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Eur J Cardiothorac Surg 2001;19:115-117
© 2001 Elsevier Science NL

Presidential address

Thoracic surgery in Europe

Back in business?

Received 18 December 2000; received in revised form 9 January 2001; accepted 9 January 2001.

	Dear Colleagues and Friends,

Top Dear Colleagues and Friends,

 
The end of my term as your president is near and so is the magic year 2000. The transition from the old into the new millennium didn't change the world. The millennium bug if there was any at all, did not cause great damage, and apart from the New Year Eve's fireworks and champagne the year 2000 has seen business as usual. But the change of the millennium gives me the opportunity to reflect on the destiny of Europe's Thoracic Surgery. Are we back in Business? Throughout the last few decades of the 19th century operative interventions in the heart, lungs, and other organs in the chest almost invariably had fatal results. Accordingly, little interest was expressed in the establishment of thoracic surgery as a speciality. However as more and more papers on thoracic surgery were being presented during the first twenty years of the 20th century this attitude changed. Both in the United States and in Europe, Thoracic Surgical Societies emerged and in 1933 the Society of Thoracic Surgeons of Great Britain and Ireland was founded. The development of general anaesthesia, and later in the twenties, the development of endotracheal intubation by Rowbothamm and Magill allowed the maintenance of pulmonary function during anaesthesia. This was a critical break-through. Although fundamental contributions to Thoracic Surgery, such as the first successful esophagectomy and pneumonectomy for cancer were performed by Torek and by Graham respectively in the US, equally major developments came from Europe. Theodore Billroth was the first to perform successful operations on trachea, oesophagus and stomach. His views on surgical training and education were unique for the time in which he lived, resulting in the famous Viennese School of Surgery so prominent on the European Surgical scene at the beginning of the 20th century. Czerny, Mickulicz, Sauerbruch, Tuffier, and von Hacker were other explorers of that ‘terra incognita’ of Thoracic Surgery. Between the two world wars and after World War II, many European surgeons contributed substantially to further developments in thoracic surgery.

Thoracic surgery was the aristocrat discipline of post World War II surgery. But times changed rapidly. The explosion of cardiac surgery, especially of coronary bypass surgery, absorbed much, far too much, attention and masses of young surgeons fell in love with this ‘call girl’ of surgery letting down the ‘grand old lady’ of Thoracic Surgery. Back in 1981 Donald Paulson in his AATS presidential address brought into attention the imbalance in training between cardiac and general thoracic surgery in the US, and the danger of a vacuum in the practice of thoracic surgery, resulting in incompetence in General Thoracic Surgery. While the mean number of cardiac operations per year for a trainee increased from 55 in 1971 to 166 in 1980 the number of general thoracic cases remained almost unchanged over the same time zone. Paulson warned against general thoracic surgery being increasingly performed without careful consideration or an operative plan. In his address he noticed the encroachment into thoracic surgery by specialists in traumatology, oncology, and gastroenterology.

It was a period where barely a few centres in the US could offer sufficient workload for a proper training programme in General Thoracic Surgery. In Europe, the situation didn't differ. Cardiac surgery dominated the scene, and the introduction of videoscopic surgery in the late eighties resulted in further fragmentation of thoracic surgery, especially of oesophageal surgery, and in particular, reflux surgery has been lost to the general or so called visceral surgeons.

In 1995 amongst the 120 cardio-thoracic consultants in the UK who performed thoracic surgery the mean number of lobectomies was around 20/year/surgeon. Only about 10 centres out of 40 were performing more than 200 pulmonary cases a year. In my own country, in the same year half of all major pulmonary resections were performed in 16 hospitals, whereas 104 hospitals had a maximum of 12 cases a year, that is one a month or less.

Germany in 1989 had 149 centres performing less than 100 cases a year accounting for 25% of all cases in the country. Only 19 centres had more than 200 cases a year. In the Netherlands 70% of all pulmonary resections are performed by General Surgeons with an average resection rate of 15 cases a year. These numbers are astonishing indeed and illustrate the deep identity crisis of General Thoracic Surgery.

At the annual meeting of scientific organisations in the US and Europe such as the AATS, STS and EACTS, 75% of the presentations were and still are in cardiac surgery. General Thoracic Surgeons did not feel at ease and dissatisfaction resulted in the creation of the General Thoracic Club in the US, now a powerful lobby, and the creation in 1993 of ESTS in Europe. Fortunately things have started to change in recent years. Oncologic developments, and new technologies have resulted in an increased interest towards General Thoracic Surgery. I only have to mention lung transplantation, lung volume reduction, surgery for pulmonary metastases and multimodality therapies. Expansion of cardiac surgery has slowed down, and even a decrease has been noticed in coronary bypass surgery. The cardiac call girl is somewhat less attractive, the grand old lady has undergone a nice face-lift.

Today the self-confidence and identity of General Thoracic Surgery has improved greatly.

The challenge now is how do we go forward.

The first question is: does general thoracic surgery need to become a separate speciality? In theory the answer is yes. Thoracic Surgery has an independent scientific and clinical basis. Pulmonologists, gastroenterologists and patients want their surgeon nearby. Pragmatically the answer is no. Because of the economic reality a large number of major operations, (approximately 500 cases a year) will be necessary to survive as a centre. In the UK only some five centres may reach this number; in Germany five in 1989; and in my country barely one. So Thoracic Surgery will need a back up, and whether this has to come from cardiac or visceral surgery is in fact not so relevant as long as the standards of quality are maintained. It is up to Thoracic Surgeons to decide what they want, and this may differ from country to country. Some countries have already worked out their own system, like Germany where there is now a dual track system through the cardiac surgery pathway and through the visceral surgical pathway. In the UK cardio-thoracic surgery has been one speciality from its inception, and is likely to continue as such for the foreseeable future. Like many others, I feel that it is more sensible to choose an alliance with cardiac surgery rather than link up with the remnants of the old general surgery. This allows for close cooperation sharing similar infrastructure and junior staff, which I think is less evident when working within a general surgical environment.

This is the reason why, along with others, I have been trying over the last few years to bring ESTS and EACTS as close as possible. In so doing we have kept the Board Certification for Thoracic Surgery within the European Board of Thoracic and Cardiovascular Surgery, rather than having Thoracic Surgery on its own within the UEMS Board of Surgery. Whatever the option, one thing however has to be extremely clear. Thoracic Surgeons should have full responsibility for the Thoracic Training Programme.

A second question then relates to the number of centres and the definition of the Thoracic Unit. This question obviously brings up the discussion about volume and outcome. This is a very hot topic with an increasing number of publications emerging from the recent literature. Although most of us are convinced that there is a direct relationship between volume and outcome, this remains however very difficult to prove. Furthermore one has also to take into consideration the geographical aspects of a given country. It is unrealistic to assume that all patients can be drained to a few megacentres in big urban areas. I am very much in favour of a system by which a limited number of centres of high specialisation is created. Each of them needs to link up with a network of satellite centres of good practice determined by the geographical and demographic needs of a given country. The centres of high specialisation are responsible for setting the quality criteria for the whole network. Such a centre typically, should be within an environment dealing with education, training and above all research and developmental capacities. These centres have to coordinate within this network the audit, quality control and training programmes. This to my mind is the only way to get rid of the ‘tail end centres’ performing too few operations.

At this point it is impossible to come up with figures on the number of centres and the number of operations required per centre and per pathology for the different European countries. This is a very difficult task indeed. But I am particularly pleased that I was instrumental within the EACTS–ESTS to initiate a working party that specifically tackled this problem. This working party is headed by our colleagues Klepetko, Grodzky and Velly and the results of their work will be presented during this meeting. From this survey they will try to come up with definitions of a Thoracic Unit of good practice and high specialisation.

Another very important project is the European Thoracic Database project a joint ESTS–EACTS effort led by our secretary general Richard Berrisford who will present a progress report during this meeting. I believe the results of these projects will offer unique opportunities to influence the National and European bodies such as UEMS when discussing the future of Thoracic Surgery in Europe. Your further cooperation is essential to the success of this project, and I want to thank all of you who have been contributing.

A third and final question is one concerning education and training. I strongly believe that the time has now come to create the certificate of special competence in General Thoracic Surgery, very much like the Canadian model as originated by Pearson in 1976. There is no longer a place for one single fellowship in cardio-thoracic surgery during which a trainee has to rotate alternatively over Cardiac and Thoracic Surgery after which he/she obtains a certification in cardiothoracic surgery.

Today it seems more logical to separate certification in one for Thoracic and one for Cardiac Surgery. Training in thoracic surgery, more than training in cardiac surgery requires sufficient initiation in general surgery, in particular visceral surgery for those who intend to specialise in oesophageal surgery. Such a training programme would permit board certification of young surgeons coming from either a cardiothoracic or general surgical training programme. Furthermore, I believe that it is necessary to pay sufficient attention to general surgeons willing to profile themselves in thoracic surgery.

I have spent a great deal of my professional and scientific career amongst general surgeons and I can testify that within this group whether they are visceral surgeons, general surgeons, or surgical oncologists, a good many are outstanding thoracic surgeons and scientists.

As to the specific training, a common trunk of 1-year with an alternation of 6 months in cardiac and 6 months in thoracic surgery as a junior resident seems mandatory. Thoracic residents should then continue for a number of years specifically in thoracic surgery. One extra year of Academic Research or Specialised Clinical Training would be optimal. The Board would then deliver certificates of special competence in Thoracic Surgery.

In conclusion I am convinced that the future of Thoracic Surgery is bright again, as bright as in the past. I am confident that we are back in business indeed. The upcoming 2001 joint EACTS–ESTS joint Meeting therefore offers a unique opportunity. Both organisations firmly believe that this meeting, probably the world's biggest meeting ever in Thoracic Surgery, will strengthen the profile of Europe's Thoracic Surgery and will stimulate surgeons, and above all, trainees, to dedicate their activities even more towards this fascinating speciality.

So may I, at the end of my term as your president, encourage you to promote and to prepare this meeting. A strong presence of our membership will be to the benefit of ESTS. In September 2001 Lisbon is the place to be in.

	Footnotes

 
Delivered at the 8th European Conference on General Thoracic Surgery of the European Society of Thoracic Surgeons, November 1–4, 2000, London

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