Live surgery and the EACTS advanced thoracic techniques meeting: CME and Ethical considerations
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