Adult Chest Surgery

Chapter 1. Introduction

The emergence of general thoracic surgery in North America as a surgical subspecialty distinct first from general surgery and then from cardiac surgery and congenital heart surgery occurred through dramatic and tumultuous changes that once threatened but ultimately strengthened the integrity of the discipline. The discipline evolved from general surgery in the early 1900's in response to chest morbidities prevalent at that time, primarily tuberculosis and World War I-related trauma. Hence, the systems established to guide thoracic surgery were shaped by general surgeons. War continued to play a role in shaping surgery. In the 1940s World War II required new strategies for management of injuries from new weapons. By the 1950s, new knowledge and technology began to lift the physical and psychological barriers to surgery within the chest, including the heart. The technical achievement of extracorporeal circulation by John Gibbon, first used in humans successfully in 1953, allowed the extension of cardiac and congenital heart surgery into more complex problems and ultimately new fields of specialization in myocardial revascularization, valve surgery, and heart transplantation in the late 1960s. These changes occurred as antibiotic use reduced the incidence of tuberculosis and the need for pulmonary surgery. Soon, combined cardiothoracic surgery programs began to form.

The union between thoracic and cardiac surgery, however, was not altogether ideal, and thoracic training often played second fiddle to cardiac training. In 1981, Donald Paulson, President of the American Association for Thoracic Surgery, focused on the inadequacy of training in general thoracic surgery. In his presidential address, he stated: "Failure to correct the imbalance in training of thoracic surgery has resulted in a vacuum, which could lead to disintegration of the specialty."¹ By the 1990s, the realm of general thoracic surgery was so eclipsed by the dramatic developments in cardiovascular disease that funding in combined cardiothoracic programs began to be diverted in favor of cardiac training.

This pattern was played out largely in the U. S., United Kingdom, and Europe, and threatened the ability of such programs to attract top-notch general thoracic surgeons. In an editorial symposium published in 1991 in theAnnals of Thoracic Surgery, the President of the American Association for Thoracic Surgery, John Waldhausen, addressed the broad concern that American thoracic surgery programs were failing to attract the "brightest candidates." Later that year, an educational workshop was convened in Snow Bird, Utah, to define the deficiencies in American thoracic surgery.

Meanwhile, although similarly influenced by the pace of development in cardiac and congenital heart surgery, events transpired somewhat differently in Canada. In the early 1950s there were three divisions of general surgery in Toronto. Thoracic and cardiac surgery were practiced as subspecialties in each of these divisions. In 1953, Wilfred Bigelow was appointed to head one of the three divisions. A general surgeon by training with an interest in vascular and cardiac disease, but no training or interest in thoracic procedures, Bigelow proposed a separate division, training program, and certification track for cardiovascular surgery, which was established in 1958. The two remaining general surgery divisions continued to deliver subspecialty services in thoracic surgery.

In 1967, recognizing the difficulties of providing focused training in general thoracic surgery under this decentralized scheme, F. Griffith Pearson and colleague Norman Delarue proposed a separate residency in general thoracic surgery at the Toronto General Hospital, as Bigelow had done earlier for cardiovascular surgery. A second program was soon created at an affiliated teaching hospital of the University of Toronto.

Pearson had a tremendous impact in the field of general thoracic surgery.² Throughout his tenure as chief of the thoracic division at Toronto General Hospital, Pearson oversaw important developments in lung transplantation, thoracic oncology, and clinical research, mentoring many surgical thought leaders around the globe. American surgeons with an interest in general thoracic surgery were attracted to the Canadian programs. After training, the many successful graduates of these programs brought their experiences and commitment back to the U. S., where lack of specific funding for thoracic surgery training had led to a shortage of qualified surgeons. The inevitable consequence of this pent up demand fueled the trend of establishing separate programs in cardiac and general thoracic surgery in the U. S. Dedicated thoracic surgery programs were better able to compete for funding and training programs improved. The general thoracic surgery division at Brigham and Women's Hospital grew out of this movement and was established in 1988, the first independent thoracic program in the United States.

The Brigham and Women's Hospital has a long and distinguished surgical history and a legacy of molding physicians and surgeons with equal abilities in research, patient care, and teaching. The list of noteworthy surgeons who fulfilled this triple paradigm begins with the succession of surgeons-in-chief at the Peter Bent Brigham Hospital, one of the original three institutions that combined in 1980 to form Brigham and Women's Hospital. Cushing, Cutler, Moore, and Mannick are well recognized by their monumental contributions to surgical history.

Notable pioneers in heart surgery included Dwight Harken. Although Harken is often cited for the successful removal of bullets from the hearts of wounded soldiers during World War II, as well as implantation of the first artificial heart valve, he was trained in lung and esophageal surgery, and authored a seminal report in the New England Journal of Medicine in 1954 on cervical mediastinoscopy.³ In this paper he recognized the importance of N₂ disease as a contraindication to surgical treatment of thoracic malignancies. He became Chief of Cardiothoracic Surgery at Peter Bent Brigham Hospital in 1948 and was succeeded by John Collins. Lawrence Cohn, who worked with Collins, became the chief of cardiac surgery in the late 1980s. The collective contributions of these pioneering surgical figures converged in a nexus that was propitious for the independent development of general thoracic surgery in 1988. John A. Mannick, whose tenure as surgeon-in-chief of Peter Bent Brigham Hospital bridged the merger (1974–1994), had the foresight to establish the first dedicated division of general thoracic surgery at Brigham and Women's Hospital. It was my privilege, a graduate of the Toronto program, to be appointed as the first chief of service.

Broadly speaking, thoracic surgery encompasses the surgical treatment of the chest and all of its contents, exclusive of the heart. Hence, the thoracic surgeon must master the surgical skills for the treatment of lung and esophageal cancers, lung transplantation, airway reconstruction, chest wall and diaphragm disorders, mediastinal tumors, masses and cysts, emphysema, and benign esophageal disease. But surgical skill, alone, is insufficient to conquer the intricacies of chest pathology, as exemplified by lung and esophageal cancers, which rely on a multidisciplinary approach to treatment and thorough knowledge of the underlying disease.

In the first half of the 20th century, pulmonary tuberculosis was an important activity for thoracic surgeons. After an effective chemotherapy was developed, thoracoplasty faded away in favor of drug therapy and resection only when necessary. In the second half of the century a new scourge overtook the discipline. The practice of cigarette smoking, an unfortunate byproduct of World War II, took firm hold of the American public. Shortly thereafter lung cancer became the leading cause of cancer deaths in the United States. Today, surgical extirpation of lung and other pulmonary cancers constitutes a large part of the general thoracic practice. Effective patient treatment and care relies on multidisciplinary teams from many disciplines–anesthesia, surgical intensive care, radiology, pathology, pulmonary medicine, immunology, and public health.

The role of the thoracic surgeon is mercurial: surgeon, diagnostician, and scientist. The principal roadblock to the treatment of cancer is the propensity many cancers exhibit for locoregional or systemic recurrence. The answers to these conundrums lie, presumably, at the molecular biological level. Because of the complexity of the human genome and its unique expressions in the cellular apparatus that governs the multitude of biological processes, complex analysis is required involving specialized laboratories proficient in proteomics, genomics, bioinformatics, nanoengineering, and the list goes on. The relevance of this research scenario to general thoracic practice is the role the surgeon plays in translational research, where tissue specimens obtained at bedside are brought to the laboratory for analysis and then returned to the bedside, where specialized knowledge may be used to tailor treatments for individualized patient care.

In the 1970s, a new cancer took center stage, a rare but deadly disease and a significant problem in public health. New England was once a major center for the shipbuilding industry and many of its workers who haled from communities in and around the Boston area became unwittingly exposed to asbestos, which we now know is the carcinogen responsible for the development of mesothelioma. Forty years after initial exposure, owing to the long latency between exposure and expression of the disease, many of these workers presented at local hospitals and cancer centers with symptoms of chest pain, pleural effusion, and dyspnea, harbingers of mesothelioma.

In Boston, the Brigham and Women's Hospital and Dana-Farber Cancer Institute became centers for the diagnosis and treatment of this devastating cancer. Karen Antman, a medical oncologist from the former Sidney Farber Cancer Institute who is now the dean of the Boston University School of Medicine, published her experience with malignant mesothelioma in 1980.⁴ The Pathology Department at the Brigham, under the leadership of Joseph M. Corson, refined many of the diagnostic procedures that provided the capability of distinguishing between lung adenocarcinoma and mesothelioma, and thus became a major referral center.⁵ The surgical procedure suitable for achieving macroscopic resection of the diseased pleura, extrapleural pneumonectomy, was associated with unacceptable mortality. Moreover, surgery alone was ineffective, with most patients dying within 4 to 12 months of their disease.

The Thoracic Surgery Division at Brigham and Women's Hospital became involved and with time and surgical innovation, mortality rates associated with extrapleural pneumonectomy were brought down to levels comparable with other anatomic lung resections.⁶ In concert with the Dana-Farber Cancer Institute, the Division was able to establish that multimodality treatment with surgery plus radiation and chemotherapy was an effective means of improving survival, and eventually, these efforts were rewarded with long-time survivors, although the prognosis still remains poor for most patients.⁷ With the discovery of the overwhelming propensity of this tumor to recur locoregionally,⁸ attention turned to unraveling the disease mechanism at the molecular interface, where current translational research in the laboratory is focused.

It is difficult to enumerate the challenges that lie head for our specialty. Many factors–technological, biological, sociological, political–have the potential to influence our future course. We have the opportunity, however, to build upon the firm base in general thoracic training and education that was established by our mentors in the 1980s. The future of our specialty will be shaped by the quality of our education and the institutions that have been established to keep our practitioners current and informed.

In the final analysis, the growth and direction of the general thoracic surgery discipline is determined by the needs of the patients in the community it serves. The development of the treatment paradigm for mesothelioma at the Brigham, for example, was driven by the high incidence of asbestos exposure in the New England population, but it provides a successful model for any field of specialization, in any geographic region, for any patient group. It is just one example of the fascinating and daunting nature of scientific inquiry that lies ahead for anyone with an interest in general thoracic surgery.

The many hours that have been devoted to the writing of this textbook represent the culmination of many years of experience, not only of the surgical innovators and physicians who contributed to this volume, but also of the multidisciplinary team that is so crucial to the care and survival of our patients. Their words represent the distillation of more than a century of medical and surgical knowledge. I feel confident that their words will assist you to hone your personal surgical skills, encourage you to make further contributions in your clinical practice and research, and inspire you to extend yourself personally in the care and treatment of your patients.