546
CORRESPONDENCE
that could be devoted more productively to an expanded program of cardiac and thoracic surgical instruction. I suggest that among the proposed changes, strong consideration be given to adopting a program of several (3?) years of general surgical training culminating in an examination in the principles of surgery. This common basic training and the examination could usefully be made part of the program for all surgeons, including those who go on to specialize in general surgery. The successful candidate may then commence cardiothoracic training, which should clearly be longer than the current 2 years. Near the end of the cardiothoracic training period, the candidate should face a written examination in all elements of cardiothoracic surgery-essay papers in addition to multiple-choice testing would improve evaluation of the candidates‘ process of reasoning and approach to specific problems. The written component should be followed within weeks by oral examinations for all candidates whose performance on the written test is considered satisfactory. Certification by the Board should then be mandatory for appointment as a cardiac or thoracic surgeon. I applaud your efforts to bring this vital issue to the attention of the profession.
Darryl Hoffman, FRCS(Glasg), FCS(Cardiothoracic)(SA) Department of Cardiothoracic Surgery Albert Einstein College of Medicine 1825 Eastchester Rd Bronx, NY 10461 References 1. Peters RM. Should we care? Do we care? What should we do? Ann Thorac Surg 1991;51:807-8. 2. Roth JA, Balch CM. Thoracic surgery training: it is time for a change. Ann Thorac Surg 1991;51:818-9. 3. Grillo HC. Dilemmas in cardiothoracic surgical education. Ann Thorac Surg 1991;51:809-11. 4. Kirklin JW. Training for cardiac surgery in children and adults. Ann Thorac Surg 1991;51:812-3. 5. Orringer MB. General thoracic surgery-issues and direction. Ann Thorac Surg 1991;51:814-7. 6. Benfield JR. What next in cardiothoracictraining? Ann Thorac Surg 1991;51:820.
My colleagues and I appreciate your thoughtful letter about cardiothoracic training in the United States, expressed after your having completed training in the United Kingdom and in South Africa. You suggest that general surgical training be shortened and that training in cardiothoracic surgery be extended. It certainly seems possible that such a change may occur, although there is a strong body of opinion that adheres to the need for complete training in general surgery and certification by the American Board of Surgery (ABS) as a prerequisite to examination by the American Board of Thoracic Surgeons (ABTS). During my relatively recent tenure as a director of the ABTS, the board confirmed that ABS certification was to be a prerequisite for examination. More recently, The Society of Thoracic Surgeons has appointed a committee under the chairmanship of Benson Wilcox, MD, to review training requirements in thoracic surgery. I feel certain that the issues addressed in our recent editorial symposium are also under discussion by ABTS and the Residency Review Committee in Thoracic Surgery. Thorough, healthy discussion that may lead to change is underway.
Ann Thorac Surg 1992;53544-50
I do not think it realistic to expect that rapid ABTS certification upon completion of training can become the mechanism for granting privileges in thoracic surgery. The primary purpose of ABTS is to examine individuals who have completed approved training programs and to certify that successful candidates have passed the examination. The evaluation of training programs is the primary concern of the Residency Review Committee, which is an arm of the Accreditation Council for Graduate Medical Education. Privileges to practice cardiothoracic surgery are granted, as you know, by hospitals within which the practice takes place. I cannot foresee either sufficient shortening of the ABTS examination process or nationally uniform requirement for ABTS certification. I do believe that the leaders in thoracic surgery in the United States are ready to consider proposals for constructive change in cardiothoracic training. Thank you for having taken the time to share your thoughts with us. John R. Benfield, M D Division of Cardiothoracic Surgery University of California, Davis 4301 X St, Rm 2310 Sacramento, C A 9581 8
Graduate Education in Thoracic Surgery To the Editor: Recently The Annals printed several articles [l-51 concerning the training of thoracic surgeons, instigated by the thoughtful questions raised by Richard Peters [6]. The August issue of The Annals included an editorial by Benson Wilcox [7] telling of his ad hoc committee, which is addressing this issue. Over the years, I have made some observations regarding this subject, some of which may be pertinent. Many years ago, Eye, Ear, Nose, and Throat was one specialty. These surgeons did cataract surgery and Caldwell-Lucs. It became obvious that ophthalmology and otolaryngology were entirely different disciplines, and the two became separate specialties. I wonder if cardiac and noncardiac surgery have not also become “foreign” to one another. Two discoveries led to a decline in general thoracic trainingnamely, coronary arteriography and flexible fiberoptic bronchoscopy. Coronary arteriography led to coronary artery bypass surgery. The huge numbers of these cases made cardiac surgery, by far, more dominant than general thoracic surgery in time spent in the operating room and in training. One got the impression that pulmonary surgery became the “country cousin” to coronary bypass surgery, and was done “between cases,” at the end of the day or “whenever it can be worked in.” Before coronary bypass surgery came into being, there was a pretty good balance between cardiac and noncardiac surgery in training programs. Now, however, it seems that many thoracic surgery training programs are producing essentially coronary artery surgeons. Residents are coming out of training highly skilled in coronary surgery, but many have never seen a segmental resection or a sleeve resection, and some even give the impression that hilar dissection is a mystery to them. The second discovery, ie, the flexible bronchoscope, opened the field of bronchoscopy to almost anyone, removing the thoracic surgeon as the primary investigator of intrathoracic diseas-specially tumors. Training programs may have been partially at fault as the staff was so busy getting all the coronary artery bypass procedures done each day that we lost by default to the pulmonary medicine people. Thoracic surgery residents today are inadequately trained in flexible bronchoscopy, and are entirely inept in the use of the rigid bronchoscope (still a necessary tool).
CORRESPONDENCE
Ann Thorac Surg 1992;53:%50
In conclusion, the old eye, ear, nose, and throat problem may be pertinent to the thoracic surgery enigma. Because cardiac surgery (especially coronary surgery) has become so demanding in time and effort, general thoracic surgery has taken a “back seat” in training programs. I sincerely believe that the diagnostic approach to intrathoracic pathology was done more expeditiously 10 (perhaps even 30) years ago than it is today. It would seem to me that cardiac and noncardiac thoracic surgery should become separate training grounds after 1 year of training in both. The new techniques in thoracoscopy may give additional stimulus to general thoracic training. Hopefully, this modality will remain in the hands of surgeons.
Frederick H . Taylor, M D 300 Billingsley Rd Charlotte, NC 28211
References 1. Grillo HC. Dilemmas in cardiothoracic surgical education. Ann Thorac Surg 1991;51:809-11. 2. Kirklin JW. Training for cardiac surgery in children and adults. Ann Thorac Surg 1991;51:812-3. 3. Orringer MB. General thoracic surgery-issues and direction. Ann Thorac Surg 1991;51:814-7. 4. Roth JA, Balch CM. Thoracic surgery training: it is time for a change. Ann Thorac Surg 1991;51:81%9. 5. Benfield JR. What next in cardiothoracictraining? Ann Thorac Surg 1991;51:820. 6. Peters RM. Should we care? Do we care? What should we do? Ann Thorac Surg 1991;51:807-8. 7. Wilcox BR. Graduate education in thoracic surgery. Ann Thorac Surg 1991;52:177.
Neonatal Pneumonectomy To the Editor: I read with interest the recent article by Canver and associates [l], who described the successful management of a neonate with necrotizing bronchopneumonia secondary to pulmonary artery agenesis by right pneumonectomy. I write this communication only to emphasize the need for ongoing close surveillance in this child because of the potential risk of serious tracheal obstruction secondary to compression by the aortic arch. The chest roentgenogram published in this article shows, 1 year after operation, serious mediastinal shift to the right with the entire cardiac silhouette in the right hemithorax. In the presence of a left aortic arch, this degree of mediastinal shift places substantial tension on the aortic arch, which is relatively immobile in its distal portion due to the attachments of the brachiocephalic branches and intercostal vessels. I would like to bring to the attention of the readers an article published in this journal in 1978 [2] describing a technique that was successfully employed to manage this major complication of right pneumonectomy in the presence of a left aortic arch in the neonatal period. Robert 1. Szarnicki, M D 2100 Webster St, Suite 411 Sun Francisco, C A 94115
References 1. Canver CC, Pigott ID, Mentzer RM Jr. Neonatal pneumonectomy for isolated unilateral pulmonary artery agenesis. Ann Thorac Surg 1991;52:2945.
547
2. Szarnicki RJ, Maurseth K, de Leval M, Stark J. Tracheal compression by the aortic arch following right pneumonectomy in infancy. Ann Thorac Surg 1978;25:231-5.
Reply
To the Editor:
My colleagues and I appreciate Dr Szarnicki‘s interest in our report [l], and we agree with his appeal for the need of close surveillance of this child. Postpneumonectomy syndrome produces compression and malacia of the junction of the trachea and the main bronchus due to extreme mediastinal shift after rightsided pneumonectomy or left-sided pneumonectomy where a right-sided aortic arch is present. Correction is very complex but has been done, as in Dr Szarnicki’s case [2], successfully in some patients. In general, limited pulmonary resection that preserves all functioning lung tissue, ensuring maximal improvement, has been the procedure of choice in the pediatric population. Techniques and methods employed in the adult population to prevent complications of pulmonary resection, ie, cardiac herniation and airway compression, have not been employed in pediatric patients. Rare performance of pneumonectomy in the neonatal period may also explain the lack of published experience on this issue. However, in our case, life-threatening sepsis secondary to necrotizing pneumonia necessitated right pneumonectomy in the infant. Almost 2 years after the operation she remains healthy and growing normally.
Charles C . Canver, M D Section of Cardiothoracic S u r g e y Dartmouth Medical School Dartmouth-Hitchcock Medical Center One Medical Center Dr Lebanon, NH 03756
References 1. Canver CC, Pigott JD, Mentzer RM Jr. Neonatal pneumonectomy for isolated unilateral pulmonary artery agenesis. Ann Thorac Surg 1991;52:29&5. 2. Szarnicki RJ, Maurseth K, de Leval M, Stark J. Tracheal compression by the aortic arch following right pneumonectomy in infancy. Ann Thorac Surg 1978;25:231-5.
Acute Postinfarction Septa1 Rupture: Long-Term Results To the Editor: We enjoyed the paper by Loisance and colleagues [l]regarding short-term and long-term outcomes in patients receiving early surgical repair for acute postinfarction ventricular septa1 rupture. We also concur that the hospital mortality is quite high (45% in this report). Without question, enhanced techniques of controlled ischemic myocardial reperfusion and improved methods of myocardial preservation delivery (antegrade and retrograde avenues) have increased our ability to assure patients’ survival with this devastating complication. Nonetheless, there still remain patients who have insufficient residual myocardium for survival. The theoretical approach alluded to by Loisance and associates of emergency cardiac transplantation has been applied at Temple University Hospital. In April 1986 a 57-year-old man was readmitted 3 days after discharge for a medically treated acute anteroseptal infarction
CORRESPONDENCE
that could be devoted more productively to an expanded program of cardiac and thoracic surgical instruction. I suggest that among the proposed changes, strong consideration be given to adopting a program of several (3?) years of general surgical training culminating in an examination in the principles of surgery. This common basic training and the examination could usefully be made part of the program for all surgeons, including those who go on to specialize in general surgery. The successful candidate may then commence cardiothoracic training, which should clearly be longer than the current 2 years. Near the end of the cardiothoracic training period, the candidate should face a written examination in all elements of cardiothoracic surgery-essay papers in addition to multiple-choice testing would improve evaluation of the candidates‘ process of reasoning and approach to specific problems. The written component should be followed within weeks by oral examinations for all candidates whose performance on the written test is considered satisfactory. Certification by the Board should then be mandatory for appointment as a cardiac or thoracic surgeon. I applaud your efforts to bring this vital issue to the attention of the profession.
Darryl Hoffman, FRCS(Glasg), FCS(Cardiothoracic)(SA) Department of Cardiothoracic Surgery Albert Einstein College of Medicine 1825 Eastchester Rd Bronx, NY 10461 References 1. Peters RM. Should we care? Do we care? What should we do? Ann Thorac Surg 1991;51:807-8. 2. Roth JA, Balch CM. Thoracic surgery training: it is time for a change. Ann Thorac Surg 1991;51:818-9. 3. Grillo HC. Dilemmas in cardiothoracic surgical education. Ann Thorac Surg 1991;51:809-11. 4. Kirklin JW. Training for cardiac surgery in children and adults. Ann Thorac Surg 1991;51:812-3. 5. Orringer MB. General thoracic surgery-issues and direction. Ann Thorac Surg 1991;51:814-7. 6. Benfield JR. What next in cardiothoracictraining? Ann Thorac Surg 1991;51:820.
My colleagues and I appreciate your thoughtful letter about cardiothoracic training in the United States, expressed after your having completed training in the United Kingdom and in South Africa. You suggest that general surgical training be shortened and that training in cardiothoracic surgery be extended. It certainly seems possible that such a change may occur, although there is a strong body of opinion that adheres to the need for complete training in general surgery and certification by the American Board of Surgery (ABS) as a prerequisite to examination by the American Board of Thoracic Surgeons (ABTS). During my relatively recent tenure as a director of the ABTS, the board confirmed that ABS certification was to be a prerequisite for examination. More recently, The Society of Thoracic Surgeons has appointed a committee under the chairmanship of Benson Wilcox, MD, to review training requirements in thoracic surgery. I feel certain that the issues addressed in our recent editorial symposium are also under discussion by ABTS and the Residency Review Committee in Thoracic Surgery. Thorough, healthy discussion that may lead to change is underway.
Ann Thorac Surg 1992;53544-50
I do not think it realistic to expect that rapid ABTS certification upon completion of training can become the mechanism for granting privileges in thoracic surgery. The primary purpose of ABTS is to examine individuals who have completed approved training programs and to certify that successful candidates have passed the examination. The evaluation of training programs is the primary concern of the Residency Review Committee, which is an arm of the Accreditation Council for Graduate Medical Education. Privileges to practice cardiothoracic surgery are granted, as you know, by hospitals within which the practice takes place. I cannot foresee either sufficient shortening of the ABTS examination process or nationally uniform requirement for ABTS certification. I do believe that the leaders in thoracic surgery in the United States are ready to consider proposals for constructive change in cardiothoracic training. Thank you for having taken the time to share your thoughts with us. John R. Benfield, M D Division of Cardiothoracic Surgery University of California, Davis 4301 X St, Rm 2310 Sacramento, C A 9581 8
Graduate Education in Thoracic Surgery To the Editor: Recently The Annals printed several articles [l-51 concerning the training of thoracic surgeons, instigated by the thoughtful questions raised by Richard Peters [6]. The August issue of The Annals included an editorial by Benson Wilcox [7] telling of his ad hoc committee, which is addressing this issue. Over the years, I have made some observations regarding this subject, some of which may be pertinent. Many years ago, Eye, Ear, Nose, and Throat was one specialty. These surgeons did cataract surgery and Caldwell-Lucs. It became obvious that ophthalmology and otolaryngology were entirely different disciplines, and the two became separate specialties. I wonder if cardiac and noncardiac surgery have not also become “foreign” to one another. Two discoveries led to a decline in general thoracic trainingnamely, coronary arteriography and flexible fiberoptic bronchoscopy. Coronary arteriography led to coronary artery bypass surgery. The huge numbers of these cases made cardiac surgery, by far, more dominant than general thoracic surgery in time spent in the operating room and in training. One got the impression that pulmonary surgery became the “country cousin” to coronary bypass surgery, and was done “between cases,” at the end of the day or “whenever it can be worked in.” Before coronary bypass surgery came into being, there was a pretty good balance between cardiac and noncardiac surgery in training programs. Now, however, it seems that many thoracic surgery training programs are producing essentially coronary artery surgeons. Residents are coming out of training highly skilled in coronary surgery, but many have never seen a segmental resection or a sleeve resection, and some even give the impression that hilar dissection is a mystery to them. The second discovery, ie, the flexible bronchoscope, opened the field of bronchoscopy to almost anyone, removing the thoracic surgeon as the primary investigator of intrathoracic diseas-specially tumors. Training programs may have been partially at fault as the staff was so busy getting all the coronary artery bypass procedures done each day that we lost by default to the pulmonary medicine people. Thoracic surgery residents today are inadequately trained in flexible bronchoscopy, and are entirely inept in the use of the rigid bronchoscope (still a necessary tool).
CORRESPONDENCE
Ann Thorac Surg 1992;53:%50
In conclusion, the old eye, ear, nose, and throat problem may be pertinent to the thoracic surgery enigma. Because cardiac surgery (especially coronary surgery) has become so demanding in time and effort, general thoracic surgery has taken a “back seat” in training programs. I sincerely believe that the diagnostic approach to intrathoracic pathology was done more expeditiously 10 (perhaps even 30) years ago than it is today. It would seem to me that cardiac and noncardiac thoracic surgery should become separate training grounds after 1 year of training in both. The new techniques in thoracoscopy may give additional stimulus to general thoracic training. Hopefully, this modality will remain in the hands of surgeons.
Frederick H . Taylor, M D 300 Billingsley Rd Charlotte, NC 28211
References 1. Grillo HC. Dilemmas in cardiothoracic surgical education. Ann Thorac Surg 1991;51:809-11. 2. Kirklin JW. Training for cardiac surgery in children and adults. Ann Thorac Surg 1991;51:812-3. 3. Orringer MB. General thoracic surgery-issues and direction. Ann Thorac Surg 1991;51:814-7. 4. Roth JA, Balch CM. Thoracic surgery training: it is time for a change. Ann Thorac Surg 1991;51:81%9. 5. Benfield JR. What next in cardiothoracictraining? Ann Thorac Surg 1991;51:820. 6. Peters RM. Should we care? Do we care? What should we do? Ann Thorac Surg 1991;51:807-8. 7. Wilcox BR. Graduate education in thoracic surgery. Ann Thorac Surg 1991;52:177.
Neonatal Pneumonectomy To the Editor: I read with interest the recent article by Canver and associates [l], who described the successful management of a neonate with necrotizing bronchopneumonia secondary to pulmonary artery agenesis by right pneumonectomy. I write this communication only to emphasize the need for ongoing close surveillance in this child because of the potential risk of serious tracheal obstruction secondary to compression by the aortic arch. The chest roentgenogram published in this article shows, 1 year after operation, serious mediastinal shift to the right with the entire cardiac silhouette in the right hemithorax. In the presence of a left aortic arch, this degree of mediastinal shift places substantial tension on the aortic arch, which is relatively immobile in its distal portion due to the attachments of the brachiocephalic branches and intercostal vessels. I would like to bring to the attention of the readers an article published in this journal in 1978 [2] describing a technique that was successfully employed to manage this major complication of right pneumonectomy in the presence of a left aortic arch in the neonatal period. Robert 1. Szarnicki, M D 2100 Webster St, Suite 411 Sun Francisco, C A 94115
References 1. Canver CC, Pigott ID, Mentzer RM Jr. Neonatal pneumonectomy for isolated unilateral pulmonary artery agenesis. Ann Thorac Surg 1991;52:2945.
547
2. Szarnicki RJ, Maurseth K, de Leval M, Stark J. Tracheal compression by the aortic arch following right pneumonectomy in infancy. Ann Thorac Surg 1978;25:231-5.
Reply
To the Editor:
My colleagues and I appreciate Dr Szarnicki‘s interest in our report [l], and we agree with his appeal for the need of close surveillance of this child. Postpneumonectomy syndrome produces compression and malacia of the junction of the trachea and the main bronchus due to extreme mediastinal shift after rightsided pneumonectomy or left-sided pneumonectomy where a right-sided aortic arch is present. Correction is very complex but has been done, as in Dr Szarnicki’s case [2], successfully in some patients. In general, limited pulmonary resection that preserves all functioning lung tissue, ensuring maximal improvement, has been the procedure of choice in the pediatric population. Techniques and methods employed in the adult population to prevent complications of pulmonary resection, ie, cardiac herniation and airway compression, have not been employed in pediatric patients. Rare performance of pneumonectomy in the neonatal period may also explain the lack of published experience on this issue. However, in our case, life-threatening sepsis secondary to necrotizing pneumonia necessitated right pneumonectomy in the infant. Almost 2 years after the operation she remains healthy and growing normally.
Charles C . Canver, M D Section of Cardiothoracic S u r g e y Dartmouth Medical School Dartmouth-Hitchcock Medical Center One Medical Center Dr Lebanon, NH 03756
References 1. Canver CC, Pigott JD, Mentzer RM Jr. Neonatal pneumonectomy for isolated unilateral pulmonary artery agenesis. Ann Thorac Surg 1991;52:29&5. 2. Szarnicki RJ, Maurseth K, de Leval M, Stark J. Tracheal compression by the aortic arch following right pneumonectomy in infancy. Ann Thorac Surg 1978;25:231-5.
Acute Postinfarction Septa1 Rupture: Long-Term Results To the Editor: We enjoyed the paper by Loisance and colleagues [l]regarding short-term and long-term outcomes in patients receiving early surgical repair for acute postinfarction ventricular septa1 rupture. We also concur that the hospital mortality is quite high (45% in this report). Without question, enhanced techniques of controlled ischemic myocardial reperfusion and improved methods of myocardial preservation delivery (antegrade and retrograde avenues) have increased our ability to assure patients’ survival with this devastating complication. Nonetheless, there still remain patients who have insufficient residual myocardium for survival. The theoretical approach alluded to by Loisance and associates of emergency cardiac transplantation has been applied at Temple University Hospital. In April 1986 a 57-year-old man was readmitted 3 days after discharge for a medically treated acute anteroseptal infarction
