The VOICE of UPMC Shadyside Winter 2021–2022

The Many Faces of Thoracic Surgery

When illness strikes, patients have an amazing team on their side

“The pain in my shoulder started early in 2019,” remembers Wendolyn McKenzie, 46, executive director of the Allegany County Human Resources Development Commission inCumberland, Maryland.

“I thought it was a pinched nerve, so I let it go, hoping it would heal itself. But it got to a point where the pain was interfering with everything. My work, my sleep. So I thought, ‘Okay, I’m going to have to go to my primary care physician and see what’s going on.’

“Well, she was sort of baffled. Arthritis? Osteoporosis? Lyme Disease? But I give her accolades that she referred me to a specialist at West Virginia University. There, they discovered a Pancoast tumor, a rare form of lung cancer. They said, ‘With your permission, we would like to refer you to UPMC. Their thoracic surgery and oncology departments are fantastic.’

“To have medical specialists of this caliber eager to do everything in their power to help me was just phenomenal.”
- Wendolyn McKenzie

“When I first arrived at UPMC Shadyside and Hillman Cancer Center, they had all my appointments set up that day with the whole team who would be treating me: Dr. Daniel Petro, my oncologist, and his nurse practitioner, Stephanie Kaiser; Dr. David Clump, my radiologist; and my thoracic surgeon, Dr. Neil Christie, and his team. And I’m like, ‘This is amazing.’ I’m from a very rural area in western Maryland. To have medical specialists of this caliber eager to do everything in their power to help me was just phenomenal.

“I started the radiation immediately, to treat the tumor. I would get to UPMC Shadyside every morning at 7:30. My husband, Roy, a police officer, drove me. The trip takes us about two hours. We would drive up in the morning, I would get my radiation, we would drive back, and I would go to work for the day. I did the chemotherapy the same way. And I never missed work other than for my surgery.

“I’m a woman of extreme faith, first and foremost. I decided I was going to treat cancer like it was something that I could overcome. I’m going to deal with it and, with God’s strength and my family, move forward. I have a very strong support system and an amazing husband. Roy and I started dating when I was 15 years old, so yeah, he’s my rock, for sure.

“In October 2019, Dr. Christie operated. He and his team assumed it would be about an eight-hour procedure, but it took about 11 and a half hours. He removed the top lobe of my right lung, four ribs, and part of my chest wall. I have a mesh implant in my chest to keep everything from collapsing. The cancer had started to invade my vertebrae, so he had to scrape all that down. They had to disconnect pretty much all the muscle tissue and nerves in my right upper body then put all of that back.

“Dr. Christie is just so very attentive. Everyone told me, ‘You’re in such great hands. He’s a helicopter doctor. He’s not going to do these massive surgeries, send you on your way, and hope that you do well. He’s going to stay with you every step of the way.’

“And sure enough, my journey wasn’t over yet. In 2020, an MRI revealed a brain mass. It was treated successfully by my neurosurgeon, Dr. Pascal O. Zinn, and Dr. Stephen Burton, radiologist. And again, I received the most amazing, attentive care.

“Today, I consider myself cancer free. I’m so thankful to God and the staff of the oncology and thoracic surgery departments of UPMC Shadyside and Hillman Cancer Center. I know others are not so fortunate. But I wanted to share my story to help people who might not know where to turn when they face an illness this severe. I tell everyone that you want this amazing team on your side. They are true professionals as well as helpers — and as a social worker, helping others is where my heart is.”

Wendolyn McKenzie’s story could never have been told 20 years ago — before thoracic surgery became a significant specialty at UPMC Shadyside. “This was a complicated case,” says surgeon Neil Christie, MD. “And I believe she benefited from the technical expertise and the team approach we offer.”

Thoracic surgeons, often confused with heart surgeons, specialize in caring for patients with diseases affecting the lungs, chest wall, diaphragm, esophagus, stomach, and proximal small intestines. According to lung specialist David O. Wilson, MD, MPH, “Shadyside had no dedicated thoracic surgeons when I first started seeing patients in the late ’80s. But when the hospital merged with UPMC in 1997, one of the first new programs developed here was thoracic surgery,” says Dr. Wilson. “And the credit for that goes to Jim Luketich.”

James D. Luketich, MD, FACS, chair of the Department of Cardiothoracic Surgery at the University of Pittsburgh and chief of the Division of Cardiothoracic Surgery at UPMC Shadyside, is an internationally recognized pioneer in minimally invasive techniques for esophageal and lung surgeries. Shrinking incisions from six inches to one inch and even less, these innovations revolutionized surgery and have vastly improved patient comfort and recovery. Minimally invasive techniques have become the standard of care worldwide as Dr. Luketich has trained hundreds of surgeons from around the globe. “He has built one of the top thoracic surgery programs in the world,” says Dr. Wilson, who is the associate director of the Lung Cancer Center at UPMC Hillman Cancer Center. “All of our patients have benefited.”

“Thoracic surgery at UPMC is a leading force within the thoracic surgery community,” observes transplant surgeon Pablo Sanchez, MD, PhD, FACS, chief of the Division of Lung Transplant and Lung Failure at the University of Pittsburgh. “When you look at thoracic surgery places where you want to train or you want to be, this is one of them.”

Dr. Luketich also is a very successful talent scout. “My role at Shadyside is finding the right people for the job,” he says. “My colleagues there are just fantastic — innovative and forward thinking.”

“I believe it is a privilege and an honor to take care of people, so it’s great when we can bring new technologies to bear that we know are improving care.”
- Inderpal S. Sarkaria, MD

“Minimally invasive thoracic surgery was just starting to blossom when I came to Pittsburgh in 1998,” remembers Neil Christie, MD, chief of Shadyside’s foregut surgery section. (Foregut surgery deals with the upper gastrointestinal tract: the esophagus, stomach, pancreas, liver, and bile ducts.) “I had the benefit of being on the leading edge of these procedures.”
Dr. Christie was one of Dr. Luketich’s first fellows at UPMC. Very soon after Shadyside merged with UPMC, Dr. Luketich, recognizing his talents, brought Dr. Christie to Shadyside to develop minimally invasive thoracic surgery as one of the first teams of UPMC surgeons on staff at the hospital. “I quickly recognized his talents and soon made him chief, and he has continued to lead,” Dr. Luketich comments.
“I considered Shadyside my home from the start,” Dr. Christie says. “I very quickly established my whole practice here. The vast majority of what we do is lung and esophageal cancer surgery, and also benign disease, primarily gastroesophageal reflux disease and hiatal hernias.”

But it’s hard to talk about thoracic surgery in isolation because it’s such a team effort,” Dr. Christie emphasizes. “Thoracic surgeons collaborate with radiation oncologists and medical oncologists, and the pain team and the intensive care doctors, as well as our colleagues in pulmonary medicine. We’ve been working along with Dr. Wilson and some of our pulmonary colleagues on newer robotic bronchoscopy techniques for diagnosing very early-stage cancers.”

Oncologist David Friedland, MD, has worked in collaboration with Dr. Christie for more than 20 years. “We were among the first to create these multidisciplinary programs,” Dr. Friedland says. “It’s a really good way of directing all these levels of expertise to each patient. Kind of a one-stop shop. We have regular conferences together to discuss how we’re going to approach the treatment so that everybody’s on the same page for every patient.”

Dr. Friedland is also amazed by the advances of the last 20 years. “With newer, less invasive surgical techniques, the amount of trauma and the incisions are so much smaller, and the recovery is so much better. Immunotherapy, once a dream, has become a standard now; it often follows concurrent chemotherapy and radiation therapy. We have studies that show that it offers a real benefit in terms of reducing the risk of recurrence and spread of both lung and esophageal cancer, the two biggest thoracic cancers that we deal with.

“On the radiation side,” Dr. Friedland continues, “Dr. Stephen Burton is one of the pioneers of focused, pinpoint radiation. That has made the targeting so much better and more effective than it was before, and the toxicity is much less too.”

“Thoracic surgery at UPMC is a leading force within the thoracic surgery community. When you look at thoracic surgery places where you want to train or you want to be, this is one of them.”
- Pablo Sanchez, MD, PhD, FACS

“At Shadyside Hospital and the Hillman Cancer Center, there are treatments and opportunities and experience that are unparalleled anywhere else in UPMC,” Dr. Christie believes. “I consider myself very fortunate to be able to have this care for my patients.”

Dr. Christie is “also proud that we have trained many, many thoracic surgeons who now practice locally and elsewhere in the country. I’m proud too that I’ve been able to influence some good students to pursue a career in surgery — including my youngest son, who is just completing his third year in medical school and decided to pursue a career in cardiothoracic surgery as well. That’s something that, for me, validates what we have achieved here.”

Rajeev Dhupar, MD, MBA, always wanted to be a cancer specialist. “I saw that treating patients with cancer really allows you to help a patient in all realms,” he says. “When cancer metastasizes, lungs are the second-most-common place it tends to spread (the first-most-common site is the liver). So you’re not just treating lung cancer — it’s actually breast cancer, colon cancer, ovarian cancer, pancreatic cancer.”

Dr. Dhupar came to Shadyside in 2014 after a cardiothoracic fellowship at MD Anderson Cancer Center. “I think we do great things for patients with cancer here at UPMC Shadyside,” he says. “The unique environment here allows us to care for patients and also do basic scientific and translational research aimed at offering them the newest treatments. This is a special place.

“A particular focus of mine is patients with advanced cancers that have spread to the chest from other sites,” he says. “With minimally invasive surgery, I get to help people breathe better, which is really one of the most gratifying things that you can try to do for somebody. We’re often able to make them feel much better with very minimal discomfort.”

In his research, Dr. Dhupar seeks to find new treatments for patients who have problems breathing once cancer has spread to the area around their lungs. “My goal is developing new immunotherapies, and I do this mainly through the fluid that develops around people’s lungs,” he explains. “Surprisingly, that fluid contains often valuable immune cells that can give us a lot of information about how each patient would respond to cancer treatments. My hope is that someday we can use that fluid to help patients get over their cancer. It is something that relatively few people are doing.”

Like his colleagues, “and indeed most thoracic surgeons who came into practice within the last 10 years or so,” Dr. Dhupar uses robotic technology on a regular basis.

“I’m particularly interested in the robotic bronchoscope, a new tool for diagnosing very-early-stage lung cancers.”

 

“It’s hard to talk about thoracic surgery in isolation because it’s such a team effort.”
- Neil Christie, MD

“I believe it’s a privilege and an honor to take care of people, so it’s great when we can bring new technologies to bear that we know are improving care,” says Inderpal S. Sarkaria, MD, an established expert thoracic surgeon and researcher in esophageal cancer, lung cancer, and other less common cancers of the chest, such as mesothelioma and tumors of the mediastinum (middle chest). Dr. Christie describes him as “a world leader in robotic surgery.” Dr. Luketich says that Dr. Sarkaria has helped make UPMC Shadyside “one of the leading centers in the world for robotics. Along with the other thoracic surgeons at Shadyside, I’m now using the robotic platform as well,” Dr. Luketich adds.

As Dr. Sarkaria, director of Thoracic Robotics and vice chair of Pitt’s Department of Cardiothoracic Surgery, says, “Robotics is where it’s at.”

In 2010, after a fellowship at Pitt, Dr. Sarkaria started a minimally invasive surgical program at New York’s prestigious Memorial Sloan Kettering Cancer Center. “This led to my introduction of both advanced robotics and sophisticated surgical imaging techniques to thoracic operations early in my career,” he explains. These techniques can give surgeons “new and better ways of seeing anatomy and cancers than with the naked eye, and also improve the surgeon’s ability to identify and safely remove all of the tumor with less pain and quicker recovery for the patient.”

Then in 2014, Dr. Luketich called with an invitation — come back to Pittsburgh and build an advanced robotics program for complex thoracic surgical procedures. “I was delighted,” Dr. Sarkaria said. “UPMC is one of the top institutions in the world, including the use of robotics. The depth and breadth of robotic expertise here, across many surgical disciplines, is phenomenal.”

Dr. Sarkaria points out that “robotic lobectomy (surgical removal of a lobe of a lung) for early-stage lung cancer is improving on our standard minimally invasive approaches, with better outcomes in both cost and quality. And we are working to look at the same types of advances in esophageal cancer and other cancers, and benign thoracic surgical conditions as well.”

With an eye to the next innovation, Dr. Sarkaria believes that “advanced imaging — how we see and identify tumors in the lung and other organs and how we treat them — is becoming very much a part of robotics technology. An example is intraoperative molecular imaging (IMI). It provides a tremendous increase in the amount of information to the surgeon, and that allows us to do a better job overall.”

Shadyside, for instance, is one of the primary sites nationally for two large, multi-institutional trials looking at an advanced near-infrared tumor-highlighting technology — OTL38 — that radically improves the visualization of lung cancer tissue in real time using fluorescence to make tumors “glow” as the surgeon is operating. This groundbreaking diagnostic tool could help physicians identify and remove more tumor cells than ever before.

Dr. Sarkaria presented the results of the first OTL38 trial to the Society of Thoracic Surgeons in 2020 (“Firstof- its-Kind Technology Lights Up Lung Cancer Cells, Helps Improve Patient Outcomes” on YouTube).

The surgeon also praises robotic bronchoscopy as a “true step forward in diagnosing lung cancer more safely and less expensively. We’re very excited about new developments in that technology that may allow us to non-surgically treat early lung cancers and small tumors that may have in the past required much larger operations with higher rates of potential complications.

“And the pace of development of these technologies is escalating. So it’s a very exciting time for us, and for robotics overall.”

“You realize how you truly appreciate someone who takes time to answer your questions.”
- Nirav Patel, MD

Nirav Patel, MD, woke up one Monday morning and thought he had the flu. “This was March 2020, right when we knew about COVID but maybe a week before everything got very crazy,” remembers the kidney specialist. “I hated calling in sick, but I couldn’t go to work that day. Or the next two. I kept spiking fevers and having night sweats.

“I went for influenza and COVID testing at a nearby urgent care center and tested positive for the flu. They discovered that my heart rate was also very rapid with concern for dehydration, so I drove myself to Sewickley Hospital, which was nearby. 

“My lab results showed that, yes, I was dehydrated, but my chest X-ray also showed that I had pneumonia. So I was admitted to the hospital and was given antibiotics as well as IV fluids, but my fever still wouldn’t come down.

“A CT scan was then obtained for further investigation. The scan showed something blocking one of the areas in my airways. I was evaluated by a pulmonologist who performed a bronchoscopy — and he found a tumor in my lung.

“I was shocked. I had just turned 41. I was a nonsmoker. I’m physically active. The tumor was ultimately found to be a carcinoid tumor, which is an uncommon, slow-growing tumor. My treating doctors told me that I probably had it for a while.

“I was pretty shaken up. That’s when my oncologist at Sewickley sent me to Dr. Inderpal Sarkaria at UPMC Shadyside. ‘If you’re going to see anyone,’ she said, ‘Dr. Sarkaria is the guy you want to see.’

“Dr. Sarkaria put me at ease right away. He just had such a calm demeanor, and he was very patient in answering my questions and my family’s questions. We physicians think we understand how important it is to talk to patients and make them feel comfortable. But when you are a patient yourself, having that role reversed, you realize how you truly appreciate someone who takes time to answer your questions. Especially when you’re dealing with lung cancer.

“This was a scary time, especially with COVID cases on the rise. I had ongoing fear that if I were to be exposed to COVID, the lung tumor could put me at risk for severe complications. So the first thing Dr. Sarkaria did was to remove part of the tumor by robotic bronchoscopy. But he didn’t yet know how much surgery I would need. In the best-case scenario, he would take out a small portion of my lung (lung-sparing surgery) with a complex procedure called a ‘sleeve’ resection, most often requiring a big incision and open surgery. Another possibility was that I could lose up to two-thirds of my lung. I was very anxious about that. But Dr. Sarkaria told me he’s had patients who’ve had more of their lung removed, and even if he had to do that, he informed me that I would still be able to lead a very normal and active life.

“It was a long surgery because of the complexity and also because he was so careful. Using robotic surgery, he was able to remove only a partial section of my airway and a small portion of my lung and sew the remaining parts back together to preserve the rest of my lung. The robotic technology meant that there would be less scarring and a shorter recovery time and helped avoid a big open incision. I had the surgery on Monday and went home on Thursday morning.

“Dr. Sarkaria told me recovery would take about two months. The first two weeks I had some difficulty walking around, but by week three, I was able to start doing some video visits from home with my patients. By week seven, I was back on call and working my regular schedule. I am now tumor free, and he told me that the likelihood of recurrence is minimal.

“I feel very thankful that we have surgeons like Dr. Sarkaria here. He is awesome. I can’t say enough good things about not only his skill but his bedside manner. He made me realize how important it is to sit down and spend time with patients and their families. Even though I’m a physician, I have questions, fears, and knowledge gaps as well. Dr. Sarkaria’s patience and communication made such a big difference to me. I hope I have learned from it.

“And I wanted to tell my story because maybe it will help other people who may be faced with a serious illness. I hope they feel, ‘Well, he did it, I guess I can do it too.’”

Margie Dailey, RN, BSN, a nurse at Shadyside for 41 years, has worked with Dr. Christie for about 15 years. She is each patient’s go-to person.

“I do a lot of patient education, a lot of patient emotional support,” she says. “I understand that they are worried, anxious, and scared. They need to have reassurance. They don’t remember three-quarters of what is said to them in the clinic. A lot of times they just hear the word ‘cancer’ or the word ‘surgery,’ and they block everything else out. So oftentimes the next day or a couple of days later, after they’ve calmed down or looked things up on the internet — which can open a whole new ball of anxiety — they call with their questions. And I can put their minds at ease by answering their questions. I want them to know that we do want to help them.

“It’s rewarding when you know that you’ve alleviated their anxiety, even if it’s taking it down a notch. We get close to patients when you follow them for months and years. We’ve lost a few that we were close with. Sometimes the disease wins.” Ms. Dailey also organizes Dr. Christie’s surgical schedules and makes sure every patient has everything they need to get to surgery safely and efficiently. After the surgery, she helps guide patients through the next steps of their care — and that involves good collaborations with other specialties. “It’s a really good, collegial group of people,” she says.

“I’ve been with the thoracic group here at Shadyside since 2012,” says Mary Graham, MSN, CRNP, a nurse practitioner who leads a team of six advanced practice providers (APPs).

“When I started, we only had three APPs. And now we’re at six. We support a group of extremely talented and dedicated surgeons who set a very high standard of care, and our role is to provide the consistency of excellent care they expect. We make sure that everything is communicated among the team and to the patients. We see outpatients in the clinic, and we go into the operating room and cover there as well.”

The APPs also attend the regular meetings where the radiologists, the pathologists, the medical and radiation oncologists, and the surgeons look at complicated cancer cases and decide on the best approach from all disciplines.

“There’s nobody that knows what the exact right answer is,” Ms. Graham says, “but they’re willing to put their heads together to come up with the best approach and treatment plan for the patient. I believe that’s hugely beneficial for the patient, that all their physicians are talking and communicating.”

“I’ve never not found nursing to be rewarding,” she says. “But thoracic surgery is special. It is a good feeling to be on the same page as surgeons who have so much experience, so much care and concern for how their patients are doing, and who are always interested in new, innovative ways of treating as well. It’s challenging and interesting. It makes you feel you’re growing as a provider.

“And when you see those patients back at six months, or a year out, two years out, three years out, five years out — and all that additional living they’ve been doing, that’s the reward.

“It’s all about the patients — that’s our focus.”

“It takes a village to manage these complex thoracic surgical patients and deal with all the day-to-day issues,” says Angela Gallagher, CRNP, who was instrumental in helping to launch thoracic surgery at Shadyside. “We try to put a team around the surgeons to support them, so everything gets addressed by the appropriate level and discipline. It’s about caring for people and making sure they get the care that they need.

“I don’t think people realize what dedicated surgeons we have,” she adds. “I mean it’s not just being in the operating room. It’s being on the phone constantly, taking care of issues with patients and returning their calls.” Mrs. Gallagher has worked with thoracic surgery patients at UPMC Presbyterian since the early 1990s. In 1997, she started working for Dr. Luketich, who calls her “the glue of the program.”

“Dr. Luketich loves what he does,” she says. “I don’t go into surgery, but when I talk to people that do, they’ll say he has the best hands they’ve ever seen.

“And he just had really great ideas for developing a lung cancer and esophageal cancer program. From the start, it was always meant to be multidisciplinary — to involve as many specialties as needed,” Mrs. Gallagher says. “I feel very good about how it has developed so successfully.”