Eur J Cardiothorac Surg 2001;20:663-668
© 2001 Elsevier Science NL
Structure of General Thoracic Surgery in Europe
By The EACTS/ESTS Working Group on Structures in Thoracic Surgery
, Chairmen:Walter Klepetko,
Torkel H.J. Aberg,
Antoon E.M.R. Lerut,
, Project coordination:Tomasz Grodzki,
Jean-Francois Velly,
William S. Walker,
, With contributions from:C. Ahren,
A. Arsovski,
I. Bellenis,
S. Bequiri,
R.G. Berrisford,
D. Branscheid,
J. Bibicic,
A. Csekeö,
I. Drescik,
J. Dussek,
J. Erzen,
F. Furmanik,
M.T. Godinho,
P. Goldstraw,
G. Gotti,
S. Halezeroglu,
J. Hamzik,
S. Harustiak,
J. Hasse,
P. Hartl,
P. Hostrup,
T. Horvat,
N. Ilic,
K. Jeyasingham,
A.P. Kappetein,
L. Kecskes,
T. Laisaar,
L. Lampl,
Ph. Levasseur,
G. Maggi,
G. Magnanelli,
G. Massard,
K. Moghissi,
T. Molnar,
Ph.H. Noirhomme,
T. Orlowski,
P. Pafko,
A. Petricevic,
J.L. Pujol,
E.M. van Raemdonck,
G. Ramos Seisdedos,
H.B. Ris,
J. Salo,
P. van Schil,
R.A. Schmid,
A. Thorpe,
H. Toomes,
A. Varela,
G. Varela,
F. Venuta,
V.M.sa Vieira,
W. Weder,
J.M. Wihlm,
P. Zannini,
, Project management:Gabriel Mihai Marta
Corresponding author. Department of Cardiothoracic Surgery, University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria. Tel.: +43-1-40-400-5620; fax: +43-1-40-400-5642
e-mail: walter.klepetko{at}akh-wien.ac.at
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1. Executive summary
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- This document presents a professional view of the optimal organization of General Thoracic Surgery (GTS) in Europe.
- It is intended as guidance to national governments and regional authorities and has been approved by the Councils and confirmed by the General Assemblies of the European Association for Cardio-thoracic Surgery (EACTS) and the European Society of Thoracic Surgeons (ESTS). Together, these societies represent the majority of European surgeons specialising in GTS.
- Current facilities and arrangements for the care of thoracic surgical patients are of variable quality throughout Europe with experience, workload and resources being sometimes below an acceptable level.
- A structure is foreseen with some GTS units being larger and having advanced with major thoracic surgical programs, providing subspeciality services such as transplantation (so called units of higher specialization). These units would also possess research facilities and cater for advanced educational needs within the speciality.
- Smaller units would be more generally distributed and would provide a more standard care, still with sufficient numbers of patients to achieve a sound overall level of expertise in thoracic surgery (so called units of standard).
- In both types of units the infrastructure should be orientated around patient needs and should encompass such features as: quality assurance, data collection in a European Registry, risk stratification, reciprocal voluntary audits, individualised surgical results, collaboration in clinical research, structured continued education and re-certification.
- The same specific expertise and organisational background should apply to other members of the team caring for thoracic surgical patients, especially anaesthetic, nursing and physiotherapy personnel. A larger amount of patients in each unit will allow for dedicated operating room, intensive care and general ward facilities.
- These outlined measures are expected to result not only in an improved quality of patient care European wide, but also in an improved cost-efficiency of GTS.
- To guarantee quality of education and recertification a European Board of Thoracic and Cardiovascular Surgeons (EBTCS) has been established, which is offering examinations in cardio-thoracic as well as thoracic surgery.
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2. Introduction
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This is a document prepared by the European Association for Cardio-thoracic Surgery (EACTS) and the European Society of Thoracic Surgeons (ESTS). It gives the professional view of the requirements and organization of GTS as guidance for the national governments and regional bodies. The EACTS and the ESTS represent the majority of European surgeons specializing in GTS.
GTS is one of the smaller speciality groups in medicine. It has developed differently throughout Europe. Thus, in some countries it is a subspeciality of Cardio-thoracic Surgery, while in others it lies within the remit of General Surgery. In some countries it is a recognized speciality of its own. This document is concerned with the practice of non-cardiac thoracic surgery, which is predominantly surgery to the lungs, oesophagus and mediastinum and all aspects of intrathoracic work excluding the heart and great vessels.
The uncertain speciality position of GTS has meant problems for surgeons dedicating themselves to and patients needing GTS. One consequence is, that the number that a unit may handle each year may range from as low as 10 to over 1000 patients each year. The experience levels can vary considerably.
In order to improve results and diminish suffering for our patients, the most effective measures we currently can undertake are organizational. Such organizational measures vary, but in essence, they are meant to build a dedicated team around the needs of the patients. In order to do that in a cost-effective way, there must be an element of centralization. This is feasible, as most thoracic conditions require elective management, so that a limited number of units placed strategically in urban areas would serve the great majority of the European population. Only in some, sparsely populated countries and areas, does travel time need to be considered as a factor for medical organization.
We foresee a structure built on some larger units of higher specialization with a high volume of patients, research facilities and educational tasks. Such units already exist in several countries. Furthermore, units of more standard care are foreseen with a lower, but adequate volume of patients. In both types of units, the infrastructure can be built around the patient's needs and encompasses a dedicated team, not only of doctors but also of nurses and other personnel. Furthermore, a higher level of quality assurance than presently established will be introduced. This includes the introduction of such features as a European Registry, risk stratification, reciprocal voluntary audits, feed-back of results to each individual surgeon, structured collaboration for clinical research, regulated education, re-certification, etc.
The developments suggested in this document will have to be handled differently by each nation and may take some years to implement as medical structures within each country vary. However, the patients’ needs are similar in all countries and it would seem intuitively correct to orientate service delivery around the needs of the patient. We are convinced, that the most effective measure to improve quality of care and provide optimal results for patients with thoracic surgical diseases, is to modify the current organization as described in this document.
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3. General Thoracic Surgery (GTS)
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3.1. Definition
GTS encompasses the factual knowledge, technical skill and judgement required to diagnose accurately and to manage surgically, diseases of the thorax (chest). The knowledge base includes, but is not limited to, diseases of the chest wall, pleura, lungs, trachea and bronchi, mediastinum, diaphragm and oesophagus. GTS requires in-depth knowledge of physiology, diagnostic imaging, organ function testing, semiinvasive and invasive investigation, preoperative evaluation, postoperative care, critical care, trauma, oncology and transplantation. It also includes experience in multidisciplinary treatment protocols.
3.2. Clinical competence
Competence in GTS entails the continued appropriate and skilled management of general thoracic surgical problems. This requires an active caseload of diseases of the thorax and a continued interest in the practice of GTS, as evidenced by attendance and participation in appropriate speciality meetings and symposia as well as involvement in research and education.
General thoracic surgeons are especially qualified to manage complex surgical situations that involve the organ systems detailed above. They are also qualified to assist in the management of pulmonary, pleural, oesophageal, mediastinal, chest wall and tracheal problems that arise in the course of patient management by allied specialists.
The main competence of a thoracic surgeon lies in the pre-, intra- and postoperative care for patients with general thoracic surgical diseases. This includes the investigation of patients, decision-making process on the indication for surgery in each individual, maintaining a highly specialized operating team to perform the specific procedure on each individual patient and to see him through the postoperative period. In essence, the main competence of a general thoracic surgeon is the ability to perform various operations, including all kinds of open, endoscopic or video-assisted surgical procedures in children and in adults as enumerated below.
- Operations involving resection, reconstruction, repair and biopsy of the lung.
- Operations involving the chest wall, including resection and reconstruction for neoplasms, thoracoplasty and repair of pectus excavatum and pectus carinatum and other chest wall deformities, as well as the management of traumatic chest wall instability.
- Operations involving resection, reconstruction and repair of the trachea and bronchi for neoplasms, strictures and trauma.
- Operations involving resection, reconstruction and repair of the oesophagus, including laparoscopic or thoracoscopic techniques and endoluminal procedures.
- Operations involving resection, reconstruction and repair of the diaphragm.
- Operations involving the mediastinum, including biopsy and resection of neoplasms, drainage of infections, mediastinal lymphadenectomy, mediastinotomy and mediastinoscopy.
- Operations of the pericardium involving resection, reconstruction and drainage.
- Endoscopic procedures using both the flexible and rigid scopes and instrumentation of the tracheobronchial tree and oesophagus.
- Operations for biopsy of the cervical, mediastinal and axillary lymph nodes.
- Operations on the thoracic sympathetic nerves.
- Operations to correct abnormalities of the thoracic outlet.
- Operations necessary for airway control, including tracheostomy, tracheal intubation and endoluminal procedures.
- Operations for management of pleural and pleural space problems, including thoracocentesis, tube thoracostomy, shunting for pleural effusion, management of pneumothorax, pleurectomy, decortication and drainage and resection of empyema
- Operations to provide exposure for interventions made by other specialists.
- All operations incidental to the performance of the above operative procedures.
- Operations for functional corrections and complications of emphysema.
- Operations involving transplantation of one or two lungs or lobes, including all diagnostic or therapeutic procedures related to the field.
- Operations for traumatic injuries to the chest or to organs within the chest and their sequelae.
- Operation on vascular structures, related to the management of any pathology treated within the field of GTS.
- Critical care management and procedures, including placement of central venous lines, Swan–Ganz catheters, arterial lines, ventilator management and total enteral and parenteral nutrition management.
- Management of the complications of the above procedures, if necessary by further specific thoracic procedures.
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4. Structure of a General Thoracic Surgical Unit
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4.1. General principles
To ensure the highest possible patient care within the field of GTS and to promote continuous development of the speciality itself, GTS needs to be performed within the logistical and economical framework of specialised units. The structure of these units should be designed to allow:- Patient care and treatment at the level of accepted standards.
- Education of surgical trainees in the field of GTS according to valid criteria.
- Continuous development and research in the field of GTS.
To meet these demands and to become accepted as a unit specialised in GTS, a certain organizational background and a number of minimum requirements, depending on the individual level of standard or high specialization, are thought to be necessary.
4.2. Institutional status
GTS units of high specialization should be within a university setting or alternatively linked to a university. The unit should be headed by a surgeon certified by the European Board of Thoracic and Cardiovascular Surgery (EBTCS), or an equivalent body recognized by the EBTCS, preferably possessing academic qualifications. This Head of Department should be entrusted with educational and scientific responsibilities, and should possess a minimum experience of five years clinical practice as a qualified GTS surgeon. There should be a separate budget and clearly defined staff and institutional resources.
GTS units of standard should be either entirely freestanding or within a combined unit with cardiac/vascular/general surgery. If the latter is the case, budget, personnel and institutional resources for GTS should be clearly defined and separated. The head of such a unit should be an EBTCS-certified person with predominant and profiled engagement in GTS, with a minimum experience of 5 years clinical practice as qualified GTS surgeon.
4.3. Institutional resources
4.3.1. Surgeons
GTS units should have a dedicated staff equivalent to one EBTCS approved surgeon per 150 major thoracic procedures per year. Adequate on-call arrangements should be in place to ensure that patient care is continuously provided. In units of higher specialisation surgical staff are expected to participate in research activities.
4.3.2. Operating theatres
The number of fully equipped operating theatres within a GTS unit may be calculated on the basis of 1 per 300–400 major thoracic procedures per year. A fully equipped operating theatre includes standard equipment for video-assisted surgery. One additional operating theatre should be available for minor procedures generated by this case load.
4.3.3. Advanced care facilities
GTS units of higher specialisation should preferably have access to a dedicated thoracic Intensive Care Unit (ICU). Standard units require access to dedicated thoracic beds within a larger ICU, either together with the cardiac unit or in a multispecialty ICU. The average number of beds required is 1–2 per 300 major thoracic procedures per year. In addition, High Dependancy Unit beds are necessary at a rate of 1 per 100 major thoracic procedures.
4.3.4. Ward care
GTS patients should be cared for in a dedicated GTS surgical ward with full supporting paramedical staff, including dedicated physiotherapists. Optimally, there should be 4–6 beds per 100 major thoracic procedures per year. One wound treatment room should be available on every ward. Segregated male and female areas and facilities should be provided and at a minimum one bed should be in a single room to allow provision for barrier nursing.
4.3.5. Outpatient
There should be sufficient facilities for outpatient visits with same visit access to radiology.
4.3.6. Inpatient diagnostic facilities
GTS units must have access to on-site support facilities. Minimum facilities must include:
- haematological, biochemical and microbiological laboratories;
- respiratory pathophysiology laboratory;
- endoscopic examinations by bronchoscopy and oesophagoscopy;
- radiological investigation by plain X-ray, contrast studies, ultrasound, vascular imaging and CT-scan;
- cytology, histopathology and frozen section analysis.
Units of higher specialization should also have access to:
- an oesophageal pathophysiology laboratory;
- more advanced imaging techniques including MRI and, ideally, PET scanning;
- specialist laboratories relevant to subspeciality work, such as transplantation.
4.3.7. Education
There should be in-house facilities for education with adequate provision of meeting and lecture rooms and access to medical libraries, databases, e-mail and internet.
4.4. Minimal annual medical care activities
- The overall number of major thoracic procedures per year should be more than 150±50 in centres of standard and more than 300±50 in centres of high specialisation
- Oesophageal resections should be performed only in units with special interest and should be more than 25 resections per year.
- Lung transplantation and its alternative procedures should be performed only in centres with high specialisation and with cardiac surgical facilities. A number of 10 transplantations per year is regarded as minimum.
4.5. Quality surveillance
- Quality surveillance has to be performed in every GTS unit. There must be a computerized documentation of all procedures performed together with a documentation of all major adverse events. Results should be analyzed on a regular basis.
- There should be a recognized and generally accepted system for risk stratification. Complications should be discussed regularly and a feedback of risk stratified individual results should be given to every surgeon.
- Procedure specific mortality figures (i.e. pneumonectomy, lobectomy, oesophageal resection, one year survival for lung transplantation) should be in the official range given by the European Registry according to the spectrum of the database.
- GTS units should report to the European Registry for Thoracic Surgery on a regular basis. Information from this registry should be analyzed and given to every surgeon and to the GTS staff.
- Regular analysis of long term follow-up should be performed.
4.6. Educational and experimental facilities
- GTS units need to provide the logistic basis for ongoing education and research.
- GTS units should be the only recognized training centers for GTS.
- GTS units of high specialisation should provide the facilities and ambience for advanced postgraduate education for GTS surgeons.
- GTS units of high specialisation must have, and units of standard care should have, access to experimental laboratories and to basic science laboratories.
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5. Training of general thoracic surgeons
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- Surgical trainees who specialize in GTS with the aim of qualifying as an EBTCS approved surgeon will have had their specialized education in units recognized and authorised for training in GTS according to the rules in each country.
- Special training in GTS in order to qualify for independent positions needs a minimum duration of 3 years.
- Experience of general as well as cardiac and vascular surgery is mandatory.
- During the training in GTS, a comprehensive knowledge of the entire field of GTS must be offered to the trainee. A certain minimum number of operations according to the requirements of the EBTCS have to be performed by every surgeon during this training period.
- At the end of the training period the surgeon should apply for official certification by the EBTCS.
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6. Recertification of GTS Surgeons and Units
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- GTS surgeons approved by the EBTCS need to recertify after a period of every 8 years. Criteria for recertification should include evidence for their ongoing work in the field of GTS together with records of their operative practice within the period of time since their last certification.
- GTS units officially acknowledged by the certification process need to undergo recertification according to the rules of the certification process.
- Minimal demands of activities should meet the range defined by this document.
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7. Notes
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- The patient flow of GTS patients can be divided into detection, investigation, treatment and follow-up. This ‘patient chain’ or ‘clinical pathway’ is variably organised in each hospital with many departments being involved including pulmonology, ENT, internal medicine, anaesthesiology, etc. Also, some GTS units concentrate on the operative treatment, whereas others take a much broader responsibility for the diseases concerned, including preoperative investigation and postoperative medical treatment and follow-up. The recommendations in this document should be interpreted with this in mind, as resource requirements may vary.
- Resource requirements are often given as a fraction per ‘100 major operations’ in the denominator. A major operation is here defined as a ’thoracotomy or any mini-invasive procedure of equal time requirement’. However, for every 100 major operations many minor or intermediate grade diagnostic, assessment or staging procedures are also required. As these are often performed in GTS units, an allowance has been made for these procedures within the identified resource requirements. If these lesser procedures are performed in another speciality, the resource requirements have to be calculated accordingly.
- In this document, several new features of quality surveillance are introduced. During the preparation and discussion of the document, a broad consensus has been evident among GTS surgeons that these features are helpful and indeed necessary. The two Societies (EACTS and ESTS) have decided to organise quality surveillance with regard to the following features: European Board Examination and Re-certification for individual surgeons, Good Practice Certificates and re-certification for GTS units, a GTS European Registry including risk stratification, mortality and morbidity, with the possibility of feed-back to the individual surgeon.
- Non-profit reimbursement for the costs of these processes will have to be charged to each unit. The initiators of this document anticipate that each hospital will wish to participate in these quality surveillance features by paying relevant charges. We also expect that the necessary infrastructure for quality surveillance (i.e. computers, computer programs and some staff assistance) will be provided.
- This document will be sent to each hospital where a member of the two Societies works, to each national medical society organizing GTS, as well as to each European Government Agency responsible for Health Care. In addition, each member of the two Associations will receive a copy. It will also be featured on the HomePage of the Cardio-thoracic Surgeons, the CTSNet (http://www.ctsnet.org/). Lastly it will be sent to the UEMS.
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Top
1. Executive summary
2. Introduction