Minutes
of the ESTS General Assembly
2nd November 2000
Commonwealth Institute. London
- President's
report
- Treasurer's
report
- Secretarys
report: membership;
ESTS home page; new
constitution; Elections; New
secretariat
- New
President's address
The outgoing president, Toni
Lerut, addressed the general assembly. His Title Was Thoracic
Surgery In Europe - Back In Business?
The text of this address has subsequently been
reproduced in the February newsletter.
Dear colleagues and friends
In that might tell us
your president is near and so is the magic year 2000 transition
from the old into the new millenium didn't change the world. A
millenium bug, if there
was any at al,l did not cause great damage and apart from the new
year's Eve fireworks and champagne year 2000 has seen business as
usual. But the change of the millenium gives me the opportunity to
reflect on the destiny of Europe's Thoracic Surgery.
Throughout the last few
decades of the nineteenth century operative interventions on the
heart, lungs and other organs in the chest almost invariably
produced fatal results. Accordingly, little interest was expressed
in the establishment of thoracic surgery as a specialty. However
as more and more papers on thoracic surgery were being presented
during the first 20 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 20's the development of endotracheal
intubation by Rowbothamm and Magill allowed the maintenance of
pulmonary function during anaesthesia. This was a critical
breakthrough. Although fundamental contributions to thoracic
surgery, such as the first successful oesophagectomy and
pneumonectomy for cancer were performed by Torek and by Graham
respectively in the US, equally major developments came from
Europe.
Theodore Billroth was first performed successful operations on
trachea, oesophagus and stomach. His views on surgical training
and education with 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 two, many European
surgeons contributed substantially to further developments
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 practise 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 one six six in 1980 the number of general
thoracic cases remained almost unchanged over the same time zone.
Paulson warned against general Thoracic Surgery been increasingly
performed without careful consideration or operative plan. In his
address he noticed the encroachment into Thoracic Surgery by
specialisconnexions you separate areats
in traumatology, oncology and gastroenterology.
It was a period where they only 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 80's resulted in further
fragmentation of Thoracic Surgery and in particular reflux surgery
has been lost to the general also called visceral surgeons.
In 1995 amongst the 120 cardiothoracic consultants in the UK who
performed Thoracic Surgery the mean number of lobectomies was
around 20 a year per surgeon. only about ten 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 sixteen hospitals, whereas 104
hospitals had a maximum of twelve 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 nineteen
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 header straight 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, send you 5% of the
presentations were and still are in cardiac surgery. General
thoracic surgeons did not feel at ease and dissatisfaction result
in the creation of the General Thoracic Club in the US, a now
powerful lobby and the creation in 1993 of ESTS in Europe.
Fortunately things started to change in recent years. Oncology
developments of new technologies have resulted in an increased
interest towards general Thoracic Surgery. They only have to
mention lung transplantation, lung volume reduction surgery for
pulmonary metastases and multimodality therapies. Expansion in
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 a identity of general Thoracic
Surgery has improved greatly.
The challenge now is how would we go forward.
The first question is :
Does general Thoracic Surgery need to become a separate
specialty ? 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 of
a large number of operations (approximately 500 cases a year)
would be necessary to survive as a centre. In the UK in only some
five centres may reach this number, in Germany five in 1989, and
in my country barely one stop said Thoracic Surgery will need a
black cab whether this has to come from cardiac all this will
surgery is in fact no longer relevant as long as the standards of
quality are maintained. It is up to us 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 a dual track system through the cardiac surgery
pathway and through the visceral surgery pathway. In the UK
cardiothoracic surgery has been one specialty from its inception,
and is likely to continue as such for the foreseeable future. Like
many others I feel 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 most evident
when working within the general surgical environment.
This is the reason why, along with others, I have been trying over
the last few years to bring the ESTS and EACTS as close as
possible. Into doing we have kept the Board Certifiaction 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. But over the option, one
thing however has to be extremely clear. Thoracic surgeons should
have full responsibility for the thoracic training programme.
A second question that 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. Is
unrealistic to see a little patience can be trained to a few
megacenters in big urban areas I am very much in favour of a
system by which a limited number of centres of excellence has
created. Each of the a needs to link up with a network of
satellite centres determined by the geographical and demographic
needs of a given country. The centres of excellance are
responsible for setting quality criteria for the whole network.
Such a centre of excellence typically should be within an academic
environment giving of education, training and above all research.
The centres of excellence 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 on the number of operations require 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 EACTS-ESTS to initiate a working party
that specifically tackled this problem. This working party is
headed by Klepetko, Velly and Grodzky and the results of their
work will be presented during this meeting. From this survey they
will try to come up with a definition of a thoracic unit and/or of
the centre of excellence.
Another very important project is the European thoracic database
project a joint EACTS/ESTS 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 Thoracic Surgery in Europe.
Your further cooperation is essential to the success of this
project and I want a call of you who have been contributing.
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 has originated by Pearson in
1976. There is no longer a place for one single fellowship in
CardioThoracic Surgery during which a trainee has to rotate
alternatively over cardiac and Thoracic Surgery after which he/she
obtains a certification in CardioThoracic Surgery.
Of 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 because sufficient
initiation in general surgery, in particular visceral surgery for
those who tend to specialise in oesophageal surgery was to such a
turning programme would permit zero certification of young
surgeons coming from either a cardiothoracic or general surgical
training programme. I believe that it is necessary to pay
sufficient attention to general surgeons willing to profile
themselves and 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 one year with an
alternation of six months in cardiac and six months in Thoracic
Surgery as a junior resident seems mandatory. Thoracic residents
should then continue for a number of years of specifically on
Thoracic Surgery. One extra year of academic research or
specialised technical training would be optimal or stop the board
would then delivers 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 outcome 2,001 joint EACTS-ESTS
meeting therefore offers a unique opportunity. Both organisations
firmly believe that this meeting probably is the world's biggest
meeting ever in Thoracic Surgery and will stimulate surgeons, and
above all trainees, to dedicate their activities even more towards
this fascinating specialty.
So may I, at the end of my time 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
Hans-Beat Ris presented the
accounts of the society such as they were, summarised by CASIL. He
explained that the society currently had 451 members but that only
1/3 of these members had paid their subscriptions. In he explained
that the cost to the society of each European journal was 180DG (
approximately £50) and that unless members pay their
subscriptions the Society would become financially embarrassed. He
explained the need for an increase in the membership fee and asked
the Society to approve a new membership fee of £132 which was carried.
Richard Berrisford explained
that of 470 members from 35 countries only one in three members
had paid their subscription for year 2000. He presented the
breakdown of membership by country and then presented a bar chart
showing the proportion of payment by members in each country.
He explained for mailing which
was sent out in June 2000 being sent to 420 members and 750
potential members. The latter list of 750 potential members was
collected at great pains mainly by Tony Lerut and incorporated
into CASIL database. Richard Berrisford detailed the mailing to
regents in July 2000 with lists of their own countries membership
details.
The secretary explained the
launch of on-line secure payments in August 2000.
In June, 2000, 51 members were
paid 1999, and 81 members were paid 2000. By October
2000 114 members were paid 1999 and 147 members were paid
2000.
At the time of the 2000
conference there were 185 members including new members of ESTS.
The secretary hoped that many more unpaid members would be able to
find the membership fee and consolidate the societies numbers.
Richard Berrisford conveyed the feelings of council to the society
that by next year's conference only paid up members would be
considered within the membership.
The secretary explain the
benefits of paying membership fees, namely
- The
continued existence of ESTS
- Receipt
of the European Journal of Cardiothoracic Surgery
- European
database software for unit
- No
early registration fee for Lisbon 2,001
Richard Berrisford
demonstrated the ESTS home page by projection from the Internet
and explained some of the facilities available to members
including on-line membership payment.
The secretary explained
the need for the society to become registered with the Charity
Commission, the regulatory body in the UK for charities. This
would allow any new income to the society to be managed
efficiently. He explained that the original constitution drawn up
in Heidelburg had to
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