Minimally Invasive Thoracic Surgery with Barry Gibney, DO

MUSC Health offers the latest in thoracic surgery, including surgical care of people with lung and esophageal cancers, end-stage lung disease and lung transplant surgeries. This episode features Barry Gibney, DO, who performed South Carolina's first lung transplant for a COVID-19 patient. Gibney is a thoracic surgeon as well as an associate professor in the Division of Cardiothoracic Surgery at MUSC. He discusses the various leading-edge treatments he and his team provide, including minimally invasive, robotic surgery.

“The robotic platform has helped us extend minimally invasive approaches, not only to the stage I cancer patients, but also stage II and stage III patients. It has been a great benefit for our patients because the incisions are smaller and the recovery is faster.”
—Dr. Barry Gibney

Topics Covered in This Show

• Lung cancer is the number one cancer killer worldwide and can be broken down into the two cell types: small cell lung cancer and non-small cell lung cancer. Non-small cell lung cancers, which are most common, are cancers typically associated with people who have used tobacco throughout their lives or have been exposed to asbestos or other carcinogens.
• Generally speaking, the gender breakdown of lung cancer patients is relatively equal, meaning 50/50 between male and female. However, non-smoking lung cancer patients are more often female.
• Patients commonly visit Gibney’s clinic due to nodules being detected on a CT scan. Sometimes this is the result of standard lung cancer screenings for patients who have a tobacco use history. In other cases, spots can be detected on the lungs after having been examined for other conditions, such as a bad cough or chest pain
• Due to the difficulty of diagnosing lung cancer at early stages, lung cancer screenings are crucial. However, implementation of screening programs at hospitals across the country is unfortunately quite low. MUSC Health doctors have taken a leadership role in South Carolina by implementing screening programs in partner hospitals as well as Veterans Administration hospitals.
• For the most part, the history of lung cancer treatment has been unchanged since roughly the 1930s, when the first lung resection for lung cancer was performed. In the 1950s, it was discovered that removing a lobe of the lung, as opposed to a pneumonectomy (or removal of the whole lung), was just as effective.
• However, with the development of immunotherapy in recent years, lung cancer treatment has dramatically changed, improving survival rates in patients, especially those in stage three lung cancer
• For many years, MUSC Health doctors have also been using minimally invasive surgical approaches for stage one lung cancers. More recently, they’ve switched from traditional, minimally invasive surgery to a robotic platform, which has helped extend minimally invasive approaches to patients in second and third stage lung cancers.
• These minimally invasive approaches combined with chemotherapy immunotherapy have drastically improved survival rates in lung cancer patients in the last few years
• At the Hollings Cancer Center, Gibney works with thoracic oncologists, pulmonologists, and radiation oncologists, which allows for free flowing ideas between specialties to give patients more robust individual treatment
• Gibney and his colleagues also care for end-stage lung disease patients as part of the multidisciplinary lung transplant team at MUSC Health. Similar to cancer care, treatment for end stage lung disease is a team based approach and includes pulmonologists, social workers, and nutritionists
• MUSC Health is the only lung transplant center in South Carolina. Most notably, Gibney has performed three lung transplants for COVID-19 patients at MUSC Health and shares his experiences with these patients

Read the Show Transcript

Erin Spain, MS [00:00:04] Welcome to advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. MUSC Health offers the latest in thoracic surgery, including surgical care of people with lung and esophageal cancers, end-stage lung disease, as well as lung transplant surgeries. In fact, today's guest, Barry Gibney, DO, performed South Carolina's first lung transplant for a COVID-19 patient. Dr. Gibney is a thoracic surgeon as well as an associate professor in the Division of Cardiothoracic Surgery at MUSC. He joins me to talk about the leading-edge treatments he and his team provide. Welcome to the show.

Dr. Barry Gibney [00:00:53] Thank you, Erin. Thank you very much for having me.

Erin Spain, MS [00:00:55] Share with us the types of patients that you see and the conditions that you treat as a thoracic surgeon.

Dr. Barry Gibney [00:01:02] Sure. So we see patients really from a large age range. Typically the youngest that we'll see is 18 for things like spontaneous pneumothorax. And the majority of our patients tend to be somewhere between 50 and 80 years of age and primarily treating cancers.

Erin Spain, MS [00:01:19] Cancers. And in fact, lung cancer is one of the most common and deadly cancers in the U.S. and one of the most common conditions that you treat. Tell me about lung cancer, the different types of lung cancer you see. What causes it and makes this so deadly?

Dr. Barry Gibney [00:01:34] Sure. So that is correct, that lung cancer is the number one cancer killer, not only in the U.S., but also worldwide. And lung cancer is broadly broken down into the two cell types. There is non-small cell, which is the majority of what I deal with and the majority of what we think about when we're treating lung cancer. And then there's small cell, which is a whole different thing that I think is better suited for a different day of discussion. But non-small cell lung cancer are the cancers that we typically associate with people who have used tobacco throughout their lives or have had other exposures such as asbestos or other carcinogens. Although I will say that there is a significant portion of our patients that have never had a smoking history that develop lung cancers.

Erin Spain, MS [00:02:16] And does it affect women more so than men? Who do you see coming in with lung cancer?

Dr. Barry Gibney [00:02:21] Well, so it's relatively equal in terms of the gender breakdown broadly. So about 50% of patients are male and female. However, the nonsmoking patients that have lung cancer do tend to be female.

Erin Spain, MS [00:02:32] So tell me, how do people end up coming to you? What is that process like? How do they realize that they need to be screened and then they get diagnosed with lung cancer and then they come to you for surgery?

Dr. Barry Gibney [00:02:42] Well, the most common way people end up in my clinic is from a nodule that's detected on a CT scan. Whether that is a formal screening CT scan, meaning somebody who has a tobacco use history and meets criteria for screening, or whether it's somebody who just has a CT scan for some other reason, such as they had a cough or chest pain and a spot on the lung is detected and then further worked up. Those are the two most common reasons that people will show up at our clinics.

Erin Spain, MS [00:03:10] I'm curious, in these couple of years after the height of the COVID-19 pandemic, are you seeing more folks coming in with lung cancer? I know that you actually wrote a paper on the ethics of whether or not lung cancer screening should or should not be suspended during the pandemic. Tell me what's happened and the sort of the fallout of so many folks who weren't going to the doctor during that time.

Dr. Barry Gibney [00:03:34] Yeah. So we've actually seen a slight increase in the number of patients that we see, although as a program, we did prioritize cancer care during the COVID height when it first started. So we were continually seeing patients and still operating on them during that time. And the hospital used its resources to help provide care to those patients, not just lung cancer patients, but all our cancer patients. So specifically to that paper and specifically to lung cancer screening, lung cancer screening is really very important and it is unfortunately somewhat nascent in its adoption across not just the state of South Carolina, but really all states. A lot of programs don't implement it or don't know how to implement screening programs. And that is something that we've really prided ourselves on at MUSC through the leadership of Dr. Silvestri and Dr. Tanner. The two of them are really working hard to go across the state and implement screening programs not only through our partner hospitals, but also through the network of the Veterans Administration hospitals to keep lung cancer screening appropriate and robust.

Erin Spain, MS [00:04:35] So you also treat esophageal cancers. Tell me about those a bit. How do they differ from lung cancer as far as who's diagnosed and how deadly the disease is?

Dr. Barry Gibney [00:04:45] So esophageal cancer is unfortunately a very aggressive cancer. And oftentimes we don't detect it until it is fairly advanced because usually the reason we diagnose it is somebody has developed a new difficulty with swallowing. So they will say, you know, they've had some trouble swallowing and now food is getting stuck and they'll go for an endoscopy and that's where it will be diagnosed. And unfortunately, of those patients, a significant portion are already found to have metastatic or disease that has spread throughout the body at that point. So unfortunately, with esophageal cancer, again, we see it at a later stage. However, when we do detect it, we do have treatments that can both be curative at the best and extend life otherwise.

Erin Spain, MS [00:05:30] Walk me through the treatment plans. Let's start first with lung cancer and then esophageal cancer.

Dr. Barry Gibney [00:05:37] Lung cancer is actually quite difficult, especially in the last few months. For the most part, the history of lung cancer has been unchanged since roughly the 1930s when we performed the first lung resection for lung cancer. Now, at that time, it was a pneumonectomy, which means removing the entire lung on the side that the cancer was on. Sometime in the 1950s, a group in New Orleans discovered that you can have the same results if you just remove the lobe of the lung as opposed to the pneumonectomy. From that time on, we really haven't made much changes in how we've treated lung cancer. If it's early stage, meaning stage one lung cancer, where it has not spread to the lymph nodes, we treat it with a surgical lobectomy meaning removing that lobe of the lung. If there is shown evidence of involvement of the lymph nodes, if there are lymph nodes close to the cancer, we treat you with a lobectomy before you get chemotherapy afterwards. And if it's spread to the lymph nodes a little farther away from the cancer, meaning in the middle of the chest, previously we would treat them with either chemotherapy and radiation followed by surgery, or just chemotherapy and radiation alone. Now, in the last few years, with the invention of immunotherapy, which is a type of medicine that kind of tells your immune system to go attack cancer, things have changed quite drastically. Taking that last example of the lymph nodes being in the middle of the chest, for patients who are unable to get surgery, they get the same chemotherapy and radiation, but then they get immunotherapy afterwards, which has really improved survival in these patients that were considered stage three. In patients that are surgical candidates, we now have a couple options for them. We can treat them with chemotherapy and immunotherapy before taking them to surgery and then take them to surgery. Or we can do surgery first and then treat them with chemotherapy and immunotherapy afterwards. Now, both of those treatment options are relatively new, so we don't have the full maturity of the trials. But when we look at survival over the course of the first two to three years after those treatments have been implemented, they're drastically better than what we were previously doing. And both of those treatment options extend down to that second stage of patients where the lymph nodes are close to the cancer. So really the only thing we're doing the same as what we have been doing is stage one lung cancer, where we still take them straight to surgery if they're a surgical candidate. Otherwise, it's become a much more nuanced decision tree and much more multidisciplinary, which means that not only are our patients seeing somebody such as myself, but they're seeing my colleagues in medical oncology as well as at pulmonology, and is allowing multiple brains to come up with an individualized treatment plan to help maximize the chances for survival.

Erin Spain, MS [00:08:15] Well, an important thing to mention is that surgery is done a little differently now with minimally invasive techniques. Here at MUSC Health, you're using video assisted technology for these procedures, which is very state of the art. Tell me about this minimally invasive surgeries that you're performing for lung and esophageal cancers.

Dr. Barry Gibney [00:08:35] Yeah. So for many years we've been using the minimally invasive surgical approach for stage one lung cancers. And more recently, we've switched from what is considered traditional, minimally invasive surgery, which still involves an incision, a camera, although the incisions much smaller than it used to be. But now we use a robotic platform which has really helped us extend minimally invasive approaches, not only to the stage one patients, but also stage two and stage three patients, and sometimes even more complex operations such as sleeve resections, where we're reconnecting the airway in a minimally invasive fashion. So it is been a great benefit for our patients because the incisions are smaller, the recovery is faster, and a team of pulmonologists and social workers, nutritionists

Erin Spain, MS [00:09:27] Explain to me how busy your team is and the number of surgeries, the volume that's coming through MUSC Health and you know, how you're able to really offer the very best care in the region.

Dr. Barry Gibney [00:09:38] Our surgical team operates four days out of the week at the Ashley River Tower, and we operate essentially morning till the evening on each one of those days. The day that we are not operating, the three of us are in clinic at Hollings Cancer Center, where that clinic, which happens on a Tuesday, is the highest volume clinic, not just from a surgery standpoint, but from a lung pathology standpoint. And it's a clinic where we share with our thoracic oncologists, our pulmonologist, our radiation oncologist, and it really allows for free flowing ideas. If I have a patient that I think needs a little extra help from, say, my pulmonologist to make a diagnosis, I can just walk right into their room and say, you know, do you mind popping over and seeing this patient? Which really makes it easier on the patient so that they don't have to come back from multiple appointments. So that's kind of the the typical week for us. In terms of what we do, we end up doing somewhere around 150 lung cancer operations per year. We do somewhere around 50 esophageal cancer operations per year. And then we do several other operations for things such as sarcomas, palliative procedures to manage things like fluid in the chest, and then other operations such as lung transplant, which you alluded to earlier on, and then some benign esophageal stuff we otherwise will take care of for our patients.

Erin Spain, MS [00:10:52] You care for end stage lung disease patients as part of the multidisciplinary lung transplant team at MUSC Health and have perform the most lung transplants completed at MUSC Health in 2021. It's also MUSC Health is the only lung transplant center in South Carolina. So tell me about what's happening right now with lung transplants at MUSC.

Dr. Barry Gibney [00:11:13] Much like the cancer care, it's also a team based approach. So it's a team of pulmonologists and social workers, nutritionists. We all get together to manage these patients that have end stage lung disease. The majority of our patients have end stage lung disease secondary to lung fibrosis, which is something that MUSC is quite excellent in caring for. There is a multidisciplinary fibrosis clinic run by the pulmonary division. So it's the majority of who we see for lung transplant as well.

Erin Spain, MS [00:11:42] But just recently, you have performed surgery on not one, not two, but three COVID-19 patients who have received lung transplants at MUSC Health. Now, this is something that's been happening in other places around the country, but now more so recently here. Tell me about this procedure and what it was like to take part in this procedure.

Dr. Barry Gibney [00:12:02] Sure. So the very first one was really kind of at the beginning of our understanding of what COVID pneumonia can do to patients and where we were trying to determine if this was a good use of both resources and the ability to get the patient through it. Now, the initial patient ended up being a fairly young gentleman who rapidly got sick at the very beginning of the pandemic and was exceedingly motivated and had family support that was also very motivating for him. So when he arrived at MUSC, he was on a ventilator, was unable to do much of anything from a breathing standpoint. The team got together to discuss whether this was something where we could potentially rehabilitate him to the point that either he may not need a transplant or get him in shape for a transplant. It seems kind of silly to say that we want a patient to be in shape for a transplant. However, if you are stuck in a bed and paralyzed, you end up doing quite poorly after a transplant. So we really emphasize the physical therapy side of things, getting out of bed and walking. So to do that for this patient is really hard to walk on a ventilator. What we ended up doing was putting him on something called ECMO: extracorporeal membrane oxygenation. So it's a machine that takes the blood out of your body, oxygenates it and puts it back in the body. And we did that. And he was motivated enough that with this circuit and with this machine and with the help of our nursing staff and the ICU and our physical therapists, he would get up and on a daily basis go for walks, sometimes walking the entire lap of the ICU. And when he showed us that he was motivated and strong enough to do that, it was a very easy decision to put him through and list him for a lung transplant. And when an appropriate donor offer came in, we were able to do the procedure. And thankfully his being young and motivated really helped him get through the operation. We were able to get him off of ECMO immediately after putting in the new lungs. His heart tolerated it wonderfully. His lungs were working excellently and he continued to be motivated afterwards and was able to get out of the hospital within our usual window, which is about 3 to 4 weeks after the operation. And he continues to do quite well with his new lungs and hopefully has a new lease on life.

Erin Spain, MS [00:14:16] And since then, you've been able to do two other such surgeries.

Dr. Barry Gibney [00:14:20] Yeah. So those thankfully, those were patients that were able to get out of the hospital and not need such kind of drastic interventions to get them to a transplant. However, they were patients that were oxygen dependent and really unable to do much more than walk, say, the length of three football fields. But both of those patients also were very motivated, did everything we asked them to do from getting in shape for the operation. And again, when donor offers came in, they did exceedingly well with their transplants.

Erin Spain, MS [00:14:47] There's been so many improvements and technologies in recent years in your field. What do you expect to see in the next five to 10 years? How are things going to change?

Dr. Barry Gibney [00:14:56] I think that probably the biggest area for improvement is still stage one lung cancer. And the reason I say that is, even though it is stage one lung cancer, when you look at the outcomes for stage one lung cancer, the five year survival is still only around 65 to 70%. Now, what that means is not a probability that if you're diagnosed with cancer, you only have a 70 percent chance of living. What it means is that I have 100 patients that all have stage one lung cancer, I only expect 70 to be alive in five years. And when we contrast that with, say, breast cancer, where if stage three breast cancer, that number is somewhere around 90 to 92, we have a long way to go with lung cancer. Part of the things that we do here at MUSC are constantly looking for ways to improve the care that we provide the patients. Again, it's a team based approach and a multidisciplinary approach. So I work in a lab with one of our medical oncologist, John Wrangell, where we try to discover new therapies for patients and implement them through clinical trials, all in an effort to improve survival, not only for these advanced stage cancers, but also extending down as early as stage one. So I expect to see more and more people looking at ways to improve the outcomes in that stage of the disease in the future, especially as things like immunotherapy are more and more embraced across the oncology community.

Erin Spain, MS [00:16:16] What do you do to optimize your health and live well?

Dr. Barry Gibney [00:16:19] I'm a really big cyclist. I've been riding my bike since first year of medical school. Actually, my then girlfriend, now wife, was a triathlete and was looking for somebody to train with her. And I mean, I ran track in college, so I had some athletic background but hadn't ridden a bike since I was like ten. I kind of was like, Oh, this can't be hard or anything. And it turned out to be like one of my favorite things to do. It's a whole other community that gets me out of the hospital, gives me a great deal of fitness. It's a lot of fun to be out and see, you know, the environment and just be out with really nothing to worry about other than just the road and my thoughts. I definitely really enjoy that and I've even extended it down to commuting to work where it's very similar, that it's just a easy way to kind of wake up in the morning, get in and feel refreshed and awake and then to go home and kind of decompress in the same fashion. So that's probably the biggest thing that I do for for my own physical fitness and well-being.

Erin Spain, MS [00:17:14] Dr. Gibney, thank you so much for your time today and explaining all that is happening in your field and what's offered at MUSC Health. We appreciate it.

Dr. Barry Gibney [00:17:23] Oh, well, thank you. It's my pleasure. And it was wonderful talking with you today.

Erin Spain, MS [00:17:31] For more information on this podcast, check out advance.muschealth.org.