Thoracic Surgery

As the thoracic surgery working group, we treat all surgical diseases of the lungs, the lower airways, and the pleural cavity. For more than 15 years, minimally invasive techniques—so‑called keyhole surgery—have been used for this purpose, leading to a significant reduction in pain and postoperative limitations.

Although we strive to minimize surgery‑related restrictions, keyhole techniques are not suitable in all cases. In a detailed consultation, we take the time to discuss the advantages and disadvantages of the techniques with you and to determine which surgical approach is best in your individual situation.

Lung cancer (lung carcinoma, bronchial carcinoma)

Lung cancer is a malignant tumor in the lung that can be very dangerous. Symptoms such as coughing, pain, or shortness of breath usually appear very late. The main cause of the development of lung carcinoma is smoking.

Lung cancer – overview
In the lung, both benign and malignant tumors are known. While benign tumors rarely require treatment, malignant lung tumors—also referred to as lung cancer, bronchial carcinoma, or bronchus carcinoma—represent a dangerous disease. As with any type of cancer, lung cancer develops from a cell whose genetic material is altered by various factors. The cell mutates and can divide uncontrollably. Different risk factors capable of causing these mutations are known, but cigarette smoke remains the greatest risk. Other harmful substances or chemicals that can be inhaled may also cause bronchial carcinoma.

Lung cancer is the second most common tumor disease in both men and women. The treatment of a lung tumor depends primarily on the extent of the disease. The following sections explain several aspects of diagnosis and treatment. Since the therapy of a lung tumor depends on many factors, an individualized treatment plan is usually recommended for each patient within the framework of a tumor board.

Lung cancer can often be treated successfully; therapeutic options include surgery, radiation therapy, or drug-based treatments such as chemotherapy, immunotherapy, or targeted therapy.
As with any other tumor, the following also applies to lung carcinoma: the earlier the tumor is diagnosed, the higher the chances of survival.

Different types of lung cancer
Malignant changes in the lungs are referred to as bronchial carcinoma. Based on different characteristics of the individual tumor cells, subtypes can be distinguished. Broadly, a rarer small cell lung cancer (SCLC) and the more common non‑small cell lung cancer (NSCLC) are differentiated. This distinction is made because these tumor types have very different clinical courses: small cell bronchial carcinomas grow more rapidly and aggressively and spread earlier to nearby lymph nodes or distant organs. Non‑small cell tumors can be further divided into many histological subtypes, with adenocarcinomas and squamous cell carcinomas representing the largest groups.

All malignant tumors have the potential to spread and affect other organs. This may involve nearby lymph nodes or distant organs. Such spread is referred to as dissemination or metastasis. The spread of a tumor is directly linked to its prognosis. To classify the extent of tumor spread, the TNM system is used, in which T stands for tumor size, N for involvement of lymph nodes, and M for metastasis to other organs. The extent of spread of a lung tumor is one of several factors that determine possible treatment options.

There are now additional tumor characteristics, such as the expression of surface molecules or specific mutations, which can also be decisive for the choice of drug therapy. Your medical report includes all of this therapy‑relevant information. We are happy to take the time during our consultation to review the findings with you.

Risk factors and incidence of bronchial carcinoma
Cigarette smoke is still considered the most important risk factor; nine out of ten patients who develop lung cancer are active or former smokers. About one in four adults in Austria smokes. The decisive factors are how long and how much a person has smoked. Smoking behavior is measured in pack‑years: smoking one pack of cigarettes per day for one year corresponds to one pack‑year. Quitting smoking can reduce the risk of developing lung cancer at any time. If you require medical support for smoking cessation, please feel free to contact us. Radon, passive smoking, and exposure to carcinogenic substances in the workplace are additional known risk factors. Each year, more than 4,700 patients in Austria are diagnosed with lung cancer. This corresponds to an incidence of 55 cases per 100,000 inhabitants per year. In Austria, only prostate cancer in men and breast cancer in women are diagnosed more frequently. However, lung cancer has remained the leading cause of cancer‑related death for many years.

Symptoms
Lung cancer often becomes noticeable only at a late stage. A small bronchial carcinoma rarely causes symptoms. In many patients, a tumor at this stage is discovered incidentally. As the tumor increases in size or metastasizes to other organs, symptoms such as coughing, hoarseness, bone pain, nausea, or neurological deficits may occur. Fever, weight loss, or night sweats may also appear. Not all of these symptoms mean that someone has lung cancer. If you are concerned, speak with your general practitioner about your symptoms and the next steps in evaluation.

Diagnosis of lung cancer
Lung tumors are often discovered incidentally during X‑ray or computed tomography scans. Depending on the size of what is known as a pulmonary nodule and the patient’s smoking history, the next steps are discussed. If there is a justified suspicion, an attempt is made to obtain a tissue sample from the lesion. This is necessary in order to plan further treatment. Tissue samples are often obtained during a bronchoscopy, an endoscopic examination of the trachea and bronchi; alternatively, tissue can be obtained through a CT‑guided needle biopsy. Both techniques have advantages and disadvantages. Based on the location of the tumor, your treating physicians will decide on the most appropriate method. In addition to obtaining tissue, a number of further examinations can be used for more precise staging. These include the detection of metastases using PET‑CT (positron emission tomography) or the evaluation of enlarged lymph nodes using EBUS (endobronchial ultrasound). At the end of the diagnostic work‑up, it should be clearly established whether the tumor is benign or malignant. Based on the imaging findings and the extent of the tumor, treatment for lung cancer is then planned.

Therapy
The treatment of bronchial carcinoma depends on the extent of the tumor. Small tumors without spread can usually be treated very well with local therapies. Unfortunately, many bronchial carcinomas are diagnosed at a very late stage; this is referred to as an advanced or high tumor stage. In such situations, a cure is often no longer possible, but modern treatments can help slow tumor growth. In certain tumor subtypes, targeted therapies can achieve very good treatment results even in cases of extensive metastasis. Special diagnostic tests are often required for this. To recommend the best possible therapy, these specialized investigations must often be completed first. Based on the collected information about the tumor disease, a therapy recommendation is formulated within the tumor board, in which physicians from many disciplines participate. We then discuss this recommendation with each patient in detail. Of course, your trusted companion may participate in this conversation.

Operative removal of a lung tumor
If the tumor is locally limited and lung function is sufficient, surgical removal of the lung tumor is generally performed. This can be done as a primary treatment, or alternatively, the tumor board may recommend drug therapy (chemotherapy and/or immunotherapy) before surgery. If you have questions about your treatment plan, we are happy to take the time to explain everything to you. Lung operations are performed under general anesthesia. In more than 80% of all operable lung carcinomas, we use a minimally invasive approach in which three incisions are made on the affected side of the chest. Through these three incisions, blood vessels and the corresponding part of the bronchi are divided so that the lung segment containing the tumor can be removed. In addition, surrounding lymph nodes are removed so that tumor spread can also be examined microscopically. At the end of the operation, a drain is placed to remove air and wound fluid. The anesthesia is then ended and all patients are transferred awake and breathing on their own to a monitoring unit. Most of our patients can be moved back to the regular ward after two to three hours.

Further inpatient stay
Already on the first day after the operation, our patients are assisted out of bed by our nursing staff. If the postoperative course is normal, the drain can be removed on the second or third day. If the follow‑up chest X‑ray and laboratory results are unremarkable on the next day, we discuss the optimal discharge date with our patients. At any time during your stay, you can talk to us about your recovery progress, and we are happy to provide you with detailed information.

After discharge
Our goal is for patients to be able to take care of themselves at home. The discharge date is chosen with this goal in mind. Accordingly, there are few restrictions from our side for the first period at home. Physical rest until the wounds have healed means avoiding strenuous activity. However, daily—also longer—walks are definitely recommended. Within the first 6 months, the function of the remaining lung recovers. Physiotherapy and supervised training as part of rehabilitation can help further improve the function of the heart, muscles, and lungs. We are happy to advise you if you have questions about the further course. Within 10 days after discharge, you will receive a follow‑up appointment in our thoracic surgery outpatient clinic, where we want to assess your progress. During this appointment, we also discuss the results of the histological examination of the tumor and lymph nodes, as well as the tumor board’s recommendation for further therapy. If you develop concerning symptoms after discharge, you do not need to wait for this follow‑up appointment. We can often address your concerns by phone, or arrange an earlier appointment if necessary.

Further therapies
In addition to the surgical treatment of bronchial carcinoma, there are many other therapies that can be used, depending on the findings, also in combination. If you have further questions about your treatment plan from our tumor board, or if you would like a second opinion on your lung cancer treatment plan from another tumor board, simply schedule an appointment in our outpatient clinic.

Inflammations of the lung and the pleural cavity

Pneumonia, pleural empyema, tuberculosis, bronchiectasis, actinomycosis, aspergillosis, lung abscess

Pulmonary emphysema

Pulmonary emphysema is a pathological overinflation of the lungs. It most often occurs as a consequence of chronic bronchitis in smokers from around the age of 50. Very rarely, it is caused by a congenital enzyme defect (alpha‑1 antitrypsin deficiency), which can lead to emphysema in patients under 40 years of age. Occupational factors may also be responsible. Symptoms include reduced physical performance, shortness of breath, a barrel‑shaped chest, and chronic cough. The diagnosis is made through clinical examination, chest X‑ray, lung function testing, and blood gas analysis. Treatment consists of smoking cessation, bronchodilator medication, and oxygen therapy. In advanced stages and selected cases, symptom improvement can be achieved through a procedure known as lung volume reduction surgery (LVRS). This operation is performed minimally invasively (keyhole surgery). Treatment planning is carried out in close coordination with pulmonologists, who usually also perform the diagnostic work‑up. If you would like to know whether lung volume reduction could help you, discuss this option with your pulmonologist.

Changes of the pleura and the lung lining

Pleural effusion, pleural empyema, pleural mesothelioma, pleural carcinomatosis

Pneumothorax

A pneumothorax is defined as a collapse of a lung and an accumulation of air between the pleura and the lung. A pneumothorax may occur spontaneously, after an accident, or after medical procedures such as needle punctures. The most common form is spontaneous idiopathic pneumothorax, which occurs without underlying disease and usually affects young, slender men. Initial treatment generally consists of placing a chest drain. If the pneumothorax recurs on the same side, surgical intervention is recommended. In most cases, a minimally invasive procedure (keyhole surgery) is sufficient.

Pectus excavatum

This deformity of the chest is likely caused by an enzyme metabolism disorder of the costal cartilage. A familial predisposition is frequently found. We also correct these changes today using a minimally invasive approach (keyhole surgery) according to the Nuss procedure, in which a stabilizing metal bar is inserted for a certain period of time. Because of the elasticity of the thorax, the ideal time for the procedure is shortly before puberty, but it can also be performed in adulthood. The lateral scars are barely visible.

Tumors of the chest wall

Benign: fibromas, lipomas, granulomas
Malignant: sarcomas, secondary tumors (recurrences, especially in cases such as breast carcinoma)

Congenital malformations of the lung

Bronchogenic cyst, congenital bronchial atresia, pulmonary dysplasia, pulmonary cysts, arteriovenous malformations, pulmonary sequestration
The treatment of these malformations consists, depending on the symptoms, of the surgical removal of the affected lesion or the affected portion of the lung. Ideally, these operations should be performed as early as possible, sometimes even during infancy.

Thoracic trauma

Pulmonary contusions, lacerations of the lung parenchyma, trachea, bronchi, esophagus, hemothorax (bleeding into the pleural cavity), traumatic pneumothorax