Editorial

 

General thoracic surgery as an independent specialty in Mexico

 

La cirugía torácica general como especialidad independiente en México

 

Mark B. Orringer*, Graciano Castillo Ortega, Carlos A. Olivares Torres, José Morales Gómez

 

*Head, General Thoracic Surgery Division. University of Michigan. Ann Arbor, Michigan.

General Thoracic Surgeon, Department of Surgery, General Hospital of the State. Hermosillo, Sonora, Mexico.

General Thoracic Surgeon, General Hospital of Tijuana. Tijuana, Baja California, Mexico.

Head, Division of Surgery, National Institute of Respiratory Diseases. Mexico City, Mexico.

 

Correspondence:
Dr. José Morales Gómez
Head, Division of Surgery. National Institute of Respiratory Diseases.
Calzada de Tlalpan 4502, colonia Sección XVI. México, D.F., 14080.
Teléfono 5666 45 39, extensiones 120 y 210
E–mail: Morales99_2000@yahoo.com

 

With advances on scientific knowledge and medical and information technology, the field of Medicine has been moving progressively towards greater subspecialization in recent years. It is now virtually impossible for any single individual to master all of Medicine or Surgery, and there is greater acceptance of the fact that more reproducible, high–quality patient care is provided by those who consistently and repeatedly address defined areas of pathology. With its unique anesthetic considerations, technologic breakthroughs and body of knowledge, the field of General Thoracic Surgery – surgical treatment of the chest and its contents, exclusive of the heart – has now attained sufficient status to warrant its recognition as an independent surgical subspecialty.

Historically, the field of thoracic surgery had its origin in the treatment of pulmonary tuberculosis. Several historical "milestones"¹, however, have fostered the development of General Thoracic Surgery as a distinct specialty:

1. The development of techniques to enable positive endotracheal pressure

2. The successful performance of pulmonary resections–lobectomies by Brunn in 1918 and pneumonectomy by Graham and Singer in 1933¹

3. The development and refinement of techniques of thoracoplasty for "collapse therapy" of pulmonary tuberculosis by Alexander

4. Advances in the field of esophageal surgery by Torek, Sweet, Ivor Lewis, Belsey and Orringer²

5. Successful lung transplantation by Cooper in 1983³

6. The more recent evolution of lung volume reduction surgery for pulmonary emphysema

The advent of extracorporeal circulation as a result of the pioneering work of John Gibbon, and the subsequent development of the fields of myocardial revascularization, cardiac valve surgery, and pediatric cardiac surgery, as well as successful cardiac transplantation by Barnard and Shumway, have been instrumental in separating "cardiovascular" from "general thoracic" surgery¹. Dr. F. Griffith Pearson of Toronto General Hospital, a leader in general thoracic surgery, was instrumental in establishing separate cardiac and general thoracic training tracks and certification which now exist in Canada³.

In Mexico, "pneumological", "pleuropulmonary", "thoracic pulmonary" or better yet, General Thoracic Surgery, isjust beginning to be viewed as a viable career pathway for physicians committed to the surgical treatment of thoracic diseases⁴.

General Thoracic Surgery involves more than the surgical treatment of pulmonary tuberculosis. Those properly educated in this specialty also treat benign and malignant diseases of the lung and esophagus, the diaphragm and the mediastinum. They have skill in esophagoscopy, bronchoscopy, and video–assisted thoracic surgery, the management of thoracic trauma, pulmonary infectious diseases, and diseases of the pleura^5,6.

Increasingly, cardiovascular surgeons whose professional focus is the surgical treatment of heart disease have less expertise in general thoracic surgery than those committed "full–time" to this discipline.

The question before us in Mexico is "who should be doing general thoracic surgery?" Historically, when "general thoracic surgery" was synonymous to surgery for pulmonary tuberculosis, general surgeons typically addressed these problems. However, from the beginning of the 20^th century, "thoracic surgery", in Mexico, was passed on to "pneumologists", frequently pulmonary medicine physicians with sufficient manual dexterity that allowed them to conduct thoracic surgery.

However, while antituberculosis chemotherapy has greatly diminished the need for surgery for pulmonary tuberculosis, the field of general thoracic surgery has rapidly expanded to include surgical care for lung cancer, diseases of the esophagus, chest trauma, mediastinal disease, and disease of the pleura. Despite this, no further steps have been taken in the country to encourage the production of general thoracic surgeons, those embarking upon careers in cardiothoracic surgery commonly opting for the more "spectacular" field of cardiac surgery.

Since 1994, general surgeons have been admitted to hospitals and medical schools to learn general thoracic surgery as a distinct medical specialty, ignoring our past history and displacing the "pulmonologists" with thoracic surgical experience.

But the "best" general thoracic surgeon should be neither a "part–time" cardiac surgeon nor a "part–time" general surgeon. Rather, this individual should devote 100% of his professional efforts to the breadth of pathology encompassed within this field. General thoracic surgeons should be well educated in surgical techniques, principles of wound healing, and pre– and postoperative care. This general thoracic surgeon should be fully committed to his field and to his patients and to quality of care⁷.

If high quality care of patients with general thoracic surgical diseases is to be attained in Mexico, dedicated general thoracic surgeons must be mentored, developed, educated and encouraged to assume positions of leadership in this field. This should be the rule not the exception in the field of general thoracic surgeons so they can assume their place in our specialty not only in Mexico but in the rest of the world.

 

REFERENCES

1. Eloesser L. Milestones in chest surgery. J Thorac Cardiovasc Surg 1970:60:157–165.

2. Sloan H, Kirsh MM, Orringer MB. Thoracic surgery training at the University of Michigan. Chest Surg Clin N Am 2000:10:201–211.

3. Pearson FG. Adventures in surgery. J Thorac Cardiovasc Surg 1990:100:639–651.

4. Villalba JC, García–Espinoza C. La especialidad de cirugía toracopulmonar. Rev Inst Nal Enf Resp Mex 1992:5:181–182.

5. Orringer MB. What shall we call ourselves? The time for standardization. Ann Thorac Surg 1997:64:596–598.

6. Morales–Gómez J. 60 años de cirugía en el Instituto Nacional de Enfermedades Respiratorias. Rev Inst Nal Enf Resp Mex 2004:17:109–116.

7. Grillo HC. Education or training in cardiothoracic surgery? Ann Thorac Surg 2000:69:1319–1320.