Tom Treasure Weblog

Educational opportunities for young thoracic surgeons have never been so good in Europe. Both EACTS and ESTS are running courses in October and November 2007 so there is plenty of choice. These are all at low cost or even no cost to the students and the faculty give their time pro bono. In this BLOG I will summarise what is on offer.

Bergamo: The European School of Cardiothoracic Surgery
http://school.eacts.org/

What we know affectionately as the Bergamo School must surely be one of the finest examples of educational beneficence. It was set up by EACTS around 1989 thanks to the imagination and generosity of Lucio Parenzan. The beautiful Villa Elios, in the grounds of the Gavazzeni Clinic, is the home of the school. Bergamo is a historic city about 40km NE of Milan in the North of Italy. The city is itself a delight to visit. The newer part of the city has a fine boulevard on a grand scale lined with stylish shops, restaurants and pavement cafes. A funicular takes you up through the fortified walls of the hilltop ancient city. Around every corner are architecturally breathtaking buildings, villas, churches and no shortage of trattorias and ristorantes. It is to these that the students and faculty retreat to dine together each evening. The students live economically in the seminario. It seems there is less interest then there used to be amongst Italian teenagers to enter the priesthood and there is spare capacity for budget accommodation for those whose vocation is surgery. The semi-monastic environment reminds us of what we have come to Bergamo for – not just to party!

In this wonderful location EACTS runs week long courses, six in all, three levels of thoracic and three levels of cardiac. The faculty are there with the class all day and the days are filled with high quality teaching. Bergamo has its own low cost airport a short bus ride from Villa Elios, it has good train connections and Milan’s major airports are not far away. The next Thoracic Course is 15th to 19th October 2007 usually a nice time to be in Bergamo. http://school.eacts.org/

ESTS School of Thoracic Surgery
http://www.estsschool.org/

A new initiative this year is the School of Thoracic Surgery in Antalya on the Mediterranean coast of Turkey. ESTS have taken a different approach and asked experts in the field to prepare structured lectures within templates provided by the School organisers. As we understand it, the ESTS School faculty of on-site teachers will then deliver these in the class room and lead discussions on them. This will spare busy surgeons the need to travel themselves to Antalya. It remains to be seen how well this will work. Many - maybe most - EACTS thoracic surgeons are also ESTS members. Some will be teaching at Antalya and we have all noted the ESTS approach with great interest. Those who have developed the tradition of Bergamo fear that the loss of direct contact will diminish the impact of teaching. “How could someone else deliver my lecture?” we all ask ourselves. But do we really need to be there ourselves to communicate our own material? Perhaps it is a question of style over content – and content is the more important so that is where the emphasis should rightly lie rather than with the personalities. Time will tell how well this works and we wait for the feedback. It is 14-18 November 2007 and details can be found at http://www.estsschool.org/

EACTS Toolkit Series
http://courses.eacts.org/sections/Thoracic/ThorToolKit/index.html

The Thoracic Committee of EACTS has taken a rather different stance. The Toolkit series is the brain child of Walter Klepetko. The first in what is planned to be an annual event is to be in Prague 1-3 November. Teaching will be very much face to face and as the name suggests it is a course for surgeons in their first couple of years of thoracic surgical training. We have taken the view that at this stage in their careers the students do not need advanced or highly specialised lectures but that the emphasis should be on teaching the basic elements of our craft, and teaching them well – helping the learners to know the toolkit. The aim is that the content should be basic core knowledge and practice. The faculty are chosen primarily for their ability to teach, and we will concentrate on the non controversial and evidence based elements. That is not to say they are not great experts in their fields of interest but it is their ability to communicate that brings them together. The topics for this course are lung cancer staging and pleural disease. The course is free to EACTS trainee members and 50 euros for everyone else. Further information can be found on the EACTS site http://www.eacts.org/ or by go directly to http://courses.eacts.org/sections/Thoracic/ThorToolKit/index.html

Posted by Tom Treasure at 10:24 PM | Permalink

The Royal College of Surgeons of England has inadvertently put thoracic surgery ahead of cardiac surgery in its Bulletin. A headline concerning the Society for Cardiothoracic Surgery in Great Britain and Ireland (alongside the ever smiling face of its President Sir Bruce Keogh) abbreviates the society to STCS rather than the intended SCTS.

The headline from the Bulletin of the Royal College of Surgeons of England:

I called Sir Bruce (President of SCTS GB&I); it is not that he has negotiated a change in the name of the British and Irish organisation. It was an error somewhere in the editing process. However it is amusing, maybe more to me than to Bruce. Is it perhaps a Freudian slip? The Viennese father of psycho-analysis Sigmund Freud (1856-1939) attributed such errors to the unconscious mind bringing out hidden truths.

Could it be that the Thoracic Committee of EACTS brings Professor Bruce Keogh (also the Secretary General of EACTS) under such pressure that Thoracic Surgery is in the forefront of his mind?

It is good to find a humorous side to events which are somewhat embarrassing to many serious minded European thoracic and cardiac surgeons. The world knows that after five years of highly successful joint EACTS/ESTS meetings the European Society of Thoracic Surgeons will meet separately this year in Leuven, Belgium and the European Association for Cardio-Thoracic Surgery will meet in Geneva, Switzerland. Make what you will of it - but is there something about names that rankles with a group of surgeons who do not operate on the heart?

"What's in a name?” wrote Shakespeare for Romeo and Juliet “That which we call a rose by any other word would smell as sweet."

When the American Association for Thoracic Surgery was formed in 1917 the notion of operating on the heart was regarded as crazy and when that new fangled idea arrived, initially hesitantly in the 1920s but remorselessly in the 1940s, the AATS regarded the heart as just one of the organs within its domain. The Society of Thoracic Surgeons has followed the same convention.

The British organisation was founded as the Society of Thoracic Surgeons of Great Britain and Ireland in 1933 and has changed its name twice I believe. For a while it was thoracic and cardiovascular. I suppose it might change again along the lines inadvertently proposed by Sir Bruce.

I have written before about the commitment of EACTS to surgeons (and thus to the patients in their care) whether their training and practice is combined or exclusively thoracic or cardiac. I echo Shakespeare – what’s in a name?

Nevertheless there is a rhetoric in words and little prepositions can subtly introduce strong messages. Note that some organizations are “of” surgeons and others “for” surgery. Bob Replogle has written about parsing.

I wonder will he put his mind to this one. It’s far too obscure and insubstantial for me to draw anything from it.

Posted by Tom Treasure at 08:39 PM | Permalink

Venice Meeting

The tracheobronchial surgery is technically challenging. It was a major part of the EACTS Advanced Techniques course in Venice 8-10 March 2007. Central to the meeting and arguably the key to its success was a live transmission of tracheo bronchial surgery from Padua.

There are three parts to this blog
• Ethics: I will address some of the issues, pro and con, that surround live surgical demonstrations. That is the ethical and philosophical dimension.
• Mission: The European Association for Cardio-Thoracic Surgery is committed to run high quality thoracic meetings. That is my “Mission Statement” as chair of Thoracic Surgery for EACTS.
• CME: This is a summary of what this meeting was all about. There is one key message – a matter of opinion but seemed to me a conclusion worth taking home.

The sections are labelled so you can select to read or to omit Ethics, the Mission or CME.

Ethics
Is transmission of surgery live to an audience always alright? I do not intend to take a side on this question – it is in any case far too complicated to deal with in a short paragraph as part of a BLOG. I suggest some of the many pros and cons for consideration.

Some points for:
• Surgeons have always watched one another operate. The first meeting of our national Society of Thoracic Surgeons (as it was then) of Great Britain and Ireland met in the Brompton Hospital on 11th November 1933 and the home team Roberts, Tudor Edwards, Price Thomas and Nelson did demonstration operations in the afternoon. And so it has always been.
• Now with the help of video cameras we can keep the operating room clear of "foreign bodies", reduce infection risk and distraction, but really see - from the comfort of a lecture theatre.
• Live surgery addresses the real on-the-spot difficulties encountered in real life. We saw the few moments when the bronchoscope was in the oesophagus (did the operator take longer than some of the audience to realise?). We could see that the laser resection was at times seriously obscured by bleeding. These would have been edited out of a video clip making it all look easy.
• It is in fact so popular that it is the major draw for some meetings and the income of the organisers depends on it.

Some points against:
• The exact contradiction of that last point pro – it is populist, a crowd drawer, and a money raiser say those against. It’s like motor racing or the circus – part of the excitement is that something might go wrong.
• How well informed are the patients that the operators attention will not be 100% on them but at least part on the audience?
• Will the best decisions be made for the patient or will the operator feel compelled to continue the operation as advertised?
• It is inefficient of time. We see a lot of sucking and knot tying which could be usefully edited out so that the critical points can be shown and emphasised.

For a well reasoned critique against read Duke Cameron on the subject
http://www.ctsnet.org/sections/newsandviews/inmyopinion/articles/article-55.html

The Mission
EACTS just like the North American organisations STS and AATS serves the needs of members
• who are purely cardiac surgeons,
• those who do no cardiac surgery,
• and every mix of cardiothoracic practice in between.

In some countries the disciplines are separate but in many training and practice continue as part of the same specialty. EACTS recognises that fact.

Our Association is truly international. This meeting had participants from as far North as Norway, as far South as African, India to the East and Portugal to the West - and from New Zealand. That's as far away as it is possible to be, in whichever direction you set out. There are variations in affluence and expectations of health but surgical principles and humanitarian values are held in common. For most of participants English is not their mother tongue but nor is it for most of the faculty. Our language is International English and again I refer you to Akira Furuse on the subject.

http://www.ctsnet.org/sections/newsandviews/inmyopinion/articles/article-28.html

CME
Three procedures were shown on the live surgery transmission:
• tracheal resection of tracheostomy stricture
• endobronchial laser surgery
• right upper lobe bronchial carcinoid

Lectures on tracheobronchial surgery included:
• tracheal resection for tumours,
• tracheal strictures,
• tracheo-oesophageal fistula,
• bronchial and tracheal sleeve resection,
• postpneumonectomy bronchopleural fistula and the
• bronchial anastasmosis for lung transplantation.

http://courses.eacts.org/sections/Thoracic/AdvTecThor/AdvTecThor-articles/article.html

Over the three days we had outstanding lectures on these topics. Greatly adding to the educational value was the brisk and well-informed discussion. Most of the faculty were present throughout the meeting and this ensured a high level of debate.

As always the meeting depends on the vision, energy and commitment of the local organisers, in this case Federico Rea of Padua and Stefano Elia of Rome, both in Italy.

I am a champion of Evidence Based Medicine (witness our book The Evidence for Cardiothoracic Surgery) and wish we had many more clinical trials on thoracic surgical questions. But I have also recognised how much we rely and will probably always rely on the well reasoned application of our craft skill and experience against a knowledge of anatomy, physiology and pathology. (The evidence on which to base practice: different tools for different times. Eur.J Cardiothorac.Surg 2006)

Tracheobronchial surgery illustrates this well. The first step in thinking about a randomised control trial (RCT) is to formulate in the simplest terms an outline of how the study might be structured.

The acronym PICO summarises this:
P – patient group,
I – intervention under evaluation,
C – control intervention and
O – outcome(s).

In the above list of tracheobronchial problems the individual cases are too few, their presentation too heterogeneous, and the “tricks of the trade” are too many and varied for RCTs to be conceivable for any but a few questions.

From all the excellent teaching imparted, I have a simple but maybe important take home message. Some surgeons stress the importance of techniques of wrapping every bronchial anastamosis to prevent leaks or dehiscence. Others claim never to have seen a sleeve resection leak. Why the difference?

We know how tenuous is the tracheobronchial blood supply. Lung transplantation is the most severe test: the donor bronchus has no bronchial blood supply. An extensive, clean looking dissection in a bloodless field looks good on a video clip but may be inimical to healing. John Dark’s solution is to keep both stumps as short as possible and surrounded by their adjacent tissues. That fits with my understanding of the basic principles and with my own experience.

Forthcoming EACTS thoracic meetings and courses are:
• Bergamo School 15-21 April 2007
• Bergamo School 13-19 May 2007
• EACTS annual meeting (15-18 September 2007) in Geneva with a thoracic TechnoCollege and Postgraduate day on the Saturday and Sunday
• The first in our “Toolkit” series for more junior surgeons (1-3 November 2007) in Prague
• Bergamo School 14-20 October 2007
• Update on Adenocarcinoma - Milan December

Posted by Tom Treasure at 08:41 AM | Permalink