Eur J Cardiothorac Surg 2002;21:1-4
© 2002 Elsevier Science NL
General thoracic surgery as a monospeciality — a realistic vision?
Heikki Toomes
Klinik Schillerhoehe, Solitudestrasse 18, Gerlingen, Gerlingen/Stuttgart, D-70839, Germany
Received 28 September 2001;
received in revised form 15 November 2001;
accepted 17 November 2001.
e-mail: toomes{at}klinik-schillerhoehe.de
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1. The development of General Thoracic Surgery
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With the Presidential address this year I will continue the work of former Presidents to summarize the recent activities and to give a vision of the future of General Thoracic Surgery.
Historical background is important for the understanding of ongoing processes. At the beginning of the past century the development of chest surgery was initiated by the purposeful experimentation of French, German, and other European surgeons. Professor Francisco Paris from Valencia published an overview of the ancient history of thoracic surgery, especially from the Spanish point of view in our second Newsletter. In the report of our past President Toni Lerut, you will also find important developments reported from the field of General Thoracic Surgery.
The discovery of the low-pressure method is linked with names such as Brauer, von Mikulicz, and Sauerbruch in 1904. The accurate experiments of the last-mentioned led to the development of the decompression chamber – Sauerbruch's cabinet. The high-pressure method and the introduction of endotracheal anaesthesia by Kuhn in Germany – Auer and Meltzer working in the Institute of Physiology at the Rockefeller Institute followed in the years between 1901 and 1909.
Advances in anaesthesia with endotracheal ventilation made increasingly extensive thoracic surgical interventions possible, as positive pressure could be maintained in the lungs and collapse on opening the chest avoided. Following the first atypical pulmonary resections for tuberculosis at the end of the 19th century by Delorme, Doyen, and Tuffier in France – Heidenheim undertook the first lobectomy in Worms in Germany in 1901. In 1931, Nissen successfully performed the first pneumonectomy on a child with bronchiectasis and Graham, in 1933, carried out the first pneumonectomy to remove a bronchial carcinoma.
Anatomically isolated preparation of the hilar structures was undertaken by Rienhoff in 1933, whereby considerable reduction in complications was achieved. Lung surgery progressed rapidly so that the anatomical segmental resection was employed clinically by Churchill and Belsey in 1939 in England. Edwards established the thoracic tradition of the Brompton School in London and his first assistant Price Thomas performed the first bronchial sleeve resection in 1947. An important prerequisite for the lobectomy was the introduction of suction drainage of the pleural cavity for the reexpansion of the residual lung. This was achieved using the siphon drainage developed by von Bülau in 1890.
After the Second World War General Thoracic Surgery in Germany advanced. Resection procedures became increasingly important. The introduction of extracorporeal circulation brought a new era at the end of the 1950s, allowing open-heart operations to be performed. These new surgical possibilities led to a huge expansion of heart surgery. Extensive work was done in the 1970s to ascertain the demand for operative interventions in the area of thoracic and cardiovascular surgery in Germany. The German Society for Thoracic and Cardiovascular Surgery produced an analysis of requirements as early as 1971. Three more followed in the 1970s. A large deficiency in operative capacity was demonstrated. As a result, existing departments were enlarged and new ones set up. However, the development tended to be rather one-sided in favour of heart surgery. The 20 clinics for heart surgery in the 1970s were supplemented to the now existing 
80 departments of cardiac surgery.
The development in General Thoracic Surgery has been exactly the opposite. Despite continuous increases, e.g. in bronchial carcinomas and mesotheliomas, clinics for General Thoracic Surgery have been closed during the last decades. The closure could to some extent be due to reduction of tuberculosis.
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2. Special scope of General Thoracic Surgery
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General Thoracic Surgery comprises operative measures in cases of congenital anomalies, malfunction, diseases and injuries of the thorax, the pleura, the tracheobronchial system, the lungs, the diaphragm, oesophagus, and mediastinal organs. Because of high proportion of cancer patients – about 70% – thoracic surgery today in Europe is a largely oncological surgery.
Knowledge of the diagnostic procedures in radiology, nuclear medicine, internal medicine, and pneumology is therefore necessary, and evaluation of the relevant findings must be practised so that preoperative tumour-staging can be undertaken. In the same way, the basics of oncology and radiotherapy of tumours must be mastered and their effects on the organism known. Operative success is depending on the indication and choice of surgical technique. At the beginning the risks must be ascertained; especially the functional effect of an intervention involving reduction of pulmonary capacity must be considered in terms of the immediate and later postoperative phases.
The organ-saving techniques used in lung surgery as well as the special possibilities of intensive postoperative treatment give even high-risk patients strong chances of survival. The new multimodal therapies including neoadjuvant combined chemo-radiotherapy of malignant tumours in advanced stage presuppose technical skill of the thoracic surgeon and give the patients a fair chance of survival. These therapies are getting more complex and imply a high level of special knowledge.
Extended resections of Pancoast and chest wall tumours combined with reconstruction with major flaps and ‘sandwich’ prostheses yield good results and long-term salvage. Tracheal resection and reconstruction, and oesophageal surgery are other fields of thoracic surgery requiring special knowledge and extensive experience. Videoassisted thoracoscopic surgery was introduced about 1990 and has had a furious development. In many departments, as in our own, nearly half of the thoracic surgery is performed per VATS. This kind of surgery also presupposes technical skill of the thoracic surgeon and special equipment. The role of laser-, cryo-, photodynamic therapies in the treatment of thoracic malignancies increases every year, like stenting and interventional endoscopic procedures.
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3. Determination of capacity of General Thoracic Surgery
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In 1989 a questionnaire to determine the capacity for General Thoracic Surgery was circulated on behalf of the German Society for Thoracic and Cardiovascular Surgery. Copies were sent to all heads of departments which had given thoracic surgery as a part of their work in the book ‘German Surgery 1988’.
Two hundred and fifty-nine questionnaires were sent and 190 (73.4%) answered, which is a high rate. Of 16 268 major thoracic surgical procedures, only 57.2% took place in specialized clinics. Nineteen departments with more than 200 operations a year were responsible for 55.2% of the total number of interventions. In total, 78.4% of the departments undertook the operations only occasionally. The necessary special knowledge and skills can only be gained and sustained in centres with a high rate of the appropriate interventions.
The demand of thoracic surgical interventions was calculated out of the incidence of thoracic surgical diseases using various registers in Germany. The need of surgical procedures for benign diseases and the resection rates for malignant diseases have been well-documented for decades.
The analysis showed a need for 26 927 major thoracic surgical interventions annually in the Federal Republic of Germany, at that time with 61.1 million inhabitants [1]. This corresponds to 441 major thoracic surgical operations per one million inhabitants. The analysis also shows that about 10 000 surgical procedures were not performed for whatever reasons.
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4. Specialization
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A comprehensive and well-grounded training over several years is necessary for specialization in General Thoracic Surgery. With the introduction of Thoracic and Cardiovascular Surgery as a separate surgical speciality in 1976 in Germany, a specific and organized programme for training was initiated. With the intention of offering the thoracic surgeon the whole spectrum of thoracic and cardiovascular surgery in a training programme, thoracic surgical interventions such as thoracoplasty, lung resections, operations on the tracheobronchial system as well as closed- and open-heart surgery and operations on the vessels were stipulated in the training list (Table 1).
The training programme also included knowledge and experience in pneumological, cardiological and angiological examination procedures. This training schedule closely follows Anglo–American conceptions.
In spite of this programme for specialization, the training for General Thoracic Surgery and the development in the field of General Thoracic Surgery were not satisfactory and tended to be rather one-sided in favour of heart surgery.
In the USA, also, there are complaints that in many institutions, General Thoracic Surgery has been pushed into a second-class role as a result of the enormous expansion of heart surgery. In Germany, the Society for General Thoracic Surgery was founded in 1991 to take care of the special interests of the General Thoracic Surgery. These efforts led to the introduction of General Thoracic Surgery as a monospeciality, which was accepted by the German Medical Assembly in 1992.
Certification can be achieved after certification either in cardiac or general surgery. The complete training period is 7 years including 3 years of General Thoracic Surgery. Contents of the surgical training are listed in Tables 2–4.
Since introduction of the monospeciality we have had an increase of quality in thoracic surgery. Almost every year new departments of General Thoracic Surgery have been established. Already, a few years after introduction of the monospeciality we noted a remarkable change-over of thoracic surgery towards departments performing thoracic surgery as a monospeciality.
In 1996 the German Society for General Thoracic Surgery investigated and found that 116 departments reported that they are performing General Thoracic Surgery (Table 5).
This year the German Medical Assembly accepted the Common Trunk as a basic training programme. The planned Federation of Surgery (Fig. 1) was put off 1 year to have time to carry out a similar Federation for the Internal medical disciplines.
Parallel to the activities in Germany the same development is now taking place in Europe. European Society of Thoracic Surgeons (ESTS) was founded in 1993 to take care of the special interests of the General Thoracic Surgery. In 1999, after discussions in Nancy and Glasgow, Walter Klepetko, Vienna, accepted the tremendous job to perform an European inquiry on General Thoracic Surgery. His work together with coworkers from European Association for Cardio-thoracic Surgery (EACTS) and ESTS will be presented during the Joint Meeting in Lisbon. The proposal contains the guidelines for an unit of General Thoracic Surgery and guidelines for the surgical training in General Thoracic Surgery.
We also have the great honour of having Mark B. Orringer, President of the American Society of Thoracic Surgeons (STS), as a guest at our Joint Meeting in Lisbon. He will give a lecture concerning the development of General Thoracic Surgery in the USA. We will, during our Joint Meeting, have an excellent opportunity to discuss the status of General Thoracic Surgery in Europe and the USA.
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5. European business
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Looking at the professional side of General Thoracic Surgery, I first have to explain the structure of the European Union (EU) (Fig. 2). The EU consists of 17 Directorates of which three to four are dealing with medical subjects. The advisory organ for the EU is the Standing Committee of European Doctors (C.P. – Comitè Permanent). The Union Européene des Medecins Specialises (UEMS) is the Advisor of the Directorates in medical questions. The UEMS is assisted by 27 professional (not scientific) Sections. A medical speciality can be represented either as a Section, like Paediatric surgery, or as a Division within a Section like Vascular surgery. Sections are allowed to create an European Board. Each Section has an Executive Council and a Management Council, with two representatives of each UEMS member state.
Within the European Board of Surgery there are ongoing discussions to introduce the Common trunk and the UEMS Executive Council wants to develop a Federation of Surgical Speciality Sections. So far Thoracic surgery is not a member of any Section of the UEMS. The application for an independent Section for Thoracic and Cardiovascular Surgery was made through the Dutch delegation to UEMS, in accordance with the rules of procedure of the UEMS. In December 2000 the application with a Division of Thoracic Surgery and a Division of Cardiovascular Surgery was fully supported by the EACTS, ESTS, and the European Society for Cardio-vascular Surgery (ESCVS). This year the German Society for General Thoracic Surgery also made an application for a Division of General Thoracic Surgery in the Section of Surgery. The negotiations are on-going.
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6. Monospeciality General Thoracic Surgery
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We are now coming to the question of a monospeciality for General Thoracic Surgery, and I mean, that this question can only be answered out of the scope of surgical quality.
A programme for Quality Management is sponsored by the German Society for General Thoracic Surgery since 1989. In 1996 we published this programme in Acta Chirurgica Austriaca [2].
Because of the lack of money we could not start this programme until Autumn 2000. So for the moment I do not have data to report upon.
One important report on quality in thoracic surgery was published in Chest 1998 [3]. Silvestri and coworkers analyzed the mortality rate in patients undergoing lung cancer resection.
In 1720 resections the mortality was significantly higher in patients who underwent lobectomy by General surgeon versus Thoracic surgeon (5.3 vs. 3.5%, P<0.05) and the same in patients with extreme comorbidities or age (7.4 vs. 3.5%, P<0.05).
A German analysis this year of 1561 oesophagectomies in 273 hospitals showed a mortality rate of 16.5% in hospitals performing less than six oesophagectomies a year compared to 4.8% in high volume centres [4]. These results are confirmed by reports from the USA, England, Netherlands, and Denmark.
Similar data are available in rectal surgery for carcinoma. International studies have shown that the most important prognostic factor is the surgeon [5].
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7. Conclusion
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Summarizing all facts and experiences to a conclusion I mean there is a strong need for a monospeciality for General Thoracic Surgery in Europe. In countries with a large population this is already practically the case but without a legal establishment. In countries with small populations the objection often is, that there will not be enough thoracic surgical procedures a year to maintain a centre for General Thoracic Surgery. The calculations we made demonstrate a need of 440 major general thoracic surgical procedures per million inhabitants a year. These figures correspond to a need of one or two centres per million inhabitants.
With these remarks concerning the monospeciality General Thoracic Surgery, I close the Presidential address and look forward to the planned discussions to this subject in the Joint Session EACTS/ESTS/STS.
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References
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Toomes H. Development, Prerequisites and Specific scope of General Thoracic Surgery: Analysis of Requirements and Capacity for the Federal Republic of Germany (West). Thorac Cardiovasc Surg 1990;38:324-334.[Medline]
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Friedel G., Toomes H. Qualitätssicherung – Thoraxchirurgie. Acta Chir Austriaca 1996;28:116-120.
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Silvestri G.A., Handy J., Lackland D., Corley E., Reed C.E. Specialists achieve better outcomes than generalists for lung cancer surgery. Chest 1998;114:675-680.[Abstract/Free Full Text]
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Hölscher AH. Esophageal cancer – operative therapy through high-volume centers. English summary. Dt Ärztebl 2001;98:A:1890–1894 /Heft 28-29/
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Schumpelick V, Willis S, Kasperk R. Radical and function-preserving surgical therapy of rectal cancer. English summary. Dt Ärztebl 2000;97:A:1138–1146 /Heft 17/
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