Cardiothoracic Centre

Swansea NHS Trust

Thoracic Surgery

Description of Service 2007

Executive Summary 4

Introduction 5

Background to the Swansea Service 6

Health Commission Wales (HCW) Aims and Objectives 7

For thoracic surgical services HCW aims 7

Descriptions of the relevant associated services within Swansea NHS Trust 8

Respiratory medicine 8

Video-Assisted Thoracic Surgery. 8

Endobronchial therapies 8

Cardiac surgery 8

Cardiothoracic anaesthesia and intensive care 9

Radiology 9

Plastic and Reconstructive surgery 9

Ear, Nose and Throat (ENT) surgery 10

Trauma services 10

Oesophageal disease 11

Radiotherapy & Chemotherapy 11

Palliative care 11

All Wales minimum standards 12

Description of the range of thoracic procedures offered by Swansea NHS Trust 13

Description of facilities for thoracic surgery 13

Description of MDT arrangements for lung cancer care in South West Wales 13

Moving towards a Managed Network 14

Activity Data 15

Thoracic Surgical procedures 2006-2007 15

Current activity compared with historical activity 16

Complications following thoracic surgery 16

Average and Median Length of stay 16

Mortality 16

Predicted future demand modelling 18

Assumptions 18

New scanning techniques 18

Theatre/bed capacity in cardiothoracic centre 19

Appointment of a second Consultant Thoracic Surgeon 20

Benefi ts of appointment 20

Conclusions 21

Thoracic Surgery Satisfaction Surveys 22

Glossary 25

Con

tent

s

4

Executive Summary

1. Thoracic surgery based at Morriston Hospital ensures that high quality, best value spe-

cialised treatment is provided close to patients’ homes.

2. Morriston Hospital is geographically placed in the centre of South Wales with travel

times from the west (Haverfordwest) and east (Chepstow) being 80 minutes. This im-

proves equity of access and allows the needs of patients, their families and friends to be

at the forefront of the service.

3. Morriston Hospital has the key components of lung cancer services (i.e.

respiratory physicians, thoracic surgeons, thoracic radiology, thoracic histo-

pathologist, oncology, and palliative care) already established on one site. Patients and

clinical staff are closer to the facilities and the multidisciplinary team.

4. Thoracic surgery and anaesthesia at Morriston Hospital provide support to

Respiratory Physicians in their management of non-malignant chest diseases as well as

procedures uniquely performed at Morriston Hospital such as endo-

bronchial stenting, laser, diathermy and photodynamic therapies.

5. Thoracic surgery provides support to other local and regional specialist services within

the Trust such as trauma, maxillofacial, oesophageal, plastic and ENT surgery and sup-

ports the wider activities of the Swansea Cancer centre (e.g. diagnosis and staging of lym-

phoma)

6. Education and training are important activities of the Trust and the School of Medicine,

Swansea. Thoracic surgery is an important component of undergraduate and postgradu-

ate training. Specialist Registrars in Respiratory medicine are uniquely placed to witness

the management of complex respiratory problems by medical and surgical means.

Morriston Hospital, Swansea

IntroductionThoracic Surgery is a specialty focusing on

the diagnosis and surgical treatment of disorders

of the chest that encompasses a wide range of

procedures pertaining to the chest, but exclud-

ing the heart. It includes surgery to the lung,

mediastinum, chest wall (including reconstruc-

tion) biopsies and excision of lung and pleura for

malignant and non-malignant conditions together

with miscellaneous other non-cardiac procedures.

In the UK, 60% of these surgical procedures are

performed by cardiothoracic surgeons (who also

perform operations on the heart) while 40%

are conducted by standalone thoracic surgeons.

About 50% of the work of a thoracic surgeon

is spent dealing with surgical resections of lung

cancers and other malignant diseases of the chest.

South Wales has a legacy of heavy industry and

coal mining, both of which contribute signifi cantly

to lung disease. Lung cancer is the commonest

cause of cancer death in

Wales. Tobacco smoking

has been shown to ac-

count for about 80-90%

of all cases in men and

50-80% in women. The

median overall survival

in the UK is between 4

and 6 months with an

overall 5-year survival

of <10%. The 5-year

survival in those under-

going curative resection

is 35-60% depending

on the histological type and stage of tumour. The

population of Wales has a poor survival rate for

lung cancer compared to the UK, the rest of

Europe and the USA. Surgery is the only known

cure for lung cancer, suggesting that there is a low

curative resection rate for lung cancer in Wales.

Delays in diagnosis, staging and access to surgical

resection may all contribute to this poor outcome.

Thoracic surgeons also treat non-malignant condi-

tions that are referred by respiratory physicians

such as complications of pneumonia, treatment

of air leaks from the lungs into the chest cavity,

drainage of fl uid from the lung cavities, biopsy of

infl ammed lung tissue, surgical repair of benign

narrowing of the windpipe and interruption of

specifi c nerves for severe sweating. Thoracic

surgeons also treat non-malignant tumours of the

lungs and chest wall. In addition, congenital chest

wall abnormalities are very common in the United

Kingdom. Pectus excavatum affects 1 in 500 of

the population (i.e. in South Wales alone there are

4600 cases). Many of these require surgical cor-

rection for symptomatic or psychological reasons.

Morriston Hospital in Swansea is the largest of the

acute hospitals in South West Wales and houses

many regional and specialised tertiary

services. Morriston Hospital is located

just over 1 mile from junction 46 of the

M4 motorway and is thus very acces-

sible being positioned in the middle of

South Wales and having travel times of

only 80 minutes to Haverfordwest in

the west and Chepstow in the east.

5

Background to the Swansea Service

During the commissioning of the Cardiac Centre

in the mid 1990s, the chest physicians in South

West Wales, through the Local Health Authori-

ties, approached the then Morriston Hospital

NHS Trust seeking the development of a thoracic

surgical service within the new Cardiac Centre.

Following a survey in 1996 to establish the need

for the services that was conducted by Dr Kim

Harrison and the Trust management, the Trust

agreed with the Health Authorities to provide

the service on a cost-per-case basis until proper

facilities for thoracic surgery were established.

In June 1997, Dr Gill Todd (Chief Executive of Bro

Taf Health Authority, representing all 3 Health

Authorities in South Wales) set up and chaired

the thoracic strategy group for South Wales (fi rst

review). This group had representatives from

all stakeholders of the services including two

external advisors from the Society of Cardiot-

horacic Surgeons of Great Britain and Ireland,

namely Professor Tom Treasure and Mr John

Dark. This group advised and concluded that the

service should be provided both in Cardiff and

in Swansea and that Thoracic Surgery at Lland-

ough Hospital should be moved to the University

Hospital of Wales within the Cardiac Centre.

The cardiothoracic surgeons began to offer tho-

racic surgery on a “case-by-case” basis thereafter.

Over subsequent years, as the volume of work

increased, it was clear that cardiac surgical capac-

ity was being compromised as a consequence of

thoracic surgical activity. Furthermore, lack of

resources made it diffi cult to meet All Wales

Minimum Standards for timely lung cancer

resection. Therefore, a decision was made

to suspend the service temporarily (despite

the demand) until it was resourced appropri-

ately with provision of dedicated facilities.

A second review of thoracic surgical services was

commissioned in 2002 but the report was not

published. After the input of dedicated funds by

Health Commission Wales, the thoracic surgical

service recommenced in March 2004. Additional

beds were ring-fenced on Morriston Hospital’s

ward S and theatre space and high dependency

beds arising out of the phase I (cardiac surgi-

cal) upsizing of the Cardiac Centre were al-

located to the service. Three of the in-house

cardiothoracic surgeons provided additional

sessions to cover the Thoracic Surgical activity.

In July 2005, the Thoracic beds were relocated

from Ward S into the main Cardiac Centre as

a result of space vacated by the move of the

cardiology day-case unit in the Cardiac Centre

(Phase II of upsizing). Nursing care is now de-

livered by cardiothoracic nursing staff based on

Cyril Evans ward leading to economies of scale.

6

Health Commission Wales (HCW)

Aims and Objectives

The HCW website states:

The primary objective of Health Commis-

sion Wales (Specialist Services) is to en-

sure that Wales derives the maximum pos-

sible benefi t from the Specialist Services

Commissioning and, in particular to:

1) Secure an appropriate range

of high quality, best value

specialised services for the

people of Wales within an

agreed budget

2) Place the needs of patients,

their families and friends and

the public at the forefront of

HCW(SS) business

3) Develop effective partner-

ships with all key stakehold-

ers

4) Ensure effective com-

missioning processes are

consistent with NHSWD

targets, priorities and objec-

tives and with LHB commis-

sioning

5) Ensure equity of access

6) Ensure the customer focus

of operational

processes

For thoracic surgical services HCW aims

“To provide an integrated, audited, safe, high

quality, sustainable thoracic surgery serv-

ice to the residents of South Wales that:

• Meets relevant national and

international standards;

• Has the potential and fl exibil-

ity to meet all the present and

future needs (including currently

unmet needs) and requirements;

• Is provided by skilled, account-

able professionals (working in

MDTs) as close to the patient’s

home as possible.

• Is adequately resourced”.

7

Descriptions of the relevant associated services within Swansea NHS Trust

Respiratory medicine

The Department of Respiratory Medicine pro-

vides clinical services at Morriston and Singleton

Hospitals. There are 2 consultant physicians based

at Morriston Hospital (Dr Kim Harrison and Dr

Emrys Evans) and 3 based at Singleton Hospi-

tal (Dr Phil Ebden, Dr Stuart Packham and Prof.

Julian Hopkin). They diagnose and treat common

conditions such as lung cancer, asthma, bronchitis,

emphysema and pneumonia as well as less com-

mon conditions such as tuberculosis, occupational

lung diseases and sleep disordered breathing. The

Respiratory Physicians co-ordinate the multidisci-

plinary team for treating patients with lung cancer.

Diffuse parenchymal lung disease (DPLD) is one

of several disease groups that the Welsh Assembly

Government has identifi ed as requiring guidelines

for management through the Respiratory Imple-

mentation Group. It recommended that patients

with DPLDs should have access to Regional

Centres where diffi cult cases can be discussed and

the requirement for surgical lung biopsy consid-

ered (as demonstrated by a survey conducted

by Dr Kim Harrison in 2002). This is likely to

increase the number of surgical biopsies that are

undertaken in Wales by approximately two-fold.

Video-Assisted Thoracic Surgery.

Video-assisted tho-

racic surgery (VATS)

is a minimally invasive

technique that has

been used routinely

by the cardiotho-

racic unit since it

opened in 1997. It is used for the treatment

of pneumothorax, pleural procedures includ-

ing pleurodesis and surgical lung biopsies. VATS

reduces morbidity (especially pain) and thus

length of hospital stay leading to cost-effi ciencies.

Endobronchial therapies

Morriston Hospital is the only centre in Wales

to provide an extensive range of therapies

such as endobronchial stenting, laser, dia-

thermy and photodynamic treatment. These

are undertaken by the Respiratory Physicians

at Morriston through on-site support of the

cardiothoracic surgeons and anaesthetists.

Cardiac surgery

Cardiac Surgery is based in the Cardiac Centre

at Morriston Hospital. There are 2 dedicated

cardiothoracic theatres, 8 Intensive care beds, 8

High Dependency beds and 20 ward beds. The

unit undertakes all types of adult cardiac surgery

including major surgery on the thoracic aorta but

does not undertake complex congenital heart

disease or transplant surgery. Annual activity

is 750 – 800 cardiac surgical procedures. The

Cardiac Centre has some of the best outcomes

in the UK for fi rst-time coronary artery by-pass

surgery and aortic valve surgery over many years

(http://heartsurgery.healthcarecommission.org.uk).

All 5 consultant cardiothoracic surgeons in the

unit are fully trained in both cardiac and thoracic

surgery. All nursing and support staff are trained

to manage thoracic surgical patients. The presence

of thoracic surgery on-site has undoubtedly helped

recruitment and retention of staff within the unit.

8

Cardiothoracic anaesthesia and intensive care

There are 5 Consultant Cardiothoracic Anaes-

thetists in the Cardiac Centre who provide

theatre sessions and cover for the 8-bed-

ded Cardiothoracic Intensive Care unit.

Additional appointments are currently being made.

The existing consultant cardiothoracic

anaesthetists are fully trained in cardiac

and thoracic anaesthesia. Many see the

attraction of the post in the unit as the mix

of both cardiac and thoracic surgery.

In April 2007, the Car-

diac Intensive Care Unit

was re-accredited as a

Practice Development

Unit following review by the University of

Leeds. The reviewers met with a number of

patients and made the following comments:

“Patients on the unit spoke movingly and

powerfully of the effect that the team had

had upon their lives, and others were patient

representatives from the wider Trust who

clearly enjoyed working with the team.”

“The range of presentations demonstrated

clearly the multi-disciplinary nature of the

practice development unit and how effectively

the various disciplines worked together.”

All the presentations had patients, their experi-

ences and their outcomes as crucial components.”

“This is absolutely not a team that pays lip serv-

ice to the notion of patient centredness.”

“We were also pleased to hear of the

close and collaborative relationships

that the team have developed with col-

leagues in the University of Swansea.”

Radiology

The Department of

Radiology houses a wide

range of imaging facili-

ties including spiral multi-array X-ray computed

tomography (CT), Magnetic Resonance Imaging,

ultrasound, Digital Subtraction angiography and

gamma camera imaging. Dr David Roberts, Dr

Liam McKnight and Dr Derrian Markham provide

on-site expertise in chest radiology. Following

an agreed investigation and treatment strategy at

the MDT meeting, they undertake endoscopic-,

CT- and ultrasound-guided fi ne needle aspira-

tions and biopsies on behalf of the team. The

Respiratory Physicians also undertake diagnostic

trans-bronchial needle aspiration based on CT

imaging. . In addition, a new 3 Tesla MRI scanner is

currently being commissioned at Singleton Hospi-

tal to increase imaging capacity within the Trust.

Plastic and Recon-

structive surgery

The Welsh Centre

for Burns and Plastic Surgery was transferred

from St. Lawrence Hospital Chepstow to Mor-

riston in 1994 in order to be at the centre of

the South Wales catchment area and to benefi t

from the presence of other services in Swansea.

Plastic surgeons are able to carry out complex

reconstructions of the chest wall for trauma and

malignant disease (e.g. invasive breast cancers, soft

tissue sarcomata) in combination with thoracic

surgery colleagues. The burns centre is expected

to be awarded Su-

pra-Regional Burns

Centre Status in the

near future and is

ranked top against

the UK standards

for burns care. One

9

component of these standards was the pres-

ence of other trauma services on site. The Welsh

service can confi dently receive burn patients

with any type of associated trauma including

thoracic injury in the knowledge that all ap-

propriate specialists are available in the Trust.

Ear, Nose and Throat (ENT) surgery

ENT surgery is based in Swansea. The tho-

racic surgeons and ENT surgeons occasion-

ally undertake joint operations for example

because a surgical resection of the larynx re-

quires mobilisation of the bronchial tree or

if a tracheal lesion such as a stricture or tu-

mour extends from the chest into the neck.

Trauma services

Morriston Hospital has emerged as the Trauma

Centre for South West Wales. Previously, a small

number of patients with severe chest injuries

would have been transferred to Cardiff for surgical

intervention. Clearly it is undesirable for patients

with major injuries who may be critically ill to be

moved when all facilities and expertise are on site.

In addition, they would

potentially be moved

away from on-site

expertise in burns,

plastic and recon-

structive surgery and

maxillofacial surgery.

Lack of emergency thoracic input in specifi c cases

would inevitably put patients at increased risk.

There are approximately 40 cases of signifi cant

thoracic trauma per year admitted to Morriston

Hospital. About 4 to 6 patients require emergency

thoracotomy, but the remainder require thoracic

surgical consultation for advice requiring the man-

agement of their injuries, the placement, manage-

ment and removal of intercostal chest drains.

Clinical outcomes following trauma are collected

by the national Trauma and Research Network

(TARN) database. Details for Wales can be found

at https://www.tarn.ac.uk/Content.aspx?c=587

The fi gures released in August 2007 showed

that Morriston Hospital has the highest number

of trauma admissions in Wales. It was the only

hospital in Wales where data on all injured pa-

tients between January 2004 and December 2005

admitted to the Trust were submitted to the

database. Trauma to the chest is one important

component of these statistics. The Royal College

of Surgeons and British Orthopaedic Association

state in their guidelines on standards of care 13.3:

“Examination of the chest is a fundamental com-

ponent of the cardiopulmonary assessment of the

seriously injured and should be supervised by the

most experienced clinician”. The TARN statistics

therefore identify the number of chest injuries

and the proportion assessed by consultants.

The fi gures reveal that survival rates in Swan-

sea are 2.1 per cent higher than expected, plac-

ing Morriston in the top 15 UK hospitals that

took part in the research. Between 2003/4 and

2005/06, Morriston admitted 943 trauma pa-

tients. According to TARN, 847 of these patients

were expected to survive, but in fact, the fi gure

was higher, at 869. Of the patients admitted with

chest injuries, 49% were assessed by consultants

(compared with the national average of 43%).

10

The table below demonstrates the comparative

data for comparable centres closest to Wales.

Morriston

Hospital,

Swansea

University

Hospital

of Wales,

Cardiff

Bristol Royal

Infi rmary and

Frenchay

Royal

Devon and

Exeter

Hospital

University

Hospital,

Birmingham

Wythenshawe

Hospital,

Manchester

Manchester

Royal Infi rmary

The Royal Liverpool

University Hospital

Additional

survivors (per

100 treated)

+2.1 0.0 No data -0.6 +0.6 -2.2 No data -1.6

Number of

chest injuries

140 110 No data 133 23 81 No data 88

Number seen

by consultant

49% 25% No data 66% 26% 43% No data 28%

Oesophageal disease

Oesophageal surgery is performed at Morris-

ton Hospital by general surgeons with a specifi c

expertise. Some surgery is performed with the

input of thoracic surgeons (e.g. trachea and

bronchus injury, empyema) and has been per-

formed collaboratively since the opening of the

Cardiac Centre in 1997. The thoracic surgeons

also provide support for general surgeons when

their patients develop pulmonary complications.

Radiotherapy & Chemotherapy

The Swansea Cancer Centre is based at Single-

ton Hospital, Swansea and has the benefi t of a

newly appointed chair of Clinical Oncology (Prof.

Taylor). Radiotherapy is offered at the Regional

Cancer Centre based at Singleton Hospital, which

has recently benefi tted from an additional linear

accelerator to improve treatment access times. A

new CT simulator is expected to be operational

during this fi nancial year and the Trust has re-

cently appointed an additional Consultant Clinical

Oncologist to support lung cancer treatment.

Improved chemotherapy regimes that successfully

downsize lung tumours will increase the number

of resectable cases. In addition, chemotherapy

for mesothelioma (which will increase in inci-

dence over the next 10-15 years) will render such

tumours more amenable to surgical resection and

modern chemothera-

pies for other malig-

nancies (e.g. bowel,

malignant melanoma)

will increase the

number of resections

required for “solitary”

11

lung secondaries. These factors will increase the

need for thoracic surgery in the future. The Trust

provides clinical leadership for sarcoma in South

Wales and the sarcoma MDT works closely with

the thoracic surgery team to ensure that biopsy

or metastatectomy is offered where appropriate.

Palliative care

The hospital and commu-

nity palliative care teams are

based in Ty Olwen, within the

grounds of Morriston Hospital.

Medical or nursing members of

the team attend the MDT meet-

ings at Morriston Hospital.

Core membership of the lung cancer MDT in-

cludes a consultant in

palliative medicine who

sees patients as neces-

sary in the multi-profes-

sional lung cancer clinic.

Communication with Primary Care teams

General Practitioners generally refer patients very

promptly when there is a suspicion of lung cancer.

The outcomes of the MDT meetings are com-

municated back by fax to the GP within 24 hours.

All Wales minimum standards

Swansea NHS Trust audits its lung cancer

service annually against the “Lung Cancer Mini-

mum standards”. During 2006/7, there were 46

MDT meetings that were well attended by vari-

ous members of the MDT. At these meetings,

240 patients with a diagnosis of lung cancer were

discussed. The lung cancer clinical nurse specialist

saw 214 of these patients. All general practition-

ers were notifi ed of a diagnosis of lung cancer

(when made) within 24 hours following a patient’s

attendance at Morriston Hospital. Generally,

each patient was provided copies of in-house and

externally produced publications together with

information on self-help and support groups.

The Swansea MDT Team

The Duchess of

Gloucester visiting Ty

Olwen

12

Description of the range of thoracic

procedures offered by

Swansea NHS Trust

A wide range of invasive and minimally

invasive thoracic surgical procedures are pro-

vided at Morriston Hospital. A glossary of

these procedures is provided in Appendix 2.

• Bronchoscopy (rigid or fl exible)

• Mediastinoscopy, mediastinotomy and resection

of mediastinal tumours (neurogenic tumours,

bronchogenic cysts, tumours of the thymus)

• VATS (Video-assisted thoracoscopic surgery)

• Lung or pleural biopsy

• Lung resection (segmentectomy, lobec-

tomy. sleeve resection, pneumonectomy)

• Chest wall resection and reconstruction

• Correction of congenital abnormalities of

the sternum (e.g. pectus excavatum)

• Metastatectomy

• Pleurodesis, pleurectomy and decortication

• Repair of diaphragmatic hernia

• Tracheal surgery and reconstruction

• Surgery for mesothelioma

• Pacing of the diaphragm

• Cervical sympathectomies for hyperhidrosis

Description of facilities for thoracic surgery

There are 5 full-time Consultant Cardiothoracic

Surgeons based in the Cardiac Centre. Mr Mah-

mood Ashour took up his post as locum Con-

sultant Thoracic Surgeon at Morriston Hospital

in January 2006. He has 3 theatre sessions per

week and 5 in-patient beds dedicated to thoracic

patients in addition to the other beds on Cyril

Evans ward that can be used fl exibly. He is sup-

ported by Mr A Youhana who covers his annual

and study leave utilising a combined waiting list.

There are out-patient facilities within the Cardiac

Centre and weekly lung cancer MDT meetings

in Morriston Hospital, West Wales General Hos-

pital and Prince Phillip Hospitals in Carmarthen-

shire. The Cardiac Centre has purchased modern

telemedicine facilities making the clinicians more

accessible to neighbouring hospitals within the

network. Telemedicine conferences are held

fortnightly with Bronglais Hospital in Aberyst-

wyth, weekly with West Wales General Hospital

and Prince Phillip Hospital in Carmarthenshire

and weekly with Singleton Hospital in Swansea.

There is a full range of support services on-

site that includes a respiratory unit led by 2

consultant chest physicians, complemented

by consultant radiologists, histopatholo-

gists and full lung function testing facilities.

Description of MDT arrangements for

lung cancer care in South West Wales

The weekly Lung Cancer MDT and multi-profes-

sional Lung Cancer Clinic are at the forefront of

modern clinical practice and were acknowledged

to be excellent by Dr Martin Muir and Professor

John Dark when they visited Morriston Hospital

in February 2004. The

clinic is attended by

consultant respiratory

physicians, consult-

ant radiologists, a

consultant oncologist,

a consultant cardi-

13

Mr Aprim YouhanaTelemedicine facilities

othoracic surgeon and a palliative care doctor

or nurse. The Clinic is increasingly active as a

Centre for the West Wales Network. The physi-

cal presence of a Consultant Thoracic Surgeon

is of fundamental importance to its function.

The developing South West Wales Lung

Cancer Network is the most advanced and sophis-

ticated of the site-specifi c groups in South West

Wales. Local protocols have been adapted from

the NICE guidance for diagnosis and treatment

and include key roles for thoracic surgery. It has

been accepted by all clinicians in West Wales and

provides equity of access for patients.

This network is now in a strong

position to work with other net-

works in Wales to disseminate best

practice and further improve equity.

Moving towards a

Managed Network

The “Option Appraisal” of 2004

proposed a ”Managed Network” as

one possible solution to the uncer-

tainties regarding the development of

Thoracic Surgical Services in South

Wales. The Thoracic Surgical Service

at Morriston could sit comfortably

within such a network by provid-

ing local services for the population

of West Wales. This is in keeping

with the Welsh Assembly Govern-

ment’s policy of providing healthcare

as close to the patient’s home as

possible. It also allows the Chest Physicians of

West Wales greater access to, and interaction

with, Consultant Thoracic Surgeons on a personal

level. Such access invariably generates greater

options for investigation and treatment of both

malignant and non-malignant thoracic disease.

The isochrone below indicates that Swansea

is strategically placed in the centre of South

Wales such that over two thirds of the popu-

lation of Wales are within 90 minutes of the

Thoracic Unit at Morriston Hospital.

14

Activity Data

Thoracic Surgical procedures 2006-2007

Summary by operation type

Pneumonectomy 14

Lobectomy 37

Bullectomy 15

Repair Of Diaphragmatic Hernia 1

Open Lung Biopsy 13

Pericardectomy 1

Open Pleurectomy 2

Thymectomy 3

Metastatectomy 4

Open Decortication 6

Bronchoscopy 57

Pericardial Biopsy 1

Mediastinal Mass/tumour 9

Thoracotomy 2

Open Pleural Biopsy 14

Mediastinoscopy 12

Repair Of Pectus (Pectoral Flaps) 3

Repair Of Diaphragm & Chest Wall 1

Partial Resection Of Lung 2

Mediastinal Lymphalectomy 2

Mediastinotomy 3

Vats Biopsy & Pleurodesis 2

Vats Lung Biopsy 1

Vats Pleural Biopsy 7

Debridement Of Wound 1

213

Summary By OPCS code

Opcs Code Complex/extra Major/major/

intermediate/minor

Number

E54.1 Complex 14

E54.3 Complex 37

E57.2 Complex 15

E59 Complex 13

E55.1 Complex 6

E54.4 Complex 4

E54.5 Complex 2

K67.1 Complex 1

G23.2 Extra Major 1

B18.1 Extra Major 3

T09.2 Extra Major 14

T07.2 Extra Major 2

T02.1 Extra Major 3

G23.2 Extra Major 1

T03.9 Major 2

E61.4 Major 3

E61.1 Major 9

T85.3 Major 2

K71.1 Major 1

133

E51.1 Intermediate 57

T11.9 Intermediate 2

T11.9 Intermediate 7

T11.2 Intermediate 1

E63.1 Intermediate 12

S57.1 Intermediate 1

80

Total 213

15

Current activity compared with historical activity

Data are presented for the fi nancial years 1998 to 2001 and 2004-7 following resumption of

the thoracic surgical service at Morriston Hospital. The data include all complex, major and in-

termediate cases. Minor procedures (averaging about 50 per year) are not included.

Procedures 1998-1999 1999-2000 2000-2001 2004-2005 2005-2006 2006-2007

Major and intermediate

(non-VATS)

50 110 119 167 114 203

VATS 18 19 25 31 26 10

TOTAL 68 129 144 198 140 213

Thoracic Surgery New

Outpatient Referrals by

LHB - 2006/2007

16

Complications following thoracic surgery

Cardiovascular = 3 (1 post-op MI,

2 re-operation for bleeding)

Pulmonary = 8 (2 collapse/pneumotho-

rax, 1 pneumothorax, 5 “other”)

Renal = 2 (1 H/F dialysis, 1 “other”)

Infective = 3 ( 1 Broncho pleural fi s-

tula, 1 wound infection,1 “other”)

Neurological = 2 (confusion, peripheral nerve injury)

Post op arrhythmias = 9 (all AF/Atrial fl utter/SVT)

Gastrointestinal = 1 (1 “other”)

Average Median

Lung Cancer 10.9 8

Mediastinoscopies 1.5 1

VATS 7.2 5

Bronchoscopies Day case Day case

Mortality

Over the last 5 fi nancial years (2002-2007) there has

been only one death complicating a lung resection

(pneumonectomy) which was caused by an embolus

to the abdomen and leg. This equates to a mortal-

ity rate of ‹1%. The national average for mortality

after lobectomy is 2.6% and pneumonectomy 5-7%,

suggesting excellent early outcomes for patients.

BRIDGENDCARMARTHENSHIRECEREDIGIONGWYNEDDMONMOUTHSHIRENEATH/PORT TALBOTNEWPORTOATSPEMBROKESHIREPOWYSRHONDDA, CYNON TAFFSWANSEATHE VALE OF GLAMORGANTORFAEN

Average and median lengths of stay

During 2006-2007, three patients died dur-

ing their index hospital admission.

One died in the Palliative care unit (Ty Ol-

wen) from metastatic squamous cell car-

cinoma of the lung that had been diag-

nosed following surgical biopsy.

A second died following salvage surgery

for mesothelioma of the pericardium.

A third patient died on the general in-

tensive unit. This patient had under-

gone surgery of her chest (closure of

multiple diaphragmatic perforations) as part of

the treatment of a chyloperitoneum complicat-

ing a laparotomy for intra-peritoneal bleeding.

It is reasonable to conclude that non of these

deaths was related directly to thoracic surgery.

Although the Cardiothoracic Centre at Morriston

Hospital is a relatively new unit, more than 150

lobectomies have been performed. Our results are

consistent with an article published by Treasure

et al (BMJ 2003 327: 73) relating to outcomes

following lobectomy in the UK. Patients who

were operated on by one group of 49 surgeons

with an annual volume of one to 15 lobectomies,

compared well with patients who were operated

on by another group of just six surgeons doing 47

to 96 lobectomies a year. Across the groups of

surgeon activity, the mortality varied from 2.0%

to 2.9%, with no evidence of relation to volume.

17The Cardiac Centre Morriston Hospital

Predicted future demand modelling

Assumptions

Assuming that current estimates for the inci-

dence of lung cancer in Wales is approximately

2000 per annum and aiming for a resection rate

of 15%, there should be 1700 lung cancer cases

in South Wales and therefore 250-300 resec-

tions per annum for lung cancer alone. In addi-

tion, there will be a requirement for other major

thoracic surgical procedures such as resection

of mediastinal, chest wall and tracheal tumours

together with decortication for empyema.

The most reliable fi gures for the incidence of

cancer in South West Wales relates to breast

cancer. There are approximately 650 new cases

per annum. The incidence of breast cancer in

the UK is 40,000 per annum and broadly similar

to that of lung cancer (38,000 per annum). As-

suming the network coverage has an incidence

similar to the UK, it is estimated that the South

Wales Lung Cancer Network should be diagnos-

ing and treating approximately 600 cases per

annum by curative resection. Again a resection

rate of 15% would suggest 110-130 cases per an-

num for West Wales alone.

New scanning techniques

Tumour type and disease staging determine

whether surgical resection is feasible. The most

accurate predictor of long-term survival in early

lung cancer is the disease stage and those tu-

mours that are more peripherally placed are

easier to remove than those placed centrally

Positron Emission Tomography (PET)

Fluorodeoxyglucose (FDG) - PET scanning is a

sensitive method to distinguish spread of malignant

cells to lymph nodes from those where enlarged

lymph nodes are reactive rather than infi ltrated

by tumour. Its use helps to guide physicians and

surgeons in the selection of patients suitable or

unsuitable for curative resection. For example,

it should reduce the number of cases of thoracic

surgery that are abandoned due to previously

undetected lymph node involvement but increase

resection rates in those who may otherwise be

turned down because of apparent lymph node in-

volvement that represented reactive changes only.

Magnetic Resonance Imaging (MRI)

MRI (as opposed to X-ray computed tomography)

further refi nes the identifi cation

of resectable thoracic tumours

particularly with chest wall and

mediastinal invasion. Imaging is

immediately available to physi-

cians and surgeons on site.

18Contrast MRI

19

Theatre/bed capacity in

cardiothoracic centre

The Cardiothoracic Unit has adopted modern

practices to deliver high levels of cardiology and

cardiothoracic surgical activity through the unit.

The unit has only 62 beds of which 8 are coronary

care beds, 8 are intensive care beds and 8 are high-

dependency beds. The fl exible use of these beds

has enabled the Centre to perform approximately

2100 coronary angiograms, 1000 angioplasties, 350

permanent pacemaker implantations and 750 car-

diac surgical operations and more than 200 tho-

racic surgical procedures annually. The addition of

5 new beds (located in the former cardiology

day case) to the surgical ward will enable the

thoracic activity to increase signifi cantly with-

out any need for further capital investment.

Appointment of a second Consultant Thoracic Surgeon

Benefi ts of appointment

Service benefi ts

Historically, thoracic surgery has been undertaken

by consultants with dual training in cardiac and

thoracic surgery. With the development of an

NSF for coronary artery disease, the adoption

of the European Working Time Directive and the

new amended Consultant Contract in Wales, it is

diffi cult for cardiothoracic consultants to commit

energies to both disciplines. In addition, the need

to achieve access targets for cardiac surgery has

meant that patients requiring thoracic surgery

have been “competing” for similar resources.

The appointment of a dedicated thoracic surgeon

has enabled the service to be placed on a proper

foundation. Mr Ashour has been able to focus

his energies to the delivery and expansion of an

already existing high quality service for the resi-

dents in South West Wales. There is a dedicated

out-patient clinic and 4 MDT meetings each week

(in Swansea and Carmarthen) and the accessibility

of a standalone thoracic surgeon locally provides

support to the Respiratory Physicians and other

clinicians in the network. Mr Ashour has raised

awareness of thoracic services (e.g. lung resection

for cancer) to primary and secondary care beyond

their current levels. However, Mr Ashour has the

benefi t of working in a Specialist Cardiothoracic

Centre with high quality facilities and receives sup-

port from cardiac sur-

gical colleagues who

are trained in thoracic

surgery (e.g. for peri-

ods of annual leave and

for the on-call rota).

The incidence of lung cancer in South West Wales

combined with the challenging access targets

for cancer treatment (maximum of 62 days from

referral with suspected cancer to defi nitive treat-

ment) means that it is not possible for a single

thoracic surgeon to fulfi l the surgical demands

for lung cancer treatment. To consolidate the

service, the Trust is planning to appoint a further

substantive thoracic surgeon. This will ensure

continuity of the service as also provide an en-

hanced infrastructure for teaching and training.

Teaching and Training

Specialist Registrars in Cardiothoracic Surgery

have regular academic teaching and practical train-

ing (in theatre) in all aspects of Thoracic Surgery.

The consultants have a keen desire to teach and

a strong track record in doing so. There is a

monthly training day for Morriston, UHW and

Bristol SpRs. The appointment of a dedicated

thoracic surgical consultant has enhanced training

opportunities within the Trust. Morriston Hospital

is the only hospital in Wales where SpRs in Tho-

racic Medicine have the opportunity to observe

surgical procedures on site. Undergraduates

based at the School of Medicine, Swansea have the

opportunity to follow from diagnosis to treat-

ment in cases such as empyema and lung cancer.

20Mr Ashour, Consultant Thoracic Surgeon

ConclusionsDespite 10 years of uncertainty, the enthusiasm

and drive to develop Thoracic Surgery at Mor-

riston Hospital continues unabated. For patients

with lung cancer, resection rates have increased

signifi cantly (from 5% to 15%) since the appoint-

ment of a dedicated thoracic surgeon. The

provision of locally-based thoracic surgical services

within a Managed Network is the best way to pro-

vide the appropriate quality of care that the popu-

lation of South Wales should expect to receive.

Swansea NHS Trust continues to view Thoracic

Surgery as an important component of the port-

folio of services that it offers to the population

of Swansea and South West Wales. Patients from

West Wales have historically had poor access to

thoracic surgical services in Llandough Hospital

and Bristol and the geographic distance to these

centres makes it diffi culty for them to receive

support from their friends and families when they

need it most. Much of the patient’s care is deliv-

ered at primary and secondary care level and an

integrated approach to the management of the

patient pathway is required. Thoracic surgery

complements other key services offered by the

Trust such as the Trauma Centre, plastic surgery

for major chest wall resection and reconstruction,

oesophageal and maxillofacial surgery (and visit-

ing ENT surgery) for Tracheal surgery. Previous

surveys of chest physicians have highlighted that

the “existing level of provision of thoracic surgery”

in South Wales “did not meet their requirements”

and they “would be prepared to refer thoracic

cases to Morriston Hospital”. The Royal Col-

lege of Surgeons state that cardiac and thoracic

surgery should be provided on the same site.

There is overwhelming support for contin-

ued and enhanced Thoracic Surgical Services

from the South West Wales Lung Cancer Net-

work, all Chest Physicians and Cardiotho-

racic Surgeons in South West Wales as well

as the local population and media.

21Lung Function Suite Morriston Hospital

Thoracic Surgery Satisfaction SurveysDuring the spring of 2007, the Thoracic Surgical Department arranged for a survey of the users of the tho-

racic surgical service to be undertaken. Paper questionnaires were sent to the last 30 patients who had

used the service as well as 12 consultants who referred patients to the thoracic surgical service. 25 and

11 anonymous replies were received respectively. The responses are detailed on the next two pages.

In summary;

Of the patients who have used the service, 96% rated their overall experi-

ence of the thoracic surgical service at Swansea as being excellent or good.

Of the consultants who have used the service, 90% rated the overall treat-

ment that their patients received as being excellent or good.

22

23

Q1 Are you?

Male …………………………………..… 80.0% Female …………………………………..20.0%

Q8 Were you given a likely date for your operation at the consultation?

Yes ………………………………….88.0% No ……………………………....…..12.0%

Q2 What age bracket are you in? 18-30 years ……………………….……....4.0% 31-50 years …………………….…….….20.0%

51-70 years ……………………….……..48.0% Over 71 years …………………….……..28.0%

Q3 Who referred you to the Thoracic Surgery Unit in Swansea?

Your hospital consultant……………….96.0% Your GP ………………………………….0.0% Other …………………………………….4.0%

Q9 How would you describe the care provided by: Excellent Good Fair Poor Thoracic Surgical 88.0% 12.0% 0.0% 0.0% Consultant

Medical Staff 80.0% 16.0% 0.0% 0.0%

Nurses 80.0% 20.0% 0.0% 0.0%

Physiotherapist 48.0% 28.0% 4.0% 4.0%

Other 48.0% 12.0% 0.0% 4.0%

Q4 How long did you wait before being seen in the Thoracic Surgical Clinic at Swansea?

I was seen within 1-2 weeks ……..……..12.0% I was seen within 2-3 weeks ………..…..60.0% I waited over 4 weeks ……………….…..28.0%

Q5 Were you given any written information before or during your consultation at the Thoracic Surgical Clinic ?

Yes ………………………………….52.0% No ……………………………....…..44.0%

Q6 Did you have the opportunity to ask questions Before or during your consultation at the Thoracic Surgical Clinic?

Yes ………………………………….92.0% No ……………………………....…..4.0%

Q10 How would you rate the follow up and after care you Received from the Thoracic Surgical Service in Swansea?

Excellent…………………………….……………..60.0%

Good ………………………………….……………36.0% Fair ………………………………….………………0.0%

Poor …………………………….…………………..4.0%

Q11 Overall, how would you rate the experience at the Thoracic Surgical Service at Swansea?

Excellent…………………………….……………..60.0%

Good ………………………………….……………36.0% Fair ………………………………….………………4.0%

Poor …………………………….…………………..0.0%

Q7 What was your first impression of the Thoracic Surgical Service provided in Swansea?

Excellent……………………..……..76.0% Good ………………………….……20.00% Fair …………………………….…….4.0% Poor …………………………….…...0.0%

Q12 Do you have any suggestions or other comments to Improve the Thoracic Surgical Service at Swansea?

Yes ………………………………….24.0% No ……………………………....…..76.0%

Free text comments to Q12 “Do you have any suggestions or other comments to improve the Thoracic Surgical Service at Swansea?” “Quality of food after operation could be improved” “More Nurses” “Post operative care excellent in HDU” “Low staffing levels on ward” “Lack of toilet facilities and proper functioning showers” “Expression of thanks to Staff” “More written information” “Follow-up treatment could be improved”

Patients who have used the service

Referrers to the Swansea Thoracic Surgical Service

About you Q4 How would you rate the overall treatment your patient received?

Q1 Are you?

Referring Consultant…………………….… 100.0% G.P. ………………………………………..…0.0% Other ……………………………………..…...0.0%

0.0%

Excellent …………………….80.0% Good …………………………10.0% Fair …………………………..10.0% Poor ……………………………0.0%

Q2 Why did you refer the patient to the Swansea Thoracic Surgical Service? (tick all that apply)

Professional recommendation ……….…60.0% Good reputation ………………………….80.0% Nearest referral centre ………..………100.0%

Satisfied with previous service ……...…70.0%

Good quality care …………………..……70.0%

Good communication ………………...….70.0%

Good patient outcomes ………………….70.0%

Good patient satisfaction …………….….60.0%

Other (please state) …………………..…20.0%

Q5 Did you receive timely information following your patient’s discharge from hospital?

Yes ……………………………..80.0%

No. …………………………..…20.0%

Q6 When you received this information would you categorise it as?

Excellent ………………………...80.0% Good ……………………………..20.0% Fair …………………………………0.0% Poor ………………………………..0.0%

Q3 How did you find the response to your referral in the Swansea Thoracic Surgical Service?

Excellent …………………………………….80.0% Good …………………………………………10.0% Fair ……………………………………… …10.0% Poor ……………………………………… ….0.0%

Q7 Do you have any suggestions to improve the service?

Yes ………………………………..70.0%

No………………………………….30.0%

BRIEF OVERVIEW OF SURVEY COMMENTS FROM REFERS TO THE SERVICE Free text comments to Q7 “Do you have any suggestions to improve the Service?” “Mr Ashour requires support to cover leave” “Patients should be able to see the Surgeon more quickly” “More operating time required” “Service excellent” “Increase number of Surgeons” “Increase number of theatre sessions”

GlossaryBronchoscopy

Rigid bronchoscopy: A rigid bronchoscope is a

straight, hollow, metal tube. Rigid bronchos-

copy is performed less often now that fl ex-

ible bronchoscopy is routinely available, but it

remains the procedure of choice for removing

foreign material and for several other treat-

ments. Rigid bronchoscopy also becomes useful

when bleeding interferes with seeing the area.

Flexible bronchoscopy: A fl exible bronchoscope

is a long thin tube that contains small clear fi bres

that transmit light images as the tube bends. Its

fl exibility allows this instrument to reach the

farthest points in an airway. The procedure can be

performed easily and safely under local anaesthesia.

Bullectomy

Bullae are formed in the lung when alveoli

rupture and combine with other alveoli to

form one alveolus. This causes a reduc-

tion in respiratory capacity and they can be

resected via a thoracotomy approach.

Chest wall resection

Major resection of the chest wall is occasionally

necessary in the treatment of malignant disease.

Small resections are usually tolerated without

requiring the reconstruction of the rigid tho-

racic cage. The extent of the resection and what

it involves will be dependent on the severity of

the disease. It is usually performed via a thora-

cotomy incision.

Chest wall re-

construction

If a major chest wall

resection has been

performed, the chest

wall may need to be reconstructed to maintain a

rigid thoracic cage. This usually requires a sand-

wich of polypropylene mesh and methyl meth-

acrylate glue. This is constructed and allowed

to solidify outside the body and then sutured

into place or it may be formed within the defect

to be reconstructed. Large defects may also be

repaired with muscle or myocutaneous fl aps.

Muscles that can be used are the pectoralis major,

serratus, latissimus dorsi or the rectus muscle.

They may then be covered by skin grafts, if re-

quired. These procedures require the skills and

expertise of plastic and reconstructive surgeons.

Endobronchial therapies

Endobronchial therapies, including, brachytherapy,

stenting, laser therapy, cryotherapy, and dia-

thermy. Stents are used to keep compromised

large airways open in a variety of malignant and

benign conditions. Diathermy resection is per-

formed via a rigid bronchoscope and diathermy

is used to resect and cauterise intraluminal tu-

mours to relieve breathlessness and haemoptysis.

Lobectomy

The lungs are divided into separate sections or

“lobes.” The left lung has two lobes and the right

lung has three lobes. During a lobectomy a sur-

geon will remove an entire lobe of a patient’s lung.

Lung volume reduction surgery

Lung volume reduction surgery is a surgical proce-

dure where the worst areas of damaged lung tis-

sue (usually due to emphysema) are removed. This

surgery can be performed by either median ster-

notomy or video-assisted thoracoscopic technique.

The goal of the surgery, with either operative

technique, is to remove up to 30 % of the lung

volume and therefore make the lungs smaller.25

Median Sternotomy

This is an incision in which the sternum (or breast-

bone) is divided down the middle from top to bot-

tom and is routinely used to access the heart and

mediastinum but is also very useful for bilateral

lung procedures such as lung volume reduction

surgery or combined cardiac and lung operations.

Mediastinoscopy

This is a procedure in which a tube is inserted

into the chest to view the organs in the area

between the lungs and nearby lymph nodes.

The tube is inserted through an incision above

the breastbone. This procedure is usually per-

formed to get a tissue sample from the lymph

nodes on the right side of the chest and is

very important for staging of lung cancer.

Mediastinotomy

This is a procedure in which an incision is

made on one side of the breastbone so the

physician can view organs of the mediastinum

that cannot be seen by mediastinoscopy

Metastatectomy

This is the excision of metastatic nodules from

areas of the lung. It can involve a small number

of nodules or can be multiple. It is performed

via a thoracotomy if one side is affected or a

sternotomy for bilateral metastatectomy.

Open lung biopsy

Open lung biopsy is a test in which a small piece

of the lung tissue is removed through a surgical

incision in the chest. The sample is then ex-

amined for cancer, infection, or lung diseases.

Pacing of the diaphragm

Patients who have sustained injuries to the high

spinal cord that affects the nerve supply to the

diaphragm may develop respiratory distress ow-

ing to paralysis of the diaphragm. This can be

ameliorated by the technique of diaphragmatic

pacing. A pacemaker device is implanted under

the skin and electrodes attached to the phrenic

nerve (the nerve supply to the diaphragm).

Pancoast tumour and Grunwald procedure

This is a tumour of the extreme apex of the

lung. It may involve invasion of the parietal

pleura, brachial plexus, chest wall, fascia at the

root of the neck, subclavian vein and artery

and the sympathetic chain. The Grunwald pro-

cedure refers to the extensive neck incision,

with or without a thoracotomy that may be

required to access and resect the tumour.

Pleurectomy

Pleurectomy is the surgical procedure to remove

the parietal pleura, the outermost lining around

the lungs. This procedure is performed for a

variety of disorders including pleural effusion,

malignant pleural mesothelioma, and trauma.

Pleurodesis

Pleurodesis is the artifi cial obliteration of

the pleural space. It is done to prevent re-

currence of pneumothorax or pleural effu-

sion. It can be done chemically or surgically.

Pneumonectomy

This is the removal of an entire lung,

for cancer, lung abscesses, bronchiecta-

sis, or extensive tuberculosis.

Rib resection

This is the removal of part or the whole rib for

disease or to obtain access to a specifi c area of

lung. It can also be

done to obtain rib

for bone grafting.

Segmentectomy

This is performed

to resect small tu-

26

mours in a segment of a lobe. It is preferred to

a lobectomy in patients with borderline pulmo-

nary status to preserve some lung function.

Sleeve resection

This is usually performed when an upper lobe is

removed with a circumferential cuff of the parent

bronchus. Continuity to the remaining lobe or

lobes is restored by an end-to-end anastamosis.

Sternal deformity correction

(e.g. pectus excavatum)

Pectus Excavatum is a congenital deformity that

causes the sternum to be depressed into the chest

causing a “caved-in” look. It causes decreased

lung capacity and often chest and back pain. This

condition occurs once in every 500 children,

normally in males. The condition often becomes

worse during the teenage years. Surgical cor-

rection can be undertaken to improve cosmetic

appearance and to improve respiratory function.

Thoracotomy

Thoracotomy is a surgical incision into the chest.

It is performed by a surgeon to gain access to

the thoracic organs most commonly the heart,

the lungs, the oesophagus, or the thoracic aorta.

Thymectomy

A thymectomy is an operation to re-

move the thymus gland. It usually results

in remission of myasthenia gravis with the

help of medication including steroids

Tracheal resection

Trauma, tracheostomy and prolonged endotra-

cheal intubation are the usual causes of benign

strictures of the trachea that may require resec-

tion. Also, malignant tumours of the trachea

may cause obstruction and require resection.

Video Assisted Thoracoscopic Surgery (VATS)

This is an advanced, minimally invasive surgi-

cal procedure used for both diagnosis and

treatment of lung cancer. Instead of mak-

ing a large incision through the chest wall, the

surgeon makes two or three small incisions

through which a tiny camera and surgical instru-

ments are introduced, and tissue removed.

27