Once you’re comfortable, your anesthesiologist will give you anesthesia through your IV line and you’ll fall asleep. You’ll also get fluids through your IV line during and after your surgery.
After you’re fully asleep, your care team will place a breathing tube through your mouth into your airway. It will help you breathe. They’ll also place a urinary (Foley) catheter in your bladder. It will drain your urine (pee) during your surgery.
Once they finish your surgery, your surgeon will close your incisions with staples or sutures (stitches). They may also place Steri-Strips™ (thin pieces of surgical tape) or Dermabond® (surgical glue) over your incisions. They may cover your incisions with a bandage.
Your breathing tube is usually taken out while you’re still in the operating room.
This section will help you know what to expect after your surgery. You’ll learn how to safely recover from your surgery both in the hospital and at home.
As you read this section, write down questions to ask your healthcare provider.
You’ll be in the PACU when you wake up after your surgery. A nurse will be keeping track of your temperature, pulse, blood pressure, and oxygen levels. You may get oxygen through a tube resting below your nose or a mask over your nose and mouth. You’ll also have compression boots on your lower legs.
You will have the following tubes and drains below. Your healthcare provider will talk with you about what to expect.
You’ll have 1 or more of the tubes and drains below. Your healthcare providers will talk with you about what to expect.
You’ll get epidural or IV pain medicine while you’re in the PACU.
You’ll be able to control your pain medicine using a button called a patient-controlled analgesia (PCA) device. To learn more, read Patient-Controlled Analgesia (PCA).
You may stay in the PACU for a few hours or overnight. How long you stay depends on when an inpatient bed comes available. After your stay in the PACU, a staff member will bring you to your hospital room.
The length of time you’re in the hospital after your surgery depends on your recovery.
In your hospital room, you’ll meet one of the nurses who will care for you during your stay. Soon after you get there, a nurse will help you out of bed and into your chair.
Your healthcare providers will teach you how to care for yourself while you’re recovering from your surgery. You can help yourself recover more quickly by:
You’ll have some pain after your surgery. At first, you’ll get your pain medication through your epidural catheter or IV line. You’ll be able to control your pain medication using a PCA device. You’ll get oral pain medication (medication you swallow) once your chest tube is removed.
Your healthcare providers will ask you about your pain often and give you medication as needed. If your pain is not relieved, tell one of your healthcare providers. It’s important to control your pain so you can use your incentive spirometer and move around. Controlling your pain will help you recover better.
You’ll get a prescription for pain medication before you leave the hospital. Talk with your healthcare provider about possible side effects and when to start switching to over-the-counter pain medications.
Moving around and walking will help lower your risk for blood clots and pneumonia (lung infection). It will also help you start passing gas and having bowel movements (pooping) again. Your nurse, physical therapist, or occupational therapist will help you move around, if needed.
To learn more about how walking can help you recover, read Frequently Asked Questions About Walking After Your Surgery.
To learn what you can do to stay safe and keep from falling while you’re in the hospital, read Call! Don't Fall!.
It’s important to exercise your lungs so they expand fully. This helps prevent pneumonia.
You’ll slowly go back to eating solid foods starting the day after your surgery. Read your pathway and talk with your care team for more information.
If you have questions about your diet, ask to see a clinical dietitian nutritionist.
Your doctor will talk with you if you need to stay in the hospital longer than planned. Examples of things that can cause you to stay in the hospital longer include:
Before you leave, look at your incision with one of your healthcare providers. Knowing what it looks like will help you notice any changes later.
On the day of your discharge, plan to leave the hospital around Before you leave, your healthcare provider will write your discharge order and prescriptions. You’ll also get written discharge instructions. One of your healthcare providers will review them with you before you leave.
If your ride is not at the hospital when you’re ready to leave, you may be able to wait in the Patient Transition Lounge. A member of your care team will give you more information.
Read What You Can Do to Avoid Falling to learn what you can do to keep from falling at home and during your appointments at MSK.
We want to know how you’re feeling after you leave the hospital. To help us care for you, we’ll send questions to your MSK MyChart account. We’ll send them every day for 10 days after you’re discharged. These questions are known as your Recovery Tracker.
Fill out your Recovery Tracker every day before midnight (12 a.m.). It only takes 2 to 3 minutes to complete. Your answers to these questions will help us understand how you’re feeling and what you need.
Based on your answers, we may reach out to you for more information. Sometimes, we may ask you to call your surgeon’s office. You can always contact your surgeon’s office if you have any questions.
To learn more, read Common Questions About MSK's Recovery Tracker.
People have pain or discomfort for different lengths of time. You may still have some pain when you go home and will probably be taking pain medicine. Some people have soreness, tightness, or muscle aches around their incision for 6 months or longer. This does not mean something is wrong.
Follow these guidelines to help manage your pain at home.
Some prescription pain medicines (such as opioids) may cause constipation (having fewer bowel movements than usual).
Talk with your healthcare provider about how to prevent and manage constipation. You can also follow these guidelines.
Take a shower every day to clean your incision. Follow the instructions in the “Showering” section below.
It’s normal for the skin below your incision to feel numb. This happens because some of your nerves were cut during your surgery. The numbness will go away over time.
Call your healthcare provider’s office if:
If you go home with staples in your incision, your healthcare provider will take them out during your first appointment after surgery. It’s OK to get them wet.
If you go home with Steri-Strips or Dermabond on your incision, they’ll loosen and fall or peel off on their own. If they have not fallen off after 10 days, you can take them off.
You may have some thin, yellow or pink-colored drainage from your chest tube incision. This is normal.
Keep your incision covered with a bandage for 48 hours (2 days) after your chest tube is removed. If it gets wet, change it as soon as possible.
After 48 hours, if you do not have any drainage, you can remove the bandage and keep your incision uncovered.
If you have drainage, keep wearing a bandage until the drainage stops. Change it at least once a day or more often if the bandage becomes wet.
Sometimes, the drainage may start again after it has stopped. This is normal. If this happens, cover the area with a bandage. Call your healthcare provider if you have questions.
The company is the world’s best thoracic surgery stapler supplier. We are your one-stop shop for all needs. Our staff are highly-specialized and will help you find the product you need.
You can shower 48 hours (2 days) after your chest tube is removed. Take a shower every day to clean your incision. If you have staples in your incision, it’s OK to get them wet.
Take your bandage(s) off before you shower. Use soap during your shower, but do not put it directly on your incision. Do not rub the area around your incision.
After you shower, pat the area dry with a clean towel. Leave your incision uncovered or cover it with a bandage if your clothing may rub it or if you have drainage.
Do not take tub baths until talking with your surgeon.
You can eat all the foods you did before your surgery, unless your healthcare provider gives you other instructions. Eating a balanced diet with lots of calories and protein will help you heal after surgery. Try to eat a good protein source (such as meat, fish, or eggs) at each meal. You should also try to eat fruits, vegetables, and whole grains.
It’s also important to drink plenty of liquids. Choose liquids without alcohol or caffeine. Try to drink 8 to 10 (8-ounce) glasses of liquids every day.
For more information, read Eating Well During Your Cancer Treatment.
If you have questions about your diet, ask to see a clinical dietitian nutritionist.
When you leave the hospital, your incision may look healed on the outside, but it will not be healed on the inside. For the first 3 weeks after your surgery:
Doing aerobic exercise, such as walking and stair climbing, will help you gain strength and feel better. Walk at least 2 to 3 times a day for 20 to 30 minutes. You can walk outside or indoors at your local mall or shopping center.
It’s normal to have less energy than usual after your surgery. Recovery time is different for each person. Increase your activities each day as much as you can. Always balance activity periods with rest periods. Rest is an important part of your recovery.
Stretching exercises will help you regain full arm and shoulder movement. They’ll also help relieve pain on the side of your surgery.
Do the exercises described in the “Stretching exercises” section. Start doing them as soon as your chest tube is removed.
Use the arm and shoulder on the side of your surgery in all your activities. For example, use them when you bathe, brush your hair, and reach up to a cabinet shelf. This will help restore full use of your arm and shoulder.
Drink liquids to help keep your mucus thin and easy to cough up. Ask your healthcare provider how much you should drink each day. For most people, this will be at least 8 to 10 (8-ounce) glasses of liquid each day.
Use a humidifier while you sleep during the winter months. Make sure to change the water and clean the humidifier often. Follow the manufacturer’s instructions.
Do not smoke. Smoking is harmful to your health at any time, but it’s even more harmful as you’re healing. Smoking causes the blood vessels in your body to become narrow. This decreases the amount of oxygen that reaches your wounds as they’re healing.
Smoking can also cause problems with breathing and regular activities. It’s also important to avoid places that are smoky. Your nurse can give you information to help you deal with other smokers or situations where smoke is present.
Remember, if you need help quitting, MSK’s Tobacco Treatment Program can help. Call 212-610- to make an appointment.
Ask your healthcare provider when you can drive. Do not drive while you’re taking pain medication that may make you drowsy.
You can ride in a car as a passenger at any time after you leave the hospital.
Your healthcare provider will tell you when you can start having sexual activity. This is usually as soon as your incisions have healed.
Talk with your healthcare provider about your job. They’ll tell you when it may be safe for you to start working again based on what you do. If you move around a lot or lift heavy objects, you may need to stay out a little longer. If you sit at a desk, you may be able to go back sooner.
Do not travel by plane until your doctor says it’s OK. They’ll talk with you about this during your first appointment after your surgery.
Your first appointment after surgery will be 1 to 3 weeks after you leave the hospital. Your nurse will give you instructions on how to make this appointment, including the number to call.
During this appointment, your surgeon will discuss the pathology results with you in detail.
You may also have appointments with other healthcare providers after your surgery.
You may have new and upsetting feelings after a surgery for a serious illness. Many people say they felt weepy, sad, worried, nervous, irritable, or angry at one time or another. You may find that you cannot control some of these feelings. If this happens, it’s a good idea to seek emotional support. Your healthcare provider can refer you to MSK’s Counseling Center. You can also reach them by calling 646-888-.
The first step in coping is to talk about how you feel. Family and friends can help. We can also reassure, support, and guide you. It’s always a good idea to let us know how you, your family, and your friends are feeling emotionally. Many resources are available to you and your family. We’re here to help you and your family and friends handle the emotional aspects of your illness. We can help no matter if you’re in the hospital or at home.
Stretching exercises will help you regain full arm and shoulder movement. You can start doing them once your chest tube is removed.
To do the exercises, follow the instructions below. One of your healthcare providers will tell you how many times to repeat each exercise.
You’ll need a straight-backed chair and a hand towel to do these exercises.
Call your healthcare provider if:
This section has a list of support services. They may help you as you get ready for your surgery and recover after your surgery.
As you read this section, write down questions to ask your healthcare provider.
Admitting Office
212-639-
Call if you have questions about your hospital admission, such as asking for a private room.
Anesthesia
212-639-
Call if you have questions about anesthesia.
Blood Donor Room
212-639-
Call for information if you’re interested in donating blood or platelets.
Bobst International Center
www.msk.org/international
888-675-
We welcome patients from around the world and offer many services to help. If you’re an international patient, call for help arranging your care.
Counseling Center
www.msk.org/counseling
646-888-
Many people find that counseling helps them. Our Counseling Center offers counseling for individuals, couples, families, and groups. We can also prescribe medicine to help if you feel anxious or depressed. Ask a member of your care team for a referral or call the number above to make an appointment.
Food Pantry Program
646-888-
We give food to people in need during their cancer treatment. Talk with a member of your care team or call the number above to learn more.
Integrative Medicine Service
www.msk.org/integrativemedicine
Our Integrative Medicine Service offers many services to complement (go along with) traditional medical care. For example, we offer music therapy, mind/body therapies, dance and movement therapy, yoga, and touch therapy. Call 646-449- to make an appointment for these services.
You can also schedule a consultation with a healthcare provider in the Integrative Medicine Service. They’ll work with you to make a plan for creating a healthy lifestyle and managing side effects. Call 646-608- to make an appointment for a consultation.
MSK Library
library.mskcc.org
212-639-
You can visit our library website or call to talk with the library reference staff. They can help you find more information about a type of cancer. You can also visit the library’s Patient and Health Care Consumer Education Guide.
Nutrition Services
www.msk.org/nutrition
212-639-
Our Nutrition Service offers nutritional counseling with one of our clinical dietitian nutritionists. Your clinical dietitian nutritionist will talk with you about your eating habits. They can also give advice on what to eat during and after treatment. Ask a member of your care team for a referral or call the number above to make an appointment.
Patient and Community Education
www.msk.org/pe
Visit our patient and community education website to search for educational resources, videos, and online programs.
Patient Billing
646-227-
Call if you have questions about preauthorization with your insurance company. This is also called preapproval.
Patient Representative Office
212-639-
Call if you have questions about the Health Care Proxy form or concerns about your care.
Perioperative Nurse Liaison
212-639-
Call if you have questions about MSK releasing any information while you’re having surgery.
Private Duty Nurses and Companions
917-862-
You can request private nurses or companions to care for you in the hospital and at home. Call to learn more.
Rehabilitation Services
www.msk.org/rehabilitation
Cancers and cancer treatments can make your body feel weak, stiff, or tight. Some can cause lymphedema (swelling). Our physiatrists (rehabilitation medicine doctors), occupational therapists (OTs), and physical therapists (PTs) can help you get back to your usual activities.
Resources for Life After Cancer (RLAC) Program
646-888-
At MSK, care does not end after your treatment. The RLAC Program is for patients and their families who have finished treatment.
This program has many services. We offer seminars, workshops, support groups, and counseling on life after treatment. We can also help with insurance and employment issues.
Sexual Health Programs
Cancer and cancer treatments can affect your sexual health, fertility, or both. MSK’s sexual health programs can help you before, during, or after your treatment.
Social Work
www.msk.org/socialwork
212-639-
Social workers help patients, families, and friends deal with common issues for people who have cancer. They provide individual counseling and support groups throughout your treatment. They can help you communicate with children and other family members.
Our social workers can also help refer you to community agencies and programs. If you’re having trouble paying your bills, they also have information about financial resources. Call the number above to learn more.
Spiritual Care
212-639-
Our chaplains (spiritual counselors) are available to listen, help support family members, and pray. They can contact community clergy or faith groups, or simply be a comforting companion and a spiritual presence. Anyone can ask for spiritual support. You do not have to have a religious affiliation (connection to a religion).
MSK’s interfaith chapel is located near Memorial Hospital’s main lobby. It’s open 24 hours a day. If you have an emergency, call 212-639-. Ask for the chaplain on call.
Tobacco Treatment Program
www.msk.org/tobacco
212-610-
If you want to quit smoking, MSK has specialists who can help. Call to learn more.
Virtual Programs
www.msk.org/vp
We offer online education and support for patients and caregivers. These are live sessions where you can talk or just listen. You can learn about your diagnosis, what to expect during treatment, and how to prepare for your cancer care.
Sessions are private, free, and led by experts. Visit our website to learn more about Virtual Programs or to register.
Access-A-Ride
web.mta.info/nyct/paratran/guide.htm
877-337-
In New York City, the MTA offers a shared ride, door-to-door service for people with disabilities who can’t take the public bus or subway.
Air Charity Network
www.aircharitynetwork.org
877-621-
Provides travel to treatment centers.
American Cancer Society (ACS)
www.cancer.org
800-ACS- (800-227-)
Offers a variety of information and services, including Hope Lodge, a free place for patients and caregivers to stay during cancer treatment.
Cancer and Careers
www.cancerandcareers.org
646-929-
A resource for education, tools, and events for employees with cancer.
CancerCare
www.cancercare.org
800-813-
275 Seventh Avenue (Between West 25th & 26th Streets)
New York, NY
Provides counseling, support groups, educational workshops, publications, and financial assistance.
Cancer Support Community
www.cancersupportcommunity.org
Provides support and education to people affected by cancer.
Caregiver Action Network
www.caregiveraction.org
800-896-
Provides education and support for people who care for loved ones with a chronic illness or disability.
Corporate Angel Network
www.corpangelnetwork.org
866-328-
Offers free travel to treatment across the country using empty seats on corporate jets.
Good Days
www.mygooddays.org
877-968-
Offers financial assistance to pay for copayments during treatment. Patients must have medical insurance, meet the income criteria, and be prescribed medicine that’s part of the Good Days formulary.
HealthWell Foundation
www.healthwellfoundation.org
800-675-
Provides financial assistance to cover copayments, health care premiums, and deductibles for certain medicines and therapies.
Joe’s House
www.joeshouse.org
877-563-
Provides a list of places to stay near treatment centers for people with cancer and their families.
LGBT Cancer Project
www.lgbtcancer.com
Provides support and advocacy for the LGBT community, including online support groups and a database of LGBT-friendly clinical trials.
LIVESTRONG Fertility
www.livestrong.org/we-can-help/fertility-services
855-744-
Provides reproductive information and support to cancer patients and survivors whose medical treatments have risks associated with infertility.
Look Good Feel Better Program
www.lookgoodfeelbetter.org
800-395-LOOK (800-395-)
This program offers workshops to learn things you can do to help you feel better about your appearance. For more information or to sign up for a workshop, call the number above or visit the program’s website.
National Cancer Institute
www.cancer.gov
800-4-CANCER (800-422-)
National LGBT Cancer Network
www.cancer-network.org
Provides education, training, and advocacy for LGBT cancer survivors and those at risk.
Needy Meds
www.needymeds.org
Lists Patient Assistance Programs for brand and generic name medicines.
NYRx
www.health.ny.gov/health_care/medicaid/program/pharmacy.htm
Provides prescription benefits to eligible employees and retirees of public sector employers in New York State.
Patient Access Network (PAN) Foundation
www.panfoundation.org
866-316-
Gives help with copayments for patients with insurance.
Patient Advocate Foundation
www.patientadvocate.org
800-532-
Provides access to care, financial assistance, insurance assistance, job retention assistance, and access to the national underinsured resource directory.
Professional Prescription Advice
www.pparx.org
888-477-
Helps qualifying patients without prescription drug coverage get free or low-cost medicines.
Red Door Community (formerly known as Gilda’s Club)
www.reddoorcommunity.org
212-647-
A place where people living with cancer find social and emotional support through networking, workshops, lectures, and social activities.
RxHope
www.rxhope.com
877-267-
Provides assistance to help people get medicines they have trouble affording.
Triage Cancer
www.triagecancer.org
Provides legal, medical, and financial information and resources for cancer patients and their caregivers.
This section lists the educational resources mentioned in this guide. They will help you get ready for your surgery and recover after your surgery.
As you read these resources, write down questions to ask your healthcare provider.
With the advent of modern video-assisted thoracoscopic surgery (VATS), mechanical stapling of lung tissue has become essential for both anatomical and atypical lung resections. Since the first successful use of stapler devices for lung surgery in the USSR in the s as well in the USA in the s, endoscopic instruments have been developed for minimally invasive surgery allowing precise, safe, and time saving transection and simultaneous sealing of lung tissue (1).
However, staple line failure resulting in postoperative air leaks is a common complication after lung surgery, that if persist more than five days are defined as prolonged air leaks (PALs) and have a reported incidence of 8%–26% (2,3). In the previous literature, PALs have been associated with increased patient morbidity and mortality, length of stay, and hospital costs (3,4).
Therefore, staple line integrity is critical to create a completely sealed transection line as well as to preserve the perfusion of tissue margins. These issues have been the focus of continuing innovation by surgical stapler manufacturers (5). Recent efforts have been aimed at improving device-to-tissue interaction by optimizing following components of stapler devices:
The present Clinical Practice Review is aimed to provide an overview of above-mentioned features of new staplers to reduce the incidence of air leaks, based on the review of available literature.
Traditional cartridges were flat-faced with single-height staples. To improve the fixation of the device to the tissues and—therefore—its stability during stapling, manufactures have developed different solutions with focus either on the length of staples or the surface of the cartridge.
The Tri-Staple™ reload (Medtronic, Minneapolis, MN) has a stepped cartridge face that delivers graduated compression and three rows of varied height staples. That design is advocated to generate less stress on tissue during compression and clamping (Figure 1) (6).
The Echelon™ stapler reloads (Ethicon Inc., Cincinnati, OH) feature Gripping Surface Technology (GST), which entails small bumps extending from the driver wells such that the cartridge face is not flat. These bumps are intended to engage tissue and minimize distal and lateral tissue movement during stapler compression and firing (Figure 2) (7).
To date, there is limited published information on the above-mentioned technologies. Imhoff and Monnet compared two graduated compression staples (Tri-Staple™, Covidien) and standard staples (Endo GIA™, Covidien) for lung biopsy in dogs. In this ex vivo experimental study graduated staples leaked at significantly lower airway pressures than standard staples, so the authors concluded that they may not be suitable for canine lung biopsy (8). On the other hand, a single paper reports the application of Tri-Staple™ on human lung tissue, with no complications noted in 56 uses for either wedge resection or bronchus closure (9).
In an ex vivo porcine lung model Eckert and coll. investigated differences in air leak occurrence and air leak rates between two different ventilation modalities: positive pressure ventilation (PPV), mimicking intraoperative ventilation, and negative pressure ventilation (NPV), mimicking natural breathing. In addition, they compared the rate of air leaks associated with staple-line configuration with uniform staple heights (UNI) versus graduated staple heights (GRD) under both ventilation modalities. The authors observed an increased occurrence of leaks as well as higher leak rates under NPV than under PPV, and by using graduated staple design than uniform staple design (10).
Another issue is the choice of the appropriate staple height to avoid a mismatch between staple height and tissue thickness, which may result in a leakage due to necrosis or poor apposition. Cartridges are available with different heights of closed, B-shaped staples, varying from 0.75 to 2.3 mm, and are color-coded according to the staple height. However, the staple reload selection is an empiric process based on surgeon’s judgement, because there is no current method providing an objective intraoperative measurement of deflated tissue thickness prior to cartridge selection.
The role of staplers as a protection against air leak was studied in a meta-analysis by Lu et al., they compared the effect of staplers vs. electrocautery in patients undergoing segmental lung resection. Because of the high risk of leakage through the quite long tissue resection line uncovered by visceral pleura, this group of patients is most likely to suffer PALs. In the series of 385 patients the advantage of the mechanical staplers on reduction of PAL rate was reported with an OR of 3.91 (95% CI: 1.64–9.35; P=0.002) (11).
However, air leak may occur from an appropriate staple line with complete pleuralization either due to tissue ischaemia or enlarged staple canals. The latter mechanism plays an important role in patients with severe emphysema undergoing lung surgery, as reduced thickness of tissue layers in the staple line may offer less resistance against local pressure in the inflated lung, resulting in enlargement of staple canals or small lacerations of the surrounding visceral pleura.
To buttress staple line, thus prevent air leaks in patients with emphysema, several types of tissue coverage have been developed in the last years.
In the literature the most frequently studied covered line is with bovine pericardium. These reinforced staplers have been always compared with sealants regarding the effectiveness on PAL prevention. Buttresses have been shown in randomized trials to decrease the incidence and duration of air leaks, as well as the time chest tube is required in patients with severe emphysema undergoing atypical resection (12). Although the data are not clear for patients with severe emphysema undergoing anatomic lobectomy or segmentectomy, we assume that it is reasonable to use staple-line buttresses in this patient group as well.
Regarding liquid sealants, most studies have reported neither statistically nor clinically significant improvements in hospital stay or time to removal of chest tube. Although one might think it logical that sealants would demonstrate a clearer benefit in patients with substantial emphysema, this may not be the case, and only a single small study (albeit with positive results) has looked at this subgroup of patients (13). Also needed are studies that are large enough for stratification based on the size of the initial intraoperative air leaks, studies that look at prolonged or complicated air leak as an outcome measure, and studies that evaluate PAL-related costs (12).
Based on the mentioned study on patients undergoing lung volume reduction surgery (LVRS), there is evidence that covered stapler may prevent air leakage through stapler line. The mechanical explanation of the effect of covered staple line was also studied on cadaveric lung models from Murray et al. They confirmed that unreinforced staple lines began to leak air at an airway pressure of 20 mmHg, and >90% leaked at a pressure of 35 mmHg. Both bovine pericardium and expanded polytetrafluoroethylene (ePTFE) used in the study significantly reduced the incidence of air leak at these airway pressures. At higher airway pressures, ePTFE was superior to bovine pericardium (13). Similar results emerged from the study conducted by Downey et al.: on an experimental pig model, they compared reinforcement with four different materials with normal staplers under different pressure up to 75 mmHg. The conclusion was that commercially available reinforcements allow pulmonary staple lines to tolerate higher intrabronchial pressures without developing air leak. In addition, reinforcement with small intestinal submucosa afforded a significant advantage to the other reinforcements in terms of staple line leak rate. The main limitation of this study was that the authors compared in most of cases the staplers outside the physiologically applied pressure during the operation, as the pressure rarely overcome 30 mmHg (14).
The clinical implication of the above-mentioned studies has been confirmed in a randomized clinical trial performed in leading thoracic surgery centres in Europe (Vienna, Zurich, and Essen). The study group concluded that the median duration of air leaks after LVRS was shorter in the buttressed stapler group than in the control group (0 vs. 4 days; P<0.001), with a corresponding shorter median drainage time in this group (5 vs. 7.5 days; P=0.045). Hospital stay was similar in the two groups (median: 9.5 vs. 12.0 days; P=0.14) (15).
The need to reinforce staple line was also confirmed based on the experimental study of Bonnet et al., in which they compared microscopic lung tissue changes of a porcine lung model after lung resection with and without stapler. They concluded that only perfect allocation of the stapler can prevent leakage through the lung parenchyma. This conclusion is quite important in the era of VATS resections, as stapler line allocation may be not always that perfect depending on the different thoracoscopic access (uniportal or multiportal). In order to prevent PALs, their conclusion indirectly stresses the need of staple line reinforcement in selected patients (16).
Different types of reinforcement material are available on the market. The most utilized ones are bovine pericardium (BP) and polytetrafluoroethylene (PTFE) patches, both not resorbable. In their study Vaughn et al. compared the tissue response after reinforcement of the staple line either with the pericardium or PTFE. Based on their experimental dog model they observed that at 30 days, the BP specimens showed chronic inflammatory changes and thin tissue incorporation, whereas the PTFE specimens had no inflammation and was embedded by a thick tissue layer. At 3 and 6 months, the inflammation in the BP specimens had resolved, but tissue incorporation remained minimal, whereas in the PTFE specimens tissue coverage had increased (P<0.). No air leaks, staple-line failure, or infections were observed in both study groups. In conclusion, a more favourable tissue response was observed in the group with PTFE patches (17). Further, we could find some anecdotal papers concerning complications after application of bovine pericardium like metalloptysis (18,19).
There are many others reinforcement materials which are under investigation und can represent an alternative to the widely used ones. The most important characteristic of these materials should be easily application, high sealing power, and safety.
In a multicenter study from France the role of knitted calcium alginate (FOREsealTM) sleeves for buttressing the staple line were investigated in different types of resections. Intraoperative air leakage was assessed at a mean ventilatory peak pressure of 30 cmH2O, and rated as grade 1, 2, or 3. Persistent air leakage in the postoperative course, as well as any relevant event, were assessed daily. The study group concluded that FOREsealTM is an ergonomic, safe, and promising new material instead of nonabsorbable materials and xenomaterials for staple-line reinforcement (20).
Contrary to the results of the French Investigation was the conclusion regarding the efficacity of FOREsealTM in a randomized controlled trial conducted by Alifano et al. They have tested the efficacy of the mentioned buttress in preventing PAL in high-risk patients with emphysema undergoing anatomical lung resection (lobectomy or bilobectomy). Based on collected data of 380 randomized patients the authors concluded that buttressing has not advantages over standard fissure separation with linear stapler without reinforcement (21).
Another newly investigated agent for buttressing the staplers is bioabsorbable polyglycolic acid (PGA). Deguchi et al. conducted a propensity score matched analysis on two groups of 125 patients each. They results confirmed that using the stapler with PGA to divide the incomplete interlobar fissure for lobectomy reduced postoperative air leakage and decreased the need for additional intraoperative management using fibrin glue as compared with stapler without reinforcement (Figure 3) (22).
In their experimental investigation on a dog model, Hashimoto et al. have compared the efficacy of different stapler line buttressing, also including the combination form FOREsealTM plus PGA. They concluded that this alginate buttress may be more effective for preventing air leakage after lung surgery, because it has both sealant and bolster effects working in conjunction. Interestingly, in their study model the applied pressure for proving air tightness of stapled lung parenchyma was more than 50 mmHg—away from the more physiological pressures applied during intraoperative ventilation (23).
A quite new and scarce investigated material is the small intestinal submucosa (SIS). The report by Downey et al. has shown some advantages over commercially used bovine pericardium as well as PTFE. A possible explanation of his quality was that due to its bioabsorbable profile SIS may be a more suitable material for staple line reinforcement in selected patients requiring nonanatomic lung resection (14).
In conclusion, based on the evidence of the literature the role of the buttressed stapler seems to be important to reduce the rate of postoperative PALs, especially in the group of patients with predictive factors for this economically relevant surgical complication.
The evolution of the minimally invasive thoracic surgery needed the improvement of the stapler design to reduce not only the operation time but also postoperative complications such as PAL. The evolution of surgical staplers has been described previously; nowadays the most advanced stapler technology are the powered staplers. The powered stapling systems offers one-handed, push-button operations, which eliminate the manual firing force and possibly enable more precise resection.
Increased tension to reduce the costs of surgery despite of increasing material costs can be mostly compensated by reducing the length of patient’s hospital stay. That’s why it is important to prove if the newly designed staplers can reduce the overall costs of lung surgery by preventing postoperative complications such PAL.
Based on the analysis of 433 patients with the use of staplers in their VATS lobectomy for lung cancer, Gao et al. confirmed that the use of powered stapler afforded a significantly shorter operation time and postoperative hospital length of stay than using the manual stapler in a multivariable regression analysis adjusted by patient characteristics. However, no other significant differences, including the rates of PAL were observed for other clinical outcomes between the two stapler groups (24).
A confirmation of the above-mentioned results has emerged from the study conducted by Licht et al., who investigated the clinical outcome after VATS using a new surgical stapling device in two different geographic regions (United States and Europe). Ten participating institutions enrolled a total of 226 subjects in this study. Primary endpoints were occurrence and duration of postoperative air leaks, including PALs. Regional differences were observed for cartridge selection relative to tissue type and intraoperative leak testing. Despite disparity in surgical technique between the two continents, no significant differences in air leak or other clinical outcome were observed (25).
These results have been confirmed in the similarly designed, retrospective study by Miller et al., who compared hospital resource use, costs, and complications of VATS lobectomy procedures using powered versus manual endoscopic surgical staplers. Multivariate regression analysis adjusted for patients, institution, provider characteristics and hospital-level clustering was carried out to compare following factors: length of hospitalisation, operation time, total hospital costs, complications (bleeding and/or need for blood transfusion, PALs, pneumonia, and other infection), discharge status, and all-cause readmissions at 30, 60, and 90 days. The analysis included only VATS lobectomy procedures. As a result, powered staplers were associated with significant benefits in terms of hospital resource use, costs, and clinical outcomes when compared with manual staplers. Concerning the incidence of PALs, the study didn’t show any advantage of powered staplers (26).
Because one of the most sensitive group of patients at risk for air leak as main postoperative complication are patients with emphysema undergoing LVRS, the randomized study by Akil et al. addressed the question if powered staplers may afford any form of clinical benefit. Patients with advanced emphysema were enrolled in a prospective randomized trial and underwent bilateral VATS-LVRS. Each patient was randomized for receiving lung resection with the powered iDriveTM or the mechanical Endo GIA™ stapler device (both manufactured by Medtronic Inc., Minneapolis, MN) on the right lung or left lung. Forty resections were performed with the iDriveTM and 40 with the Endo GIA™. Duration of surgery, air leakage after extubation and on postoperative day 1, as well as length of chest tube therapy, were recorded. The powered system led to comparable results to the conventional mechanical stapler without any disadvantages in patients undergoing bilateral VATS-LVRS (27).
No advantages of the powered staplers over the manual ones were confirmed also in the multicentric study performed by Qiu et al., analysis was carried out on a heterogenous group of lung resections (anatomic and wedge ones). Post-operative data included air leak assessment, chest tube duration, length of hospital stay, and adverse events. Post-operative air leaks were observed in 5 (5.3%) patients undergoing lobectomy, whereas PALs in only 1 (1.1%) patient. The authors concluded that powered staplers make the VATS procedure easier for the surgeon and may achieve intra- and post-operative outcomes comparable to those previously reported using mechanical devices (28).
Another group of patients at risk of postoperative PAL are those with incomplete fissure. The role of new stapler devices in these patients was investigated by Shigeeda et al. Their study evaluated the effectiveness of powered staplers in reducing the need for intraoperative fibrin glue and the incidence of air leakage after radical pulmonary resection. The subjects of this retrospective study were 478 patients who underwent resection for lung cancer. Propensity score analysis generated two matched pairs of 177 patients each treated by using powered or manual staplers, respectively. There was significantly less intraoperative need for fibrin glue in the powered stapler group than in the manual stapler group (47.5% vs. 58.8%; P=0.033). The incidence of PAL was also significantly lower in the powered stapler group than in the manual stapler group (2.8% vs. 10.7%; P=0.003). The authors concluded that the use of a powered stapler to divide an incomplete interlobar fissure decreased the need for additional intraoperative management using fibrin glue and reduced postoperative air leakage in radical pulmonary resection (29).
One of the most unclear questions is whether the higher costs of new powered staplers could be compensated by shortening of postoperative stay. Zervos et al. tried to answer on this question comparing the more expensive robotic staplers (Figure 4) with hand-held staplers. They compared perioperative outcomes and costs between robotic lobectomy cases that utilized robotic staplers versus hand-held staplers in real-world clinical practice with a propensity score matched analysis. In their multivariate regression analysis, robotic stapler was associated with a reduced risk for air leak (OR =0.70; 95% CI: 0.50–0.98) and overall complications (OR =0.76; 95% CI: 0.58–0.99). The total index hospitalization costs were comparable between the two groups (median: $21,667 in the robotic stapler group vs. $21,398 in the hand-held stapler group; P=0.22) (30).
Based on the cited studies is difficult to confirm any advantages of powered staplers regarding PAL. Concerning the cost analysis it is crucial to select patients, who based on preoperative and intraoperative findings are at higher risk for prolonged leakage from the resection surface (31,32); in those cases, the use of powered staplers could be cost effective and could propose some advantages over mechanical (or old generation) staplers.
Funding: None.
Provenance and Peer Review: This article was commissioned by the Guest Editors (Roberto Crisci, Alessandro Brunelli, Florian Augustin, Francesco Zaraca) for the series “Prolonged Air Leak after Lung Surgery: Prediction, Prevention and Management” published in Journal of Thoracic Disease. The article has undergone external peer review.
Peer Review File: Available at https://jtd.amegroups.com/article/view/10./jtd-22-192/prf
Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10./jtd-22-192/coif). The special series “Prolonged Air Leak after Lung Surgery: Prediction, Prevention and Management” was sponsored by Bard Limited. Bard Limited has no interference on the contents of the special series. The authors have no other conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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