The Society of Thoracic Surgeons National Database status report

This report describes the development of the first known national surgical database designed for the practicing community cardiothoracic surgeon. Acceptance by members of The Society of Thoracic Surgeons has been gratifying. The number of patients on the system has grown from 116,109 at the end of 1991 to an anticipated 350,000 to 450,000 by the end of 1993. At the time of this report, 842 surgeons were participating, and more than 1,200 will be on the system by the end of 1993. A risk stratification system has been incorporated into the software, which predicts each patient's risk based on the individual surgeon's past experience. Trend analyses demonstrate a substantial increase in the number of patients at increased risk for perioperative death for coronary artery bypass operations over the past 5 years, while observed mortality has remained relatively constant. Programs are available for adult and congenital heart disease, lung cancer, and esophageal cancer, and modules for mediastinal tumors, pleural disorders, and benign pulmonary disease will soon be added. We anticipate that growth will continue as the need for practice profile data increases because of reimbursement issues.

The history of thoracoscopic surgery

The necessity for thoracoscopy became apparent with the adhesions that limited the success of Forlanini's introduction in 1882 of artificial pneumothorax in the treatment of pulmonary tuberculosis. The first thoracoscopy, using a modified cystoscope, was performed by H. C. Jacobaeus, a professor of medicine, not surgery, in Stockholm, publishing in 1910. Thoracoscopy and division of adhesions (intrapleural pneumonolysis) then spread all over the world, with reports of series of 1,000 or more cases in spite of a significant incidence of complications. Its use declined rapidly after the introduction of streptomycin in 1945, becoming then confined to relatively minor diagnostic procedures except in a few European centers. The advent of video-assisted thoracoscopes and the development of ancillary instruments has allowed a new explosion of thoracoscopic surgery. Surgeons, in whose hands the procedure now rests, should nevertheless be aware of the five unacceptable thoracoscopic disasters--wrong side, kebab lung, "clotted hemothorax," artificial lunchothorax, and aorto-pleuro-cutaneous fistula.

Atrial switch operation: past, present, and future

The atrial switch operation was developed by the efforts of many surgeons, with the most notable contributions made by Blalock, Hanlon, Albert, Baffes, Senning, and Mustard. The atrial switch operation was the first definitive repair for patients with transposition of great arteries and produced good results. Although it is rarely performed today, the atrial switch is not merely of historical interest as there remain a few important indications for this operation. A thorough understanding of the atrial switch is still required for surgeons dealing with complex congenital cardiac malformations. Herein we summarize the history, review long-term results, and discuss the future of the atrial switch operation.

The rise of cardiovascular medicine

Modern cardiology was born at the turn of the nineteenth to twentieth centuries with three great discoveries: the X ray, the sphygmomanometer, and the electrocardiograph. This was followed by cardiac catheterization, which led to coronary angiography and to percutaneous coronary intervention. The coronary care units and early reperfusion reduced the early mortality owing to acute myocardial infarction, and the discovery of coronary risk factors led to the development of Preventive Cardiology. Other major advances include several cardiac imaging techniques, the birth and development of cardiac surgery, and the control of cardiac arrhythmias. The treatment of heart failure, although greatly improved, remains a challenge. Current cardiology practice is evidence-based and global in scope. Research and practice are increasingly conducted in cardiovascular centres and institutes. It is likely that in the future, a greater emphasis will be placed on prevention, which will be enhanced by genetic information.

The development of the modern oxygenator

From 1953 when Gibbon first successfully supported a patient with extracorporeal circulation to about 1980 many different types of oxygenators were developed. Since their introduction in the early 1980s, microporous hollow fiber oxygenators with blood flow outside the fiber have become the dominant type of oxygenator in use. Their success has been due to both the ability to specify the required properties for a good oxygenator and the application of modern design tools, especially computational fluid dynamics, to the design process. The result has been the availability of many oxygenators from different manufacturers that differ to some extent in their performance but all of which provide adequate performance for successful and safe clinical use.

Thoracic Surgery Education-Past, Present, and Future

Organized thoracic surgery education began with the establishment of the first thoracic residency program at the University of Michigan in 1928. Subsequent changes and progress in thoracic education have included the development of the American Board of Thoracic Surgery, the Thoracic Surgery Residency Review Committee, the Thoracic Surgery Directors' Association, the Matching Program, the In-Training Examination, and the Joint Council on Thoracic Surgery Education. Current challenges in thoracic surgery education include (1) the declining interest in medical school and especially in surgery and cardiothoracic surgery, (2) changing demographics of medical students and residents, (3) lifestyle of surgical residents and practicing surgeons, (4) changes in societal expectation, and (5) the need for better tools to assess the outcomes of surgical education and the continued competency of practicing surgeons. Despite the recent difficulty with job availability for finishing cardiothoracic residents, there is evidence that this is temporary and that there will be an increased need in the future. Recent changes by the American Board of Thoracic Surgery, including making optional American Board of Surgery certification, new pathways for entry into the cardiothoracic surgery educational process, and the recent development of a joint training proposal (4/3) by the American Board of Surgery and American Board of Thoracic Surgery, clearly signal the need for further changes in the cardiothoracic surgery educational process so that thoracic surgery remains relevant in the future care of patients with cardiovascular disease.

Norman Barrett, "doyen of esophageal surgery"

Images

History of surgery of the esophagus

The progress of esophageal surgery from the beginning of medical history through five historical eras, up to the second half of the 20th century, is reviewed. Progress was slow from the first surgical repair of the esophagus in ancient Egypt in 2500 B.C. until the end of the 19th century, when scientific discoveries made possible the solid beginnings of abdominal surgery. Thoracic surgery followed in the 20th century, with rapid strides in World War II. These wartime advances stimulated an interest in esophageal surgery in the postwar era, when operative techniques became well standardized and surgery of the esophagus was placed on a par with that of other parts of the gastrointestinal tract. Because of the limitations of time and space, much important material has had to be left out. Yet it is hoped that this brief historical overview will put in perspective the important advances of the second half of this century, which will be presented by our distinguished speakers. It has been a privilege for me to have had a part in the development of this type of surgery and to share these ideas with you.

Ernst Ferdinand Sauerbruch: rise and fall of the pioneer of thoracic surgery

Ferdinand Sauerbruch (1875-1951) was a pioneer of thoracic and cardiac surgery and is undoubtedly one of the twentieth century's most outstanding surgeons. Before 1904 operations on the thorax met with fatal complications due to pneumothorax. Sauerbruch developed a pressure-differential chamber that maintained normal respiration and enabled safe operations to be undertaken on the thorax. Together with von Mikulicz, he initiated intrathoracic operations and later developed various surgical procedures on the mediastinum, lungs, pericardium, heart, and esophagus. The simple yet effective techniques of positive-pressure ventilation replaced the expensive, cumbersome negative-pressure chamber. Sauerbruch's latter years were marred by dementia that adversely affected his personality, intellect, and capacity as a surgeon. The unjustifiable toll of increasing patient morbidity and mortality forced authorities to dismiss him in 1949. He died at the age of 76 in Berlin. After almost a century since the advent of the first safe thoracic surgery, the advances in technique and technology have been enormous. A great deal is owed to the inspiration and contributions of Ferdinand Sauerbruch.

Naming the bronchopulmonary segments and the development of pulmonary surgery

An international agreement on bronchial nomenclature and anatomy was not reached until well after operations for bronchopulmonary segmental disease were well developed. R. C. Brock, in 1950, was the reporter of the efforts of The Thoracic Society of Great Britain to bring some order to this confused state. This Society delayed its action until an ad hoc committee made up of members from other countries and specialties met at the International Congress of Otorhinolaryngology in 1949. The anatomy and nomenclature of the bronchopulmonary segments was agreed upon. The Thoracic Society then accepted the report of the ad hoc committee. The system was followed closely by the first Nomina Anatomica in 1955. This report did not open new surgical vistas but was the marker indicating that pulmonary surgery was now mature.

The European Congenital Heart Defects Surgery Database experience: Pediatric European Cardiothoracic Surgical Registry of the European Association for Cardio-Thoracic Surgery

The initial purpose of collecting data on the outcome of congenital heart surgery procedures across Europe was to make possible comparison of results and definition of mortality and morbidity risk factors as well as targeting research activities. The European Congenital Heart Surgeons Foundation, established in 1992, created the European Congenital Heart Defects Database, precursor to today's Pediatric European Cardiothoracic Surgical Registry. In 1999, initiatives of the Society of Thoracic Surgeons and the European Association for Cardio-Thoracic Surgery resulted in a series of conferences aimed at arriving at a standardized nomenclature and reporting strategies as a foundation for an international database. In April 2000 the International Congenital Heart Surgery Nomenclature and Database Project published a minimum dataset of 21 items and lists of 150 diagnoses, 200 procedures, and 32 complications, as well as 28 extracardiac anomalies and 17 preoperative risk factors. Since January 2000 the Pediatric European Cardiothoracic Surgical Registry has officially operated from the Department of Cardiothoracic Surgery at the Children's Memorial Health Institute in Warsaw, Poland, under the auspices of the European Association for Cardio-Thoracic Surgery and the responsibility of Bohdan Maruszewski. As of March 2001, 84 cardiothoracic units from 33 countries had registered in the database and data on almost 4,000 procedures have been collected. Participation in the database is free of charge through the internet for all participants. Development of data validation protocols is a work in progress.

Early Islamic physicians and thorax

Modern anatomic knowledge has developed throughout centuries with transfer of knowledge from generations to generations. Ibn-i Sina (980-1037), Razi (850-923), Davud El-Antaki (?-1008), Ali ibn Abbas (?-982), Ahmed bin Mansur (14th century), Semseddin-i Itaki (1570-1640), and Ibn-i Nafis (1210-1288) were Islamic physicians who all contributed to the understanding of anatomy. They benefited from Greek and Roman pioneers, as well as from each other. To show the situation of thoracic anatomy in early Islamic physicians, we analyzed two original manuscripts in the Süleymaniye Library and some contemporary texts. There were original drawings of the trachea, lung, and vascular system in Semseddin-i Itaki's and Ahmed bin Mansur's anatomy texts. Ibn-i Nafis's writings revealed that he was the first person to describe the pulmonary circulation. Also Ali ibn Abbas wrote that the pulmonary artery wall had two layers and these layers may have a role in constriction and relaxation of this vessel. He also stated that pulmonary veins branched together with the bronchial tree. Ahmed bin Mansur, Ali ibn Abbas, and Ibn-i Nafis each wrote that the heart has two cavities. They also added that the wall of the septum is very thick and there are no passages in between. These show that Islamic physicians had important contributions to thoracic anatomy and physiology. European physicians benefited from these contributions till the end of the 16th century.

Thoracic surgery techniques of Serefeddin Sabuncuoğlu in the fifteenth century

Serefeddin Sabuncuoğlu (1385 to 1470?) is known to be the author of the first surgery textbook, namely Cerrahiyyet'ül Haniyye (Imperial Surgery), written in Turkish in 1465. It is the first book to contain colored illustrations of surgical procedures, incisions, and instruments in the Turkish-Islamic medical literature. He was the first man to illustrate and mention introduction of a tube into the pharynx and upper esophagus, removal of foreign bodies in the esophagus by special instruments of his own design, and use of a silver ringlet in a man after tracheotomy. He also described and illustrated reduction of sternal fractures, thoracic puncture through the intercostal space for drainage of empyema cavities, and treatment of rib fractures that have severed the diaphragm. He was a humble, curious, and intelligent surgeon, and also a calligrapher and a miniature artist.

Evarts Ambrose Graham, empyema, and the dawn of clinical understanding of negative intrapleural pressure

The concept of negative intrapleural pressure is fairly new. Although the phenomenon had already been described, Wirz provided the first definitive analysis of its significance to the mechanics of breathing in 1923. By contrast, empyema has been known since antiquity; from the time of Hippocrates, treatment has consisted of open drainage. Open drainage was often successful and did not result in pneumothorax, because most cases of empyema were associated with adhesions and thickened visceral pleura that prevented the lung from collapsing. The epidemic of group A streptococcal pneumonia in military camps in 1917-1918 was associated with the rapid and early accumulation of empyema fluid and was the catalyst for renewed study of empyema. Use of open drainage to manage this illness resulted in a high immediate mortality rate, probably because patients developed pneumothorax. The work of Evarts Graham and the Empyema Commission married physiological understanding of pleural mechanics with rational clinical treatment and paved the way for further advances in thoracic surgery.